Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to a norovirus outbreak and COVID-19, Resident ID #'s 2, 4, 6, 11, 16, 21, 29, 33, 37, 43, 47, 51, 60, 65, 70, 132, 135, 136, 137,138, and 238. Findings are as follows: 1. Record review of a facility provided policy titled Isolation states in part, if equipment must be shared remove from the room it must be adequately disinfected before another use . According to the CDC document provided by the facility titled Key Infection Control Recommendations for the control of Norovirus Outbreak [Norovirus is a very contagious virus that causes vomiting and diarrhea] in Healthcare Settings states in part, .disinfection of patient care areas and frequently touched surfaces during outbreaks of norovirus gastroenteritis .disinfected .using EPA [Environmental Protection Agency]-approved products [products that are approved to kill specific bacteria, viruses, or fungi] . Record review revealed that Resident ID #2 tested positive for Norovirus on 2/15/2023. During surveyor observation from 2/13/2023 through 2/15/2023 of Resident ID #'s 2, 4, 6, 11, 16, 21, 29, 33, 37, 43, 47, 51, 60, 65, 70, 132, 135, 136, 137,138, and 238 rooms revealed isolation carts outside of each room with Micro Kill + wipes and were on precautions related to Norovirus symptoms. During a surveyor observation on 2/15/2023 at 9:04 AM revealed RN, Staff O in Resident ID #132's room with a vital sign machine taking the resident blood pressure and oxygen level. At 9:06 AM Staff O wiped the multiuse equipment with Micro Kill + and then went to the resident roommate and obtained his/her blood pressure with the same machine. Staff, O then obtained an additional multiuse blood pressure cuff and obtained Resident ID #132's blood pressure and stated to the surveyor, the resident's blood pressure was low and was vomiting the prior day. Staff O then exited the room and wiped down the multiuse equipment with Micro Kill + wipes and then gave it back to the other RN Staff, B who placed it on his nurse medication cart. Record review of a cleaner called Micro-Kill + revealed the cleaner kills 13 infectious microorganisms listed in the table in up to 5 minutes. Further review of the Micro Kill + table failed to reveal Norovirus as one the microorganisms listed that the product kills. During a surveyor interview on 2/15/2023 at 9:18 AM with RN, Staff B and RN Staff, O, they acknowledged that the facility uses multiuse equipment and Resident ID #132 was on precautions for norovirus. Additionally, they acknowledge the multiuse equipment is cleaned with the Micro Kill + and all the isolation carts had Micro Kill + on them. Furthermore, they acknowledged Micro Kill + did not list Norovirus as a microorganism killed by the product. During a surveyor interview on 2/15/2023 at 9:26 AM with the Director of Nursing Services and IP they acknowledged the Micro Kill + wipes that were on all the isolation carts and nurses cart failed to kill the norovirus microorganism. During a surveyor observation on 2/16/2023 at 12:02 PM revealed Micro Kill + wipes on the isolation cart outside of Resident ID #132's room. During a surveyor interview on 2/16/2023 with Staff O, she was unsure as to why the Micro Kill + wipes were on the resident isolation cart and removed them from the area. 2. Record review of a facility provided policy titled Isolation states in part, Policy: It is the policy of this facility to prevent the spread of infection within the facility through the use of isolation precautions .Transmission Based precautions- use the CDC [Center for Disease Control and Prevention] guidelines for Isolation Precautions to determine the infective materials, precautions needed, duration of precautions . According to the CDC document provided by the facility titled Key Infection Control Recommendations for the control of Norovirus Outbreak [Norovirus is a very contagious virus that causes vomiting and diarrhea] in Healthcare Settings states in part, .Personal Protective Equipment (PPE) if norovirus infection is suspected, adherence to PPE use according to Contact .Precautions is recommended for individuals entering the patient care area (i.e., gowns and gloves upon entry) . Surveyor observation upon entering the building on 2/13/2023 at approximately 7:50 AM revealed signage on the main door stating the facility was experiencing a gastrointestinal illness. Record review revealed a facility provided document titled, Gastrointestinal Illness Outbreak: Cumulative* Line List for RESIDENTS with a start date of the initial outbreak of 2/6/2023. Record review of contact precaution signs posted on rooms through the facility state in part, Stop .CONTACT PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves .put on gown .Clean and disinfect reusable equipment before use on another person. During