**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure resident's exhibiting symptoms of gastroenteritis were on contact precautions; failed to ensure Personal Protective Equipment (PPE) supplies were available for use (gowns); failed to disinfect resident rooms and common areas with the appropriate (Environmental Protection Agency) EPA cleaner; and failed to educate and reeducate staff on contact precautions and appropriate disinfection resulting in spread of gastroenteritis creating an immediate jeopardy situation to 9 out of 34 Resident's, as of 3/6/2023, on the B2 Unit. (Resident #41, #29, #28, #32, #13, #27, #26, #35, #4). In addition to the immediate jeopardy, the facility failed to have a risk assessment and have water management policies and procedures in place to reduce the risk of growth and spread of Legionella and other opportunistic waterborne pathogens in the facility water system resulting in potential harm that is not immediate jeopardy to 52 residents in the facility. Findings: According to the Centers for Medicare and Medicaid Services, State Operations Manual Appendix PP Guidance to Surveyors for Long Term Care Facilities rev. 211 dated 2/03/2023, page 778, Contact Precautions: Contact precautions are intended to prevent transmission of pathogens that are spread by direct (e.g., person-to-person) or indirect contact with the resident or environment (e.g., C. difficile, norovirus, scabies), and requires the use of appropriate PPE, including a gown and gloves before or upon entering (i.e., before making contact with the resident or resident's environment) the room or cubicle. Prior to leaving the resident's room or cubicle, the PPE is removed and hand hygiene is performed. On 3/6/23 at 9:21 a.m., the Acting Director of Nursing (ADON) stated, to the survey team, words to the effect of: at the end of last week we had some type of Norovirus type thing in the building on B2, now we have more residents that are not doing well. A surveyor asked what type of precautions the residents on B2 are on, and the ADON stated, standard precautions. On 3/6/23 at 9:32 a.m., in an interview with a surveyor, Licensed Practical Nurse (LPN)1 stated, on the evening shift last night [Resident #30] was nauseous, [Resident #13] had loose stool x(times) three, [Resident #21] had nausea this morning, [Resident #35] had vomiting, [Resident #50] had a loose stool and one episode of vomiting, and [Resident #4] had extra-large loose stool. On 3/6/23 at 10:38 a.m., in an interview with a surveyor, LPN2 indicated that there were three residents with diarrhea and vomiting. [Resident #4] started last night, vomiting and diarrhea; [Resident #35] started yesterday, and overnight vomiting and diarrhea, and vomiting right now; [Resident #13] started overnight, and the evening shift yesterday, diarrhea. This surveyor asked what type of precautions the residents are on. She stated, everyone is on contact, wash hands, and wash hands after gloves. The LPN did not indicate what contact precautions meant. On 3/6/23 at 11:03 a.m., a surveyor observed Resident #35 seated in a wheelchair, vomiting into a basin. Certified Nursing Assistant-Medication Technician (CNA-M)1 was holding the basin with ungloved hands. In an interview with a surveyor, CNA-M1 stated, she was off the weekend, and if there are bins (precaution supply carts) outside the room, she would have known to wear gloves into the room, the facility is not doing that. The facility has not identified it as Norovirus, they identified it as a stomach flu. The CNA-M1 stated she was given a list of people not to give laxatives to due to loose stool. At this time a surveyor requested to see the list, Residents #4, #34, #50, #27, #3, #29, #21, #35, and #13 were highlighted on the list to Please hold laxatives. On 3/6/23 at 11:07 a.m., in an interview with a surveyor, CNA3 indicated she came on shift at approximately 6:45 a.m. this morning and she said, some residents have symptoms of Norovirus, who had bowel movememt(BM ) over the last evening shift. CNA3 stated she did not write the residents down, but [Resident #4] and [Resident #30] were not feeling well. [Resident #35], [Resident #7], and [Resident #13] were not feeling well. CNA3 stated, I go between floors(works different floors/units and goes back and forth between units). When a surveyor asked what PPE the CNA should use, she stated masks and gloves on, no gown precautions. If full precautions would have gowns available. On 3/6/23 at 11:24 a.m., a surveyor observed Physical Therapy (PT) going into room [ROOM NUMBER] with no gloves on, she leaned on the bedside table, hands resting on her face and spoke with Resident #30 before taking Resident #30 into the hallway for therapy services. In an interview with a surveyor, the Physical Therapist indicated that her Rehab Manager, and LPN1 said [Resident #30] was clear (not having symptoms of nausea/vomiting). On 3/6/23 at 11:38 a.m., a surveyor observed the Rehab Manager in room [ROOM NUMBER], she was walking around the bedside of Resident #4, picking up items next to the bed, counting repetitions for Resident #4 while the resident was lifting and lowering a physical therapy long stick (piece of exercise equipment). The Rehab Manager did not have a gown, or gloves on. In an interview with a surveyor, the Rehab Manager indicated she was not aware that [Resident #4] was on contact precautions, and that [Resident #4] complains of nausea all the time. In an interview with a surveyor, at this time, the Rehab Manager indicated she was unaware that [Resident #4] had vomiting and diarrhea today. On 3/6/23 at 1:37 p.m., in an interview with a surveyor regarding gastrointestinal symptoms, LPN2 stated, it started with [Resident #29] on the 27th (2/27/23), and next day [Resident #28] was vomiting, now we've got several people with diarrhea and vomiting. On 3/6/23 at 2:23 p.m., in an interview with a surveyor, LPN2 indicated, the facility started contact precautions this morning, but had no gowns. When asked by a surveyor how staff know what type of precautions, LPN2 stated, As soon as cards (precaution signs that get posted on or near a resident room that describes what type of transmission based precautions to use when entering a room) get up here. Waiting for maintenance, the cards are in a different building The LPN2 also indicated the gowns are kept in a different building (therefore precaution indication cards and gowns were not available for staff) and she was waiting for maintenance to bring them to B2 Unit. On 3/6/23 at 1:57 p.m., in an interview with a surveyor, CNA2 was asked how she knows what type of precautions and personal protective equipment (PPE) she must wear when entering a resident room, she stated, usually, a sign and a cart outside the door. When report exchange. I know there are a lot of people sick right now, cautious, no signs up. Just make sure we wash hands before entering and leaving rooms. Some residents are having loose stool. Always glove. Not told to wear a gown. This surveyor asked if any residents are on contact precautions right now, and CNA2 stated, No. On 3/6/23 at 2:11 p.m., in an interview with a surveyor, CNA-M1 stated she was not wearing gloves when she was holding a basin that [Resident #35] was vomiting into on 3/6/23 at 11:03 a.m. CNA-M1 also stated that she cleaned up the vomit and floor area with the purple top disinfectant wipes (Super Sani-Cloth Germicidal disposable wipes (cleanser was not an EPA approved for norovirus disinfection)). She stated, Usually, housekeeping will clean it thoroughly, but I couldn't find anybody. CNA-M1 didn't disinfect the floor with an EPA approved disinfectant On 3/6/23 at 2:14 p.m., in an interview with a surveyor, LPN1 stated, regarding how to disinfect an area that a resident vomited, he said, have housekeeping come in and clean it up with chlorine concentration. I suppose we should be using gowns, but I haven't seen any up here. On 3/6/23 at 2:26 p.m., in an interview with a surveyor, CNA2 stated, no one is on precautions, and that usually, all the precaution stuff is hanging on the doors, or the nurse tells us. There is definitely something going on, residents are vomiting and pooping. [Resident #39] has very loose stool, and the facility is aware of [Resident #4]. I mentioned to LPN1 about the loose stool. On 3/6/23 at 2:29 p.m., in an interview with a surveyor, the Rehab Manager indicated that she wiped down an exercise device that [Resident #4] was using earlier with a purple top wipe (Super Sani-Cloth Germicidal disposable wipe(cleanser was not an EPA approved for norovirus disinfection)) before she left the B2 unit Resident #4 was having gastrointestinal symptoms. The Rehab Manager didn't disinfect the exercise device with an EPA approved disinfectant. On 3/6/23 at 2:35 p.m., a surveyor observed no signage on B2 unit to indicate that there is gastrointestinal illness on the unit or any directions for a visitor to the unit. During a medical record review, Resident #41's clinical note, dated 2/26/23 at 4:06 a.m. indicated, resident was vomiting during the prior shift. On 