**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility, reviewed for infection control. The facility DON (Infection Preventionist) failed to ensure: Residents who had the flu had appropriate signage on their door and PPE for use outside their door. Facility staff were utilizing appropriate PPE when caring for residents in isolation rooms. Facility staff notified the families of flu negative roommates that they were at risk of being infected with the flu. Flu negative residents were cohorted in the same room as flu positive residents. Flu negative roommates were offered the prophylactic treatment for the flu. An IJ was identified on 01/24/24. The IJ template was provided to the facility on [DATE] at 4:45PM. While the IJ was removed on 01/26/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm because all staff had not been trained on the POR. These failures could place residents at risk for the spread of infection through cross-contamination of pathogens and illness which could result in a decline in health and well-being or even death. Findings included: Record review of Flu Positive Residents, dated 01/24/24, and received from the DON, revealed 10 residents had the flu: o Resident #1 (Roommate - Resident #25 was flu negative) o Resident #41 (Roommate - Resident #31 was flu negative) o Resident #2 (No roommate) o Resident #55 (Roommate - Resident #42 was flu negative) o Resident #64 (Roommate - Resident #39 was flu negative) o Resident #12 (Roommate - Resident #49 was flu negative) o Resident #3 (No roommate) o Resident #46 (Roommate - Resident #4 was flu negative) o Resident #24 (No roommate) o Resident #70 (Roommate - Resident #57 was flu negative) 1. Review of Resident #1's MDS admission assessment, dated 01/08/24, reflected she was an [AGE] year-old female admitted on [DATE]. Her cognitive status was severely impaired. Her diagnoses included non-Alzheimer's disease. 2. Review of Resident #41's MDS quarterly assessment, dated 01/08/23, reflected she was a [AGE] year-old female admitted on [DATE]. Her cognitive status was intact. Her diagnoses included non-Alzheimer's disease. 3. Review of Resident #2's MDS quarterly assessment, dated 10/25/23, reflected she was an [AGE] year-old female admitted on [DATE]. The resident was rarely understood. Her diagnoses included non-Alzheimer's disease. 4. Review of Resident 55's MDS quarterly assessment, dated 12/14/23, reflected he was a [AGE] year-old male admitted on [DATE]. His cognitive status was intact. His diagnoses included post-traumatic stress disorder. 5. Review of Resident 64's MDS quarterly assessment, dated 01/04/24, reflected she was an [AGE] year-old female admitted on [DATE]. Her cognitive status was severely impaired. Her diagnoses included Alzheimer's disease. 6. Review of Resident #12's MDS quarterly assessment, dated 10/15/23, reflected she was an [AGE] year-old female admitted on [DATE]. The resident was rarely understood. Her diagnoses included non-Alzheimer's disease. 7. Review of Resident #3's MDS admission assessment, dated 01/18/24, reflected she was an [AGE] year-old female admitted on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included non-Alzheimer's disease. 8. Review of Resident #46's MDS quarterly assessment, dated 12/27/23, reflected he was a [AGE] year-old male admitted on [DATE]. His cognitive status was not assessed. His diagnoses included heart failure. 9. Review of Resident #24's MDS quarterly assessment, dated 01/04/24, reflected she was a [AGE] year-old female admitted on [DATE]. Her cognitive status was not assessed. Her diagnoses included stroke. 10. Review of Resident #70's MDS quarterly assessment, dated 12/15/23, reflected he was a [AGE] year-old male admitted on [DATE]. His cognitive status was severely impaired. His diagnoses included non-Alzheimer's disease. An observation on 01/24/24 at 10:47 AM of Resident #49's room revealed the resident was lying in B bed. The door was open, a sign to see the nurse was posted, and a bin with PPE was outside the door. Resident #49 requested water and CNA A entered the resident's room wearing a mask only. CNA A picked up the water bottle and gave the resident a drink. CNA A left the room. CNA A said the resident was in isolation and she got busy and forgot to wear all of her PPE into the room. She said it was important to wear PPE so that the infection did not spread. Neither resident had the curtain drawn in the room to separate them. Resident #49's flu positive roommate was not wearing a mask. An interview on 01/24/24 at 3:00 PM with the family of Resident #49 revealed they were never notified that the resident was in an isolation room with a resident that had the flu. The family member said they would not want Resident #49 to remain in the room. The family member said the facility did not contact them about administering medication prophylactically to treat for possible flu. An observation on 01/24/24 at 10:40 AM with Resident #46 revealed there was no signage on his door and there was no PPE outside of his room. The resident was interviewed by the Surveyor and said he felt ill. He was sitting up in bed with a congested cough. Resident #46 had a roommate (flu negative) who was lying in his bed. Resident #46 was not wearing a mask. An observation and interviews on 01/24/24 between 12:36 PM - 12:40 PM revealed staff shut