a surveyor observation on 2/13/2023 at 8:58 AM of Resident ID #70's room revealed signage which states, PROVIDERS AND STAFF MUST ALSO: Put on gloves .put on gown . Further observation revealed Nursing Assistant (NA), Staff H entering Resident ID #70's room without a gown or gloves on. During surveyor observation on 2/13/2023 at 9:40 AM revealed Resident ID #60's room had an isolation cart outside of the room with Micro Kill + wipes and contact precaution signage. Additionally, the resident was sitting out in common area of unit and was not redirected to return to his/her room. During a surveyor interview immediately following the above mentioned observation with Registered Nurse (RN) Staff D, she revealed that the resident is independent and noncompliant with care. Additionally, she revealed she received report the resident vomited overnight. During a surveyor observation on 2/13/2023 at 9:59 AM of Resident ID #238's room had an isolation cart outside of the room with Micro Kill + wipes and contact precaution signage. Additional observation revealed Nursing Assistant (NA), Staff I in Resident ID #238's room without a gown or gloves on. During a surveyor observation on 2/13/2023 at 10:36 AM of Resident ID #16's room that revealed signage which states, PROVIDERS AND STAFF MUST ALSO: Put on gloves .put on gown .Two housekeepers Staff J and Staff K were observed taking down the privacy curtain and replacing it with a new one without a gown or gloves on. Further observation revealed Staff J dragging the soiled curtain on the floor down the hallway. During a surveyor interview on 2/13/2023 immediately following the above mentioned observation with Staff K, he acknowledged they did not wear the appropriate PPE in the resident's room. During an additional surveyor observation on 2/13/2023 at 12:16 PM revealed NA, Staff I entering Resident ID #238's room without a gown and gloves. Additionally, during this observation the facility Social Worker entered the room without wearing a gown and gloves. During a surveyor interview immediately following the above mentioned observation with NA, Staff I, she acknowledged the signage outside of the resident's room stated to wear a gown and gloves when entering. Additionally, she revealed she forgot to put on the proper PPE. During a surveyor observation on 2/13/2023 at 12:42 PM revealed NA, Staff L in Resident ID #60's room without gloves or gown on per the signage at the door. During a surveyor interview immediately following the above mentioned observation Staff L acknowledged that the signage on the door indicated the use of gloves and gowns when entering the room and that she did not wear the proper PPE. During a surveyor interview on 2/13/2023 at 2:13 PM with the Infection Preventionist (IP), she revealed her expectation is the staff to wear gloves gown and goggle for resident on precautions. During a surveyor observation on 2/14/2023 at 8:46 AM of Resident ID #16's room revealed signage which states, Stop .CONTACT PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves .put on gown . Staff H entered Resident ID #16's room without a gown or gloves on and failed to wash her hands prior to entering or exiting the room. During a surveyor observation on 2/14/2023 at 8:58 AM of Resident ID #6's room revealed signage which states in part, .PROVIDERS AND STAFF MUST ALSO: .Put on gloves .put on gown . Further surveyor observation revealed NA, Staff M entering Resident ID #6's room without a gown or gloves on. During a surveyor observation on 2/14/2023 at 8:50 AM of Resident ID #70's room revealed signage which states, Stop .CONTACT PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves .put on gown . NA, Staff H entering Resident ID #70's room without a gown or gloves on and failed to wash her hands prior to entering or exiting the room. During a surveyor interview on 2/14/2023 at 8:53 AM with Registered Nurse (RN) Staff N, she revealed the staff should wear a gown and gloves into each room on contact precautions. During a surveyor observation on 2/14/2023 at 11:25 AM of Resident ID #60, revealed the resident out in the common dining area. Additionally, the contact precaution signage was posted on the resident's door with an isolation cart. During a surveyor observation on 2/16/2023 at 8:08 AM of Resident ID #21's room revealed signage which states in part, Contact Precautions . During a surveyor observation on 2/16/2023 at 8:08 AM revealed Resident ID #21 was sitting in the common area next to another resident. During a surveyor interview on 2/16/2023 at 8:12 AM with RN, Staff D, she acknowledged Resident ID #21 was on precautions related to having loose stool. During a surveyor interview on 2/16/2023 at approximately 1:00 PM with the DNS, she was unable to provide evidence that the staff wore the appropriate PPE and performed hand hygiene per the facility policy and signage. 