**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident representative interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection for 1 resident (R) (R14) of 1 resident who used a humidifier and contracted Legionnaires' disease. The facility also did not ensure COVID-19 positive staff members returned to work in accordance with the facility's policy. In addition, the facility did not ensure enhanced barrier precautions (EBP) were implemented for 1 resident (R25) of 2 sampled residents. R14 used a humidifier that was filled with tap water and was diagnosed with Legionnaires' disease on 3/4/25. The facility did not have a policy and procedure for the use of humidifiers and the facility's water management program did not address humidifiers as a potential source for Legionella bacteria. The first example is being cited at a level G. The facility's COVID-19 outbreak line list indicated five staff (Dietary Aide (DA)-M, Certified Nursing Assistant (CNA)-H, Social Worker (SW)-N, Licensed Practical Nurse (LPN)-O, and CNA-P) returned to work earlier than the facility's policy which follows the Centers for Disease Control and Prevention (CDC) return to work guidelines. R25 had an indwelling Foley catheter. R25 did not have an EBP sign or or near R25's door or a personal protective equipment (PPE) cart outside R25's room. In addition, CNA-E did not wash hands prior to donning gloves and did not wear a gown during catheter care. Findings include: Wisconsin Healthcare-Associated Infections in Long-Term Care (LTC) Coalition: Use of Stand-Alone Room Air Humidifiers in Nursing Homes, dated 2/2021, indicates: .Peer reviewed medical journals have reported that stand-alone room air humidifiers have been associated with cases and outbreaks of pneumonia associated with Legionella pneumoniae .Guidance related to the use of stand-alone room air humidifiers: There is a lack of evidence to support the medical benefit in the use of stand-alone room air humidification devices in nursing homes .The decision to incorporate this device as part of a resident's plan of care should be based on a case-by-case basis. The following factors should be considered prior to and during use of a stand-alone room air humidification device: 1. These devices should be used in the context of an organization's general infection control risk assessment. There are several other critical considerations that need to be addressed including: a. Policies and procedures to address proper assessment, use, maintenance, and documentation of compliance with cleaning and maintenance procedures and processes. b. Staff education and competency validation in device maintenance. c. Documentation of discussions related to resident/family education of device use, safety, and maintenance .2. Most accounts of stand-alone room air humidifier associated infections have been attributed to aerosol generating humidifiers .3. Follow the manufacturer's instructions regarding cleaning, disinfecting, and maintenance of stand-alone room air humidification devices, water reservoirs, evaporative screens, and other water contact surfaces. 4. In the absence of clear manufacturer's instructions, empty the tank, wipe all surfaces dry, and refill the water in portable humidifiers daily to discourage microbial growth or formation of biofilms. 5. Use of sterile water is recommended to minimize microbial growth. Note: Distilled water has been suggested to reduce dissemination of mineral particulates which may cause adverse health events .8. Incorporate cleaning, disinfection, and maintenance strategies of stand-alone room air humidification devices into the organization's water management treatment program. The CDC's Legionella Toolkit-Version 1.1, dated 6/24/21, indicates: .Legionella can grow in many parts of building water systems that are continually wet and certain devices can then spread contaminated water droplets. Examples include: humidifiers .Non-steam aerosol-generating humidifiers. The CDC's Interim Guidance for Managing Healthcare Personnel (HCP) with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, dated 3/1/24, indicates: HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) have improved. The facility's Transmission-Based Precautions policy, dated 4/25, indicates: Enhanced barrier precautions (EBP) expands the use of personal protective equipment (PPE) beyond situations in which exposure to blood and bodily fluids is anticipated and refers to the use of a gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staffs' hands and clothing. EBP is recommended for residents known to be colonized or infected with an MDRO as well as those at increased risk for MDRO acquisition .Examples of high-contact resident care activities requiring gown and glove use: Device care or use: central line care, urinary catheter, feeding tube, tracheostomy/ventilator .Implementation: When implementing contact precautions or EBP, it is critical to ensure staff are aware of the facility's expectations about hand hygiene and gown/glove use, have initial and refresher training, and have access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside the resident's room indicating the type of precautions and required PPE. For EBP, signage should also clearly indicate the high-contact resident care activities that require the use of a gown and gloves. Make PPE available .outside the residents' room. 1. From 4/14/25 to 4/16/25, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] and had diagnoses including dementia, chronic obstructive pulmonary disease (COPD), and stroke. R14's Minimum Data Set (MDS) assessment, dated 3/1/25, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R14 