3/8/23 at 8:37 a.m., during observation of B2 unit, surveyor observed CNA-M2 don additional PPE (gown/gloves) then grab a medicine cup and a cloth wrist blood pressure (BP) cuff and enter room [ROOM NUMBER] (Resident #30), which was posted as contact precautions for GI symptoms. CNA-M2 applied the BP cuff to the resident's wrist, obtained the reading then removed the cuff and placed it in her scrub pocket, then administered the medications to the resident. Upon leaving the room, the CNA-M2 doffed the PPE and washed her hands. The surveyor requested the BP reading, the CNA-M2 removed the contaminated BP cuff from her scrub pocket. At this time, the surveyor confirmed the BP cuff was not cleaned after coming in contact with a resident who was on contact precautions prior to being placed in the CNA-M2 pocket. During a medical record review, Resident #29's clinical note, dated 2/27/23 at 11:40 a.m. indicated, has vomited several times this morning, can't hold down fluids . one diarrhea episode this morning. During a medical record review, Resident 28's clinical note, dated 2/28/23 9:19 a.m. indicated, Resident reportedly vomited several times early this morning. No diarrhea. During a medical record review, Resident #32's clinical note, dated 2/28/23 at 2:36 p.m. indicated, admits to mild nausea, no vomiting or diarrhea, on 3/1/23 at 8:47 a.m. indicated, several bouts of diarrhea during the night .Had another large diarrhea this morning. On 3/1/23 at 12:40 p.m. indicated, had large diarrhea stool in bed. During a medical record review, Resident #13's clinical note , dated 3/4/23 at 9:15 a.m. indicated, doesn't feel good because he/she has been having diarrhea. During a medical record review, Resident #27's clinical note, dated 3/4/23 at 5:47 p.m. indicated, acute episode of nausea with vomiting, diarrhea, on 3/6/23 at 4:57 a.m. late entry, had multiple episodes of vomiting and diarrhea during the NOC (night) shift., on 3/5/23 at 2:30 p.m. indicated, had another diarrhea stool, no further vomiting. During a medical record review, Resident #26's clinical note, dated 3/1/23 10:12 a.m. indicated, provider visit, type of visit: N/V (nausea/vomiting) occasionally last 5-7 days, on 3/5/23 at 9:06 a.m. indicated, feels nauseated, just vomited yellow bile in his/her waste basket. States that he/she feels awful. During a medical record review, Resident #35's clinical note, dated 3/6/23 at 4:54 a.m. indicated, Resident has been experiencing nausea and vomiting. During a medical record review, Resident #4's clinical note, dated 3/6/23 at 1:18 a.m. indicated, Resident had x-large loose BM. Currently complaining of nausea. A review of North Country Associates Infection Control Management of Norovirus Outbreak Policy, developed: April 2007, and revised on 9/18 indicated, Noroviruses are a group of viruses that cause gastroenteritis in people infected with the virus. Symptoms of gastroenteritis include nausea, vomiting, abdominal cramping, and diarrhea. The primary mode of transmission is via poor hand washing and/or unsanitary conditions. Any surface, device, or material (e.g., commodes, bathing tubs, electronic rectal thermometers, and portable phones) that becomes contaminated with feces may serve as a reservoir for the Norovirus. Notify Maine CDC (Centers for Disease Control) to report outbreak of Norovirus like illness, follow Maine CDC recommendations, Notify resident's physician and family of Norovirus like illness. Prevention: Immediately implement Contact Precautions for residents with symptoms consistent with Norovirus. Do not wait for culture results. Re-educate staff on Standard and Contact Precautions. Thoroughly clean and disinfect contaminated surfaces immediately after an episode of illness by using an EPA registered disinfectant effective against Norovirus. Can norovirus infections be prevented? Yes .thoroughly clean and disinfect contaminated surfaces immediately after an episode of illness by using a bleach-based household cleaner. Based on the above information, IJ was called on 3/6/23 at 3:19 p.m. for the facility's failure to provide adequate infection prevention measures to mitigate the spread of infection in a timely manner. The facility's failure to provide these services constituted an immediate jeopardy situation. Please see F-0000 Initial comments related to the IJ removal plan. On 3/9/23 at 1:12 p.m., during an interview with the Administrator, he stated the facility does not have a Legionella or other opportunistic waterborne pathogen management and prevention program in place.