**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to identify and implement isolation/contact precautions for residents who were exhibiting symptoms of gastroenteritis and failed to follow the Nurse Practitioner's recommendation to ensure that Personal Protective Equipment (PPE) supplies were available for use for these residents. In addition, the facility failed to ensure all staff were knowledgeable about which residents were experiencing these symptoms and ensure PPE were used while providing care. This resulted in the spread of gastroenteritis [nflammation that spreads from your stomach into your intestines, causing pain, vomiting and diarrhea symptoms] (GI) symptoms creating an immediate jeopardy situation to 17 out of 90 residents', on 6 of 7 units: Eagle Island, Ram Island, Bluff Island, [NAME] Islan, Beach Island and Gooseberry Island. (Resident #27 #26, #25, #22, #9, #10, #13, #14, #16, #34, #4, #32, #6, #5, #7, #33, and #3) Findings: 1. On 3/17/25 the Division of Licensing and Certification received a complaint regarding quality-of-care concerns and that a resident tested positive for Respiratory Syncytial Virus (RSV). The family was not notified of a resident being positive for RSV and the facility had not implemented isolations precaution with use of PPE and signage posted notifying staff and visitors of the precautions. On 4/1/25 during a telephone interview, the complainant stated Norovirus (contagious gastroenteritis) is currently active in the facility, there is no PPE out for use, staff are not utilizing PPE and there is no posted/signage of isolation precautions out. On 4/2/25 at 8:45 a.m., upon entry to facility, during an observation, there was no posting or signage on the door of any infections/symptoms occurring in the building. In an interview, the Administrator stated there is something GI going around, a few residents have had it and believed there is one resident who was having symptoms. She then stated that both the Director of Nursing (DON) and the Assistant Director of Nursing/Infection Preventionists (ADON/IP) were out sick with nausea, vomiting and diarrhea. On 4/2/25 at approx. 8:50 a.m., 2 surveyors completed an initial tour of the facility. During this tour, the following first floor units; Eagle Island, Ram Island, Bluff Island, [NAME] Island, were observed with no isolation/contact precautions in place requiring the use of PPE. The second-floor units: Beach Island, Gooseberry Island and [NAME] Island were observed with no isolation/contact precautions in place requiring the use of PPE. On 4/2/25 at 11:13 a.m., during an interview with the Family Nurse Practitioner (FNP) and the Advanced Practice Registered Nurse (APRN. The FNP provided the surveyor with a list of 30 residents, located on all units of the facility, who have had or currently have GI symptoms with the first symptoms reported on 3/24/25. The FNP stated the main symptoms were nausea, vomiting and diarrhea. Almost everybody had fatigue, lack of appetite and lethargy for 48-72 hours. She confirmed there was a stool sample pending for Resident #27. At this time, the FNP reviewed Nordex for the stool sample results. Resident #27 results were positive for Norovirus. She stated, she had notified the facility a week ago, via email, of the concern for a norovirus outbreak and asked them to ensure isolation precautions are put into place, cleaning and use soap and water for hands not hand sanitizer stating, I sent it to everyone, the Administrator, DON and the ADON, I asked them to stop activities, and I was told its residents rights, we can't do that. At this time, FNP stated she will notify the facility of Resident #27's positive norovirus results. Review of the email the FNP sent the facility, dated 3/26/25 stated, I believe we are about to have large norovirus outbreak here: already five people have nausea and vomiting, within a 24 hour period. We will be sending some stool samples, will keep you posted. If they are positive and this continues, suspect probable outbreak. Precautions should be in place. Gowns, gloves, signage, please. Isolation should be onset of symptoms/exposure to 2 days after s/s resolve. Treatment is supportive: antiemetics, push fluids. Hand sanitizer is ineffective. Soap and water for hands, bleach for surfaces, to clean. Can Seal Rock please communicate with housekeeping to alert his staff? On 4/2/25 at 11:24 a.m., observation of Resident #7, #25 and #26 rooms to now have a Contact precaution sign posted with a PPE cart near the door. Resident #27 did not have isolation/contact precaution