Resident #46's door. Staff placed signage on the door and a PPE bin outside of the door. LVN C was standing next to her med cart outside of Resident #46's door. LVN C said Resident #46 was supposed to be in isolation because he had the flu. LVN C said she did not know why the resident did not already have signage on the door and PPE outside of the door prior to 12:36 PM. The DON walked to Resident #46's door. The DON said the resident was supposed to be in isolation because he had the flu. The DON said Resident #46's roommate did not have the flu, but there were no rooms to move him to and his family did not want him to move. An observation on 01/24/24 at 1:16 PM revealed Resident #3 had his door open. He was in his room seated in his wheelchair. There was a sign outside the room which reflected, All proper PPE must be worn upon entering. There was no PPE cart outside the room. It was not clear if the resident was in isolation or not. An interview on 01/24/24 at 1:29 PM with LVN D revealed she did not know for sure if Resident #3 had the flu . LVN D said the resident was being treated with Tamiflu (flu medication). LVN D said if the resident had the flu then there needed to be PPE outside their door because the resident would be contagious. An observation and interview with the DON on 01/24/24 at 1:47 PM revealed Resident #3 was supposed to be in isolation. The resident's door was still open. The DON said that staff must have taken the PPE cart instead of refilling it . An interview on 01/25/24 at 02:38 PM with the ADON revealed 10 residents had the flu according to the 24-hour report. She said an additional resident had been sent to the hospital for low oxygen saturation. The ADON said she would identify which residents were in isolation because they would have PPE outside of their door. The ADON said facility staff needed to wear a gown, gloves, face shield, and N95 mask to provide care to a resident with the flu. Interviews on 01/24/24 at 2:29 PM and on 01/25/24 at 3:03 PM with the DON revealed the flu outbreak started on 01/17/24 when some of the residents first showed signs and symptoms of the flu. She said flu tests were sent to the lab, but results were not received until 01/21/24. The DON said some residents started Tamiflu and some did not. She said staff were educated to wear PPE. The DON said residents and staff were not tested unless they were symptomatic. She said the facility was following the CDC guidelines for managing the flu infection and the health department had been contacted. The DON said she did not know why families of roommates of flu positive residents were not contacted by the charge nurse and she started contacting families on 01/24/24 . The DON said she did not know why staff were not changing their masks when exiting an isolation room. She said staff were supposed to wear PPE in isolations rooms which included an N95 mask, goggles/face shield, gown, and gloves . She said she saw staff were not wearing PPE appropriately and she was in-servicing them. She said 10 residents and 2 staff had the flu. She said it important to wear PPE and keep flu positive residents cohorted to prevent cross contamination. The DON said the infection spread partially because Resident #70 was ill but would walk through the halls of the facilit y. The DON said facility staff would encourage the resident to stay in her room. The DON said she did not know how many of the flu positive residents received the flu vaccine or which of their roommates received the vaccine. She said staff knew which residents had the flu because of shift-to-shift report and the signs on the door and PPE bins outside of the door. Review of the website: https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm on 01/24/24 reflected: Preventing transmission of influenza viruses and other infectious agents within healthcare settings, including in long-term care facilities, requires a multi-faceted approach that includes the following: Influenza Vaccination Influenza Testing Infection Prevention and Control Measures Antiviral Treatment Antiviral Chemoprophylaxis . Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Droplet Precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a healthcare facility. Examples of Droplet Precautions include: Placing ill residents in a private room. If a private room is not available, place (cohort) residents suspected of having influenza residents with one another. Wear a facemask (e.g., surgical or procedure mask) upon entering the resident's room. Remove the facemask when leaving the resident's room and dispose of the facemask in a waste container. Communicate information about patients with suspected, probable, or confirmed influenza to appropriate healthcare personnel . exposed residents on units or wards with influenza cases in the long-term care facility (currently impacted wards) should receive antiviral chemoprophylaxis as soon as an influenza outbreak is determined . When at least 2 patients are ill within 72 hours of each other and at least one resident has laboratory-confirmed influenza, the facility should promptly initiate antiviral chemoprophylaxis with oral oseltamivir to all non-ill residents living on the same unit as the resident with laboratory-confirmed influenza (outbreak affected units), regardless of whether they received influenza