had severe cognitive impairment. R14 had an activated Power of Attorney (POA) (POA-F). R14's medical record indicated POA-F reported to staff on 3/2/25 that R14 was not feeling well and was warm. Staff obtained R14's vital signs and noted a temperature of 99.5 degrees. Tylenol was administered. Staff checked R14's vital signs an hour later and noted R14 had a temperature of 102.9 degrees. R14's blood pressure was 122/70, oxygen saturation was 89%, respiratory rate was 16, and heart rate was 80 beats per minute. R14 was transferred to the hospital and admitted with a diagnosis of pneumonia. R14's hospital Discharge summary, dated [DATE], indicated R14's primary discharge diagnosis was community-acquired pneumonia of the lower lobe of the right lung. R14 was treated with Rocephin and azithromycin (antibiotic medications) for a positive Legionella urinary antigen. Upon review of R14's hospital discharge summary, ADON-C noted R14's urine tested positive for Legionella. The facility contacted the Public Health Department and discussed water testing. R14's humidifier was determined to be a plausible source of the Legionella. R14's medical record contained a discontinued (as of 3/4/25) order to fill R14's humidifier morning (AM) and evening (HS) two times per day. The order was created by CNA-I on 2/12/25. R14's February 2025 Treatment Administration Record (TAR) contained an order to fill R14's humidifier morning (AM) and evening (HS) two times per day, dated 2/12/25. The order was initialed as completed two times per day from 2/12/25 to 3/2/25. The order was discontinued on 3/4/25 by Assistant Director of Nursing (ADON)-C. On 3/6/25, an independent company conducted water testing at the facility and a sample was taken from R14's humidifier. The facility notified POA-F and indicated the facility disposed of the humidifier. On 3/14/25, water testing results indicated no Legionella was found. The sample from the humidifier was noted to contain multiple bacteria and the results were inconclusive. There were other suspected areas, however, there were no conclusive test results that confirmed the presence of Legionella bacteria. On 3/24/25, the Public Health Department obtained water samples from the facility. The results were received on 4/8/25. On 4/9/25, Director of Nursing (DON)-B was notified via e-mail that three positive Legionella samples were obtained. The results indicated the fourth floor whirlpool tub (which had not been used for approximately six years) was tested with the jets running (which the independent water testing company did not do) and was positive for Legionella. (Of note: R14's room was within close proximity of the fourth floor tub room.) Detailed remediation efforts and control measures were implemented by the facility. On 4/14/25 at 10:39 AM, Surveyor interviewed POA-F who confirmed R14's humidifier was brought from home and filled with tap water from R14's bathroom faucet two times daily. POA-F indicated staff were aware R14 had a humidifier and assisted with filling the humidifier. (Of note: R14's medical record did not indicate when the humidifier was brought to the facility or when R14 started using the humidifier.) On 4/15/25 and 4/16/25, Surveyor interviewed Maintenance Director (MD)-D regarding water management. MD-D indicated MD-D flushed all vacant areas in the facility, including tubs, showers, toilets and anything that was stagnant on closed units. MD-D indicated the rehab unit was closed in 2020 and remained closed until September of 2024. MD-D indicated weekly flushing was completed in the closed areas, however, MD-D did not document the weekly flushes. MD-D did not indicate if the fourth floor whirlpool tub jets were run during the flushing. On 4/16/25 at 10:23 AM, Surveyor interviewed Public Health Staff (PHS)-Q who confirmed the facility reported R14's humidifier was filled with tap water. On 4/16/25 at 4:37 PM, Surveyor interviewed CNA-G who indicated only nurses were allowed to fill R14's humidifier. CNA-G indicated POA-F talked about filling R14's humidifier with tap water in the evening. On 4/16/25 at 4:42 PM, Surveyor interviewed CNA-H who indicated only Medication Technicians or nurses could fill R14's humidifier with water. On 4/16/25 at 4:58 PM, Surveyor interviewed Registered Nurse (RN)-J who was not sure if the facility had a humidifier policy. On 4/16/25 at 5:15 PM and 5:28 PM, Surveyor interviewed DON-B who indicated the facility did not have a Legionella plan aside from what was contained in the facility's water management policy. DON-B confirmed ward clerks, CNAs, and Medication Technicians can enter nursing orders which do not need to be signed by a nurse or provider. DON-B indicated the facility did not have a policy and procedure for transcribing orders. DON-B was not sure why CNA-I entered the humidifier order. DON-B attempted to contact CNA-I during the survey but was unsuccessful. (Of note: DON-B was not aware CNA-I had entered the order prior to the survey and was not aware R14 had a humidifier until R14 returned from the hospital on 3/4/25.) DON-B indicated if DON-B or ADON-C were aware that R14 had a humidifier prior to 3/4/25, the order would have indicated only distilled water could be used. DON-B confirmed the facility did not have a humidifier policy prior to R14 testing positive for Legionnaires' disease and indicated humidifiers should not be used. DON-B indicated DON-B posted a memo by the time clock to provide education for staff on Legionnaires' disease and humidifier use. Surveyor obtained a copy of the memo posted by the time clock and a sign-in sheet that confirmed which staff read the memo. The memo and sign-in sheet, dated 3/6/25, contained 33 staff signatures and provided education on Legionnaires' disease and the use and care of humidifiers. (Of note: The facility had 116 total staff, 64 of which were nursing staff.) On 4/18/25, Surveyor received an e-mail from DON-B that contained an education sign-in sheet that indicated education was mailed on 4/17/25 to staff who were not present to sign and other staff signed on 4/17/25. (Of note: The survey was completed on 4/16/25.) The e-mail contained the facility's education on Legionnaires' disease, indicated humidifiers were no longer allowed in the long-term care, and contained information on the use and care of home humidifiers. The email also included a transcribing physician orders policy, 6/12/08, and a cleaning humidifiers policy, dated 1/2016. 