sign posted or PPE cart near the door. On 4/2/25 at 2:18 p.m., 2 surveyors observed Resident #27's room again with no isolation/contact precautions posted or PPE available. Resident #27's significant other was observed visiting sitting with the resident. On 4/2/25 at 3:39 p.m. during an observation with the Administrator and the surveyor, Resident #27's room lacked isolation/contact precautions or a PPE cart by the room. At this time, the surveyor confirmed the Administrator was aware that Resident #27 was positive for norovirus. On 4/2/25 at 5:47 p.m., during an observation, Resident #27's room continued not to have isolation/contact precautions posted and PPE available in a cart near the door. The facilities Infections Prevention and Control Program policy and procedure last revised 3/2025 states, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 7. Prevention of infection . Important facets of infection prevention include: identifying possible infections or potential complications of existing infections Cortana instituting measures to avoid complications or dissemination, educating staff and ensuring that they adhere to proper techniques and procedures, communicating the importance of standard precautions and respiratory hygiene to visitors and family members, screening for possible significant pathogens . implementing appropriate enhanced barrier or transmission-based precautions when necessary and following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). 2. Additional interviews with facility staff confirmed the lack of isolation/contact precautions being initiated upon first GI symptoms and knowledge of what residents were having these symptoms requiring isolation precautions and use of PPE: On 4/2/25 at 9:04 a.m., during an interview with Certified Nurses Aid (CNA#3) stated, we had norovirus going around, for the most part, it's cleared up. The surveyor asked if she was given a report of any residents with current GI symptoms. She stated Resident #22 did have symptoms but was not having any right now and Resident #17 had symptoms a few days ago but nothing yesterday or today. At this time, CNA #3 confirmed she had worked on 4/1/25 on the unit and both yesterday and today she was unaware of any new GI symptoms. On 4/2/25 at 9:16 a.m., during an interview, the Certified Nurses Aid (CNA#1) on Beach Island and Gooseberry Island, stated she was unaware of any resident's experiencing GI symptoms of nausea/vomiting/diarrhea (n/v/d). The surveyor asked how she would be made aware if a resident was on isolation precautions requiring PPE for care. She stated it would be posted on the resident's door. On 4/2/25 at 9:23 a.m., during an interview with Licensed Practical Nurse (LPN#1), stated he is the nurse in charge of Beach Island, Gooseberry Island and [NAME] Island (the nurse in charge of Resident #27). The surveyor asked if any residents were experiencing GI symptoms of n/v/d. He stated, he was aware of Resident #26 had n/v/d that started this weekend, Resident #25 started with loose stools yesterday and Resident #22 started with loose stools last night. He stated there has not been any testing since it started, and he is unaware of any current testing being completed. The surveyor asked if the [NAME] Island unit had any GI symptoms, he stated, a few days back but nothing since. When asked what he would do if a resident showed signs of GI symptoms, he stated he would notify the provider, put in a change of condition in the resident's chart, notify the family, and put up PPE. At this time, the surveyor asked why the residents he mentioned did not have Isolation/Contact precautions posted and a PPE cart outside of their room. He stated, he relies the Unit Coordinator/CNA (on Eagle/Ram unit, first floor) to put up the PPE for residents needing to go on precautions and he was going to be putting up precaution signs on the rooms however he is busy but will do it this morning. When asked the follow up question if there are any difficulties obtaining PPE, he stated that finding a cart to hold the PPE and the signage is very challenging. On 4/2/25 at 9:37 a.m., during an interview with Certified Nurses Aid - Medication technician (CNA-M #2) on Beach Island, Gooseberry Island and [NAME] Island, stated she is unaware of any residents having GI symptoms of n/v/d or the need to wear PPE. The surveyor asked how she would know if a resident was on isolation/contact precautions and PPE was required. She stated it would be on their door, posted with gloves and gowns. On 4/2/25 at 9:40 a.m., during an interview, with