vaccination during the current season. Antiviral chemoprophylaxis is meant for residents who are not exhibiting influenza-like illness but who may be exposed or who may have been exposed to an ill person with influenza, to prevent transmission . Review of the facility policy and procedure, IPCP Standard and Transmission-Based Precautions, dated October 2022, reflected: .4. Droplet Precautions (TBP) are used for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking (e.g. influenza). See CDC Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions for other conditions and infections in which droplet precautions are indicated. a. Implement source control by placing a mask on the patient. b. Ensure appropriate patient placement in a single room if possible. In long-term care and other residential settings, make decisions regarding patient placement on a case-by-case basis considering infection risks to other patients in the room and available alternatives. c. Use personal protective equipment (PPE) appropriately. [NAME] mask (and eye protection if indicated) upon entry into the patient room or patient space. d. Limit transport and movement of patients outside of the room to medically-necessary purposes. If transport or movement outside of the room is necessary, instruct patient to wear a mask and follow Respiratory Hygiene/Cough Etiquette . 6. Implementation: a. The facility will implement a system to alert staff, residents, and visitors that a resident is on TBP. i. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). ii. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. b. Make PPE, including gowns and gloves, available immediately outside of the resident room . e. Provide education to residents and visitors as needed. The facility Administrator was notified an Immediate Jeopardy (IJ) had been identified on 01/24/24 at 4:45 PM and was provided with the IJ template at that time. A Plan of Removal was requested. The Plan of Removal (POR) was accepted on 01/25/24 at 4:45 PM and reflected: Immediate Action: 1. The Medical Director was notified of the IJ on 01/24/2024 at 5:00 pm. 2. PPE was placed at the entrance of each isolation room and signs were posted on 1/24/24. 3. The families of the roommates were notified 1/24/24. 4. Residents will be actively monitored for signs/symptoms of influenza via physician orders that were placed 1/24/24. This process was initiated 1/24/24 and will continue for 1 week after last laboratory confirmed case of influenza is identified. Upon identification of signs and symptoms of respiratory illness; the resident will be assessed for change in condition and placed on droplet precautions, staff caring for the resident will be notified of the need for precautions, physician and family notified, tested for influenza. If positive, resident will remain in droplet precautions, physician notified, new orders for treatment/ medications will be obtained, family notified, staff caring for resident will be updated on positive flu and precautions will continue. This was included in the training with staff, initiated 1/24/24 and completed 1/25/24. 5. Staff are screened for signs and symptoms of respiratory illness using Simpliscreen prior to the start of their shift. Visitors also screen in with each visit. Signs are posted at the entrance to stop and screen, also QR code is available to both staff and visitors to screen in. 6. Following CDC guidance on discontinuation of transmission precautions: Resident's positive for influenza will be monitored for the 7-day isolation period and precautions will be discontinued only after the resident is assessed as having resolving symptoms and having no fever for more than 24 hours. The Infection Preventionist will communicate this to the Attending Physician to obtain the orders to discontinue precautions. The family will also be notified that precautions are being discontinued. This process was initiated 1/24/24 and will be documented on as their precautions are discontinued. This process was included in staff training under outbreak procedures and droplet precautions/discontinuation of precautions. 7. The Attending Physicians were notified of outbreak and CDC recommendations on administering prophylactic antivirals. All recommended antiviral use and gave orders. Families/residents were notified of recommendations and either consented or declined the orders. Documentation was completed with either the consent or declination, orders placed and awaiting delivery of medication for administration. This process was initiated 1/24/24 and completed 1/25/24. 8. Cough etiquette signs were posted on entrance doors and hallways on 1/24/24. 9. Train the trainer in-servicing was given to the DON/Infection Preventionist, ADON, Rehab Director and RN Cluster Partners by the Clinical Resource. The training includes masking, donning/doffing PPE, droplet precautions and discontinuation of precautions, procedures for outbreak including identifying respiratory illness, disinfection and handwashing all based on CDC guidance for influenza. This was completed 1/24/24 prior to start of training for all other staff. 