3. Review of a facility policy titled Testing (and Refusal) of Facility Staff and Residents and a facility provide document titled COVID-19 information for Nursing Homes dated 10/12/2022 revealed in part, Nursing home use empiric transmission based precautions (use of N95, goggles, gown and gloves) to mitigate COVID-19 transmission in order to rule out COVID-19 infection for symptomatic residents (symptoms include fever, diarrhea body aches, cough, head ache). Empiric transmission-based precautions and source control may be discontinued when residents test negative for COVID-19. During the facility entrance conference on 2/13/2023 at 8:12 AM with the Director of Nursing Services, she revealed that there was on positive case of COVID-19 in the facility. Record review revealed that on 2/10/2023: -Resident ID #70 had one episode of vomiting and diarrhea and was on contact precautions. -Resident ID #29 had two episodes of vomiting and was placed on the Norovirus Protocol [orders for labs and medication provided by the medical director]. -Resident ID #238 had four episodes of large loose stools between 7AM-10 AM and has been symptomatic since 2/8/2023. Additional record review failed to reveal evidence that the above mentioned residents were tested to rule out COVID-19 per the policy. Record review revealed that on 2/11/2023: -Resident ID #43 had two episodes of diarrhea and was on contact precautions. Additional record review failed to reveal evidence that the above mentioned resident was tested to rule out COVID-19 per the policy. Record review revealed that on 2/12/2023: -Resident ID #16 had one episode of vomiting and was placed on contact precautions. -Resident ID #138 had two loose stools and was started on the Norovirus Protocol. -Resident ID #4 had two episodes of loose stool. -Resident ID #47 had loose stools and vomiting. Additional record review failed to reveal evidence the above mentioned residents were tested to rule out COVID-19 per the policy. Record review revealed that on 2/13/2023: -Resident ID #60 had vomited twice and was on precautions. -Resident ID #33 had two episodes of vomiting, who is also the roommate to Resident ID #43, who was initially symptomatic on 2/11/2023. -Resident ID #65 was on contact precautions related to episodes of diarrhea. -Resident ID #136 had complaints of nausea and vomited small amounts of thick vomitus. Additional record review failed to reveal evidence the above mentioned residents were tested to rule out COVID-19 per the policy. Record review revealed that on 2/14/2023: -Resident ID #6 had two episodes of diarrhea, who is also the roommate to Resident ID #29, who was initially symptomatic on 2/10/2023. -Resident ID #132 had initial episode of vomiting, who is also the roommate to Resident ID #47, who was initially symptomatic on 2/12/2023. -Resident ID #2 reported nausea and vomiting. -Resident ID #37 had nausea and diarrhea with his/her hospice nurse. Additional record review failed to reveal evidence the above mentioned residents were tested to rule out COVID-19 per the policy. Record review revealed that on 2/15/2023: -Resident ID #2 stool sample had resulted positive for Norovirus. -Resident ID #137 progress note revealed s/he has the norovirus, who is also the roommate to Resident ID #138, who was initially symptomatic on 2/13/2023. -Resident ID #11 had one episode of vomiting. -Resident ID #2 roommate Resident ID #51 had episode of vomiting and was placed on precautions. -Resident ID #135 received Ondansetron (a medication used for nausea and vomiting) 4 milligrams on 2/15/2023 at 1:39 AM related to upset stomach. Additional record review failed to reveal evidence the above mentioned residents were tested to rule out COVID-19 per the policy. Record review revealed that on 2/16/2023: -Resident ID #21 had one large diarrhea. -Resident ID #39 had two episodes of diarrhea. Additional record review failed to reveal evidence the above mentioned residents were tested to rule out COVID-19 per the policy. During a surveyor interview on 2/16/2023 at approximately 1:00 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that residents with symptoms of COVID-19 were tested to rule out infection per their policy. Record review and surveyor observations on 2/16/2023 at approximately 12:00 PM revealed Resident ID #s 132 and 137 were receiving intravenous hydration following signs and symptoms of the norovirus. During a surveyor interview on 2/16/2023 at approximately 1:00 PM with the Director of Nursing Services, she acknowledged the outbreak initially started on 2/6/2023 and was still ongoing on 2/16/2023. Additionally, she was unable to provide evidence the facility provided effective infection control practices to prevent the spread of Norovirus.