Housekeeper on Beach Island and Gooseberry Island, stated she just returned from 3 days off. The Surveyor asked if she was aware of any residents having GI symptoms of n/v/d, she stated, nope, The surveyor asked how she would know if she needed to wear PPE prior to going into the rooms, she stated, it would tell you, on the door what you have to wear. On 4/2/25 at 9:45 a.m., during an interview, with CNA #2 on Beach Island, Gooseberry Island and [NAME] Island, stated she was not given any report regarding residents having GI symptoms or anyone on precautions other than Enhanced Barrier Precautions (EBP). On 4/2/25 at 9:50 a.m., during an interview with Registered Nurse (RN#1) on the Bluff Island and [NAME] Island, stated that there are a few residents who are experiencing GI symptoms, Resident #9 is experiencing nausea and diarrhea, Resident #10 has vomiting and diarrhea with a stool sample sent out and they are awaiting results, Resident #13 is experiencing nausea and dry heaves that started last night, Resident #14 has been vomiting since last night, Resident #16 has been vomiting since yesterday and there are orders to collect a stool sample. At this time, RN#1 stated she cannot confirm if there are PPE carts available or at these residents' rooms, but they all should be on precautions. On 4/2/25 at 9:55 a.m., during an interview with LPN #2 on Bluff Island and [NAME] Island, stated she would only get a report when she is the nurse in charge. She confirmed she was not the nurse in charge, only passing medications and did not receive a report. The surveyor asked if she was aware of any residents having GI symptoms of n/v/d, she stated, Yes, Resident #14 had emesis yesterday, nobody else as far as I know .Resident #34 had signs and symptoms of norovirus. The doctor said to go ahead and get a stool. Nobody I know of on Bluff side. On 4/2/25 at 10:05 a.m., during an interview, with RN #2 on the Ram Island, stated she believes that the facility has a lot of Noro cases; Resident #4 was sent out to the hospital yesterday for GI issues, Resident #32 had symptoms over the weekend which have resolved, Resident #6 started having stomach cramps this morning, Resident #5 started having diarrhea this morning and Resident #7 started vomiting this morning. RN #2 then stated that she herself had GI issues on Friday 3/28/25, called out Saturday but returned to work Sunday 3/30/25. During the week of 3/28/25 she had Resident #33 who had GI symptoms. She then stated, a lot of staff have been getting it along with the residents. On 4/2/25 at 10:15 a.m., during an interview, with LPN #3 working on Eagle Island, stated Resident #3 started to have nausea about a half hour ago and denies anyone else having GI symptoms. The surveyor asked if she gets a report on who requires PPE and/or isolation precautions, she stated, we don't, there's a sign on the door for people on precautions that we follow. On 4/2/25 at approx. 10:18 a.m., during an interview with the Administrator, 2 surveyors discussed the lack of Isolation/Contact precautions posted, the lack of available PPE carts, the lack of staff knowledge of residents who are experiencing GI symptoms, staff entering the rooms of residents with GI symptoms without the use of PPE and are unaware of the risks and the GI symptoms have been spreading throughout the facility. At this time, the Administrator stated again that both the Director of Nursing (DON) and Assistant Director of Nursing/Infection Preventionist (ADON/IP) were out sick. On 4/2/25 at 10:22 a.m. during an interview with both CNA #6 and CNA #7 on Eagle Island and Ram Island. CNA #6 stated he does not know of any residents, on his side, that are having GI symptoms or anyone needing contact precautions. CNA #7 then stated that she knows Resident #7 having symptoms and Resident #4 being sent to the hospital yesterday due to GI symptoms. The surveyor asked both CNA's which residents are on contact precautions. CNA #7 stated, the only one on my side is Resident #2 who is on EBP. Based on the above information, IJ was called on 4/2/25 for the facility's failure to to identify and implement isolation/contact precautions for residents who were exhibiting symptoms of gastroenteritis, failed to follow the Nurse Practitioner's recommendation to ensure that Personal Protective Equipment (PPE) supplies were available for use for these residents, and failed to ensure all staff were knowledgeable about which residents were experiencing these GI symptoms and ensure PPE was available. 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.