10. Training and competency on donning and doffing PPE, handwashing, droplet precautions and discontinuation of precautions, and outbreak procedures including identifying respiratory illness and disinfecting practices will be completed with all staff by 1/25/24. This training was initiated on 01/24/24 will be completed on 1/25/24 with all staff prior to the start of their next shift. The training includes masking, donning/doffing PPE, droplet precautions and discontinuation of precautions, procedures for outbreak/disinfection and handwashing all based on CDC guidance and will be provided by the DON, ADON, Clinical Resource, Cluster Partners, Rehab Director, and Executive Director and completed by 1/25/24. Train the trainer in-service was given by the Clinical Resource RN and was completed with DON, ADON, Cluster Partners, Rehab Director, and Executive Director on 1/24/24. 11. This training will be completed in-person by 1/25/24 with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all get trained prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for agency staff/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and competency. 12. An ad hoc meeting regarding items in the IJ template will be completed on 01/24/2024. Attendees will include the DON/Infection Preventionist, Medical Director, ADON, Clinical Resource, Executive Director and will include the plan of removal items and interventions. 13. The DON, ADON, or Clinical Resource RN will verify staff competency with 10 staff weekly using the PPE and handwashing competency checklists. This will be completed weekly after the initial training and competency began on 01/24/2024. 14. Influenza positive residents will be reviewed during weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to DON, ADON, Rehab Director, and Executive Director. The DON and Executive Director will be responsible for ensuring this meeting is held weekly and influenza positive residents are reviewed. This meeting will begin on 01/24/2024. 15. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x4 weeks beginning 1/25/24 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring of the Plan of Removal reflected: Observations on 01/26/24 between 9:00 AM - 4:00 PM revealed residents with the flu were in isolation and there was appropriate signage and PPE available outside of their doors. Resident #24 was observed leaving her room (isolation room) and entered the hall without wearing a mask. The ADON intervened and escorted the flu positive resident back to her room and shut her door. Staff donned and doffed PPE appropriately when entering and exiting isolation rooms. Interviews on 01/26/24 between 9:51 AM - 4:00 PM with 13 staff from all shifts, (CNA E, LVN F, LVN G, CNA H, CNA I, CNA J, ADON, CNA K, CNA L, MA M, CNA N, CNA O, and LVN P) revealed the staff were in-serviced on hand hygiene, donning and doffing PPE appropriately, identifying residents with flu symptoms and what to do with those residents. Facility staff were checked off on hand hygiene and donning and doffing PPE. Staff were able to correctly identify which residents had the flu and were in isolation. Staff said everyone was responsible for ensuring isolation rooms were correctly identified. Staff nurses said they were responsible for notifying the physician, family, facility staff, and administrative staff regarding residents with flu symptoms. Facility staff said if the flu positive resident had a roommate they would notify the family and physician to determine if they were to be treated prophylactically and if they were to remain in the room with the flu positive resident. Facility nurses said the physician had to be notified before a resident could be removed from isolation and the residents were supposed to be in isolation for 7 days. An interview with the DON on 01/26/24 at 03:34 PM revealed she had received a Train the Trainer in-service. She said she identified errors during the flu outbreak that included a delay in receiving lab results which led to a delay with when residents were placed in isolation. She said there was a rapid spread of the flu virus and that staff thought isolation ended after 5 days and were removing PPE bins before they were supposed to. The DON said that her role in the POR was to educate staff, monitor PPE use, monitor handwashing, and ensure that families were contacted. An interview with the Medical Director on 01/26/24 at 2:47 PM revealed he was contacted by facility staff regarding the Immediate Jeopardy. He said his role in the POR would be to ensure tracking was completed and that residents were prophylactically treated. He said he felt at that time the flu outbreak was under control. An interview with the Administrator on 01/26/24 at 3:48 PM revealed the issues he identified with the outbreak were that the facility did not respond correctly to ensure staff followed infection control protocols. He said his role in the POR was to educate staff and monitor to ensure the education was completed and followed through on. He said going forward a response plan would be implemented with each positive case and the issues would be discussed in QAPI meetings. He said he would ensure contact tracing and tracking of the anti-viral medication administration would be completed. The Administrator was informed the IJ was removed on 01/26/24 at 5:15 PM. While the IJ was removed the facility remained out of compliance at a scope of pattern and a severity level of no actual harm due to the facility's need to monitor the implementation and effectiveness of its POR.