2. From 4/15/25 to 4/16/25, Surveyor reviewed the facility's COVID-19 positive staff line list for December 2024 through February 2025 and the facility's staff call-in list and noted staff return to work dates were not within the CDC's return to work guidelines. For December 2024: ~ CNA-H tested positive for COVID-19. The Health Department was notified on 12/31/24. CNA-H's last worked date was 11/29/24. CNA-H had an onset date of 12/2/24 with symptoms of a sore throat. CNA-H's last symptom and return to work dates were 12/7/24. According to the CDC guidelines, CNA-H's return to work date should have been 12/13/24. ~ SW-N tested positive for COVID-19. The Health Department was notified on 12/31/24. SW-N's onset date was 12/28/24 with symptoms of a headache and congestion. SW-N's last worked date was 12/30/24. SW-N's last symptom and return to work dates were not listed on the COVID-19 staff line list. The facility's call-in list indicated SW-N's last symptom date was 1/3/25 and return to work date was 1/6/25. According to the CDC guidelines, SW-N's return to work date should have been 1/8/25. For January 2025: ~ LPN-O tested positive for COVID-19. The Health Department was notified on 1/7/25. LPN-O's last worked date was 1/3/25. LPN-O's onset date was 1/4/25 with symptoms of nausea and a sore throat. LPN-O's last symptom date was 1/9/25 and return to work date was 1/10/25. According to the CDC guidelines, LPN-O's return to work date should have been 1/15/25. ~ CNA-P tested positive for COVID-19. The Health Department was notified on 1/7/25. CNA-P's last worked and onset dates were 1/5/25 with symptoms of nasal congestion. CNA-P's last symptom date was 1/11/25 and return to work date was 1/13/25. According to the CDC guidelines, CNA-P's return to work date should have been 1/16/25. For February 2025: ~ DA-M tested positive for COVID-19. The Health Department was notified on 3/3/25. DA-M's last worked and onset dates were 2/21/25 with symptoms of a sore throat and cough. DA-M's last symptom and return to work dates were 2/27/25. The call-in list indicated DA-M's last worked date was 2/20/25. According to the CDC guidelines, DA-M's return to work date should have been 3/4/25 when calculated with an onset date of 2/21/25. On 4/16/25 at 8:55 AM, Surveyor interviewed DON-B who called ADON-C regarding the facility's return to work policy. ADON-C indicated the policy is reviewed when there is a CDC revision and when there are changes to the guidance. ADON-C indicated the facility's infection prevention and control employee health policy indicates the return to work date is five days and five days of strict masking when staff return following COVID-19 illness. When Surveyor informed ADON-C that the guidance was for non-healthcare workers, ADON-C indicated the facility follows the CDC guidelines and the facility did not have additional information on return to work dates. DON-B reviewed the facility's COVID-19 positive staff line list for December 2024 through February 2025 and confirmed return to work dates were not within the CDC's return-to-work guidelines. On 4/16/25 at 11:15 AM, Surveyor interviewed RN-K regarding the facility's return to work policy. RN-K indicated staff should be off for five days. RN-K indicated if symptoms improve, staff can return to work and wear a mask for seven days. RN-K indicated staff are not subjected to a COVID-19 re-test and indicated management calls to inquire about signs and symptoms and let staff know a return to work date. On 4/16/25 at 11:34 AM, Surveyor interviewed Dietary Manager (DM)-L who indicated DA-M was sick on 2/20/25 per DA-M's timecard and returned to work on 2/27/25. DM-L indicated DA-M tested positive for COVID-19 and DA-M's return to work date was not within the CDC's return to work guidelines. 3. From 4/14/25 to 4/16/25, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] and had diagnoses including dementia and history of urinary tract infections (UTIs) with painful urination. R25 had an indwelling urinary catheter. R25's MDS assessment, dated 4/9/25, indicated R25 had severely impaired cognition. On 4/15/25 at 11:06 AM, Surveyor observed CNA-E complete catheter care for R25. Surveyor noted CNA-E did not wash hands prior to donning gloves and did not wear a gown during catheter care. Surveyor interviewed CNA-E who was unsure if a gown should be worn during catheter care and indicated a gown was only needed if a resident was sick. CNA-E verified there was not an EBP sign or PPE cart outside R25's room. On 4/15/25 at 11:18 AM, Surveyor interviewed DON-B who indicated an EBP sign should be posted on or near R25's door. DON-B indicated CNA-E should have washed hands prior to donning gloves and verified CNA-E should have worn a gown during catheter care per the facility's EBP policy and procedure.