Brooke Knoll Village Report

PRINTED: 05/20/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
155814 B. WING _____________________________
04/13/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1108 KINGWOOD DRIVE

BROOKE KNOLL VILLAGE
AVON, IN 46123
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)
F 000 INITIAL COMMENTS F 000
This visit was for the Investigation of Complaint

IN00324083. This visit resulted in a Partially
Extended Survey - Substandard Quality of Care
-Immediate Jeopardy.
This visit was in conjunction with the Investigation

of Complaint IN00324229.
Complaint IN00324083 - Substantiated.

Federal/state deficiencies related to the
allegations are cited at F880.
Complaint IN00324229.- Substantiated.No

deficiencies related to the allegations are cited.
Survey dates: April 9, 10, 11, 12, and 13, 2020.
Facility number: 012901

Provider number: 155814
AIM number: 201215100
Census Bed Type:

SNF: 2
SNF/NF: 49
Total: 51
Census Payor Type:

Medicare: 4
Medicaid: 40
Other: 7
Total: 51
These deficiencies reflect State Findings cited in

accordance with 410 IAC 16.2-3.1.
Quality review completed on April 20, 2020.

F 880 Infection Prevention & Control F 880
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XPHD11 Facility ID: 012901 If continuation sheet Page 1 of 14
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F 880 Continued From page 1 F 880

SS=K CFR(s): 483.80(a)(1)(2)(4)(e)(f)
§483.80 Infection Control

The facility must establish and 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.
§483.80(a) Infection prevention and control

program.
The facility must establish an infection prevention
and control program (IPCP) that must include, at
a minimum, the following elements:
§483.80(a)(1) A system for preventing, identifying,

reporting, investigating, and controlling infections
and communicable diseases for all residents,
staff, volunteers, visitors, and other individuals
providing services under a contractual
arrangement based upon the facility assessment
conducted according to §483.70(e) and following
accepted national standards;
§483.80(a)(2) Written standards, policies, and

procedures for the program, which must include,
but are not limited to:
(i) A system of surveillance designed to identify
possible communicable diseases or
infections before they can spread to other
persons in the facility;
(ii) When and to whom possible incidents of
communicable disease or infections should be
reported;
(iii) Standard and transmission-based precautions
to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a
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resident; including but not limited to:
(A) The type and duration of the isolation,
depending upon the infectious agent or organism
involved, and
(B) A requirement that the isolation should be the
least restrictive possible for the resident under the
circumstances.
(v) The circumstances under which the facility
must prohibit employees with a communicable
disease or infected skin lesions from direct
contact with residents or their food, if direct
contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed
by staff involved in direct resident contact.
§483.80(a)(4) A system for recording incidents

identified under the facility's IPCP and the
corrective actions taken by the facility.
§483.80(e) Linens.
Personnel must handle, store, process, and
transport linens so as to prevent the spread of
infection.
§483.80(f) Annual review.

The facility will conduct an annual review of its
IPCP and update their program, as necessary.
This REQUIREMENT is not met as evidenced
by:
Based on observation, interview and record
review, the facility failed to follow infection control
procedures to protect residents during the
COVID-19 outbreak for 4 of 4 residents reviewed
for infection control. Isolation precautions were
not implemented and PPE was not accessible in
resident rooms for 5 of 5 residents reviewed for
infection control (Residents B, C, D, F and O).
The immediate jeopardy began on 4/8/20 when

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Residents B, C, D and F were exhibiting
symptoms of COVID-19, including fever and
cough, and were not isolated. Droplet precautions
(proper personal protective equipment of gown,
glove, and mask with face shield or eye
protection) had been in place facility-wide through
4/07/20 due to a COVID-19 outbreak, but were
discontinued. The Administrator, Director of
Nursing (DON), and the Infection Control
Preventionist (ICP) were notified of the immediate
jeopardy at 5:08 p.m. on 4/9/20. The immediate
jeopardy was removed on 4/12/20, but
noncompliance remained at the lower scope and
severity level of noncompliance remained at the
lower scope and severity level of pattern, no
actual harm with potential for more than minimal
harm that is not immediate jeopardy.
Findings include:
On 4/9/20 at 10:30 a.m., the Administrator

indicated three residents, Resident B, Resident
C, and Resident D, received orders, on 4/9/20, to
be transferred to a special COVID-19 unit in a
different facility due to laboratory result findings
and COVID-19 could not be ruled out.
During an observation, on 4/9/20 at 10:40 a.m.,

Resident B was observed in her wheelchair at her
doorway and faced towards the hallway. The
resident had no mask on and the door was open.
No stop sign or personal protective equipment
(PPE) were observed.

Resident D was observed in her room with the
door open. No stop sign or PPE were observed.

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AVON, IN 46123

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Resident C was observed in her room with the
door open. No stop sign of PPE were observed.
During an interview, on 4/9/20 at 10:45 a.m.,

Licensed Practical Nurse (LPN) 5 indicated
Resident B was not on any isolation precautions
except the use of mask by staff when resident
care was provided. The resident had no reported
cough, shortness of breath, or fever that she was
aware of. At 11:05 a.m., LPN 5 indicated she
was notified the resident had been placed on
droplet precautions due to coughing sometime
after 10:30 a.m.

Resident C was observed in her room with
Certified Nursing Assistant (CNA) 4. A stop sign
was on the door and no isolation cart was
observed outside of the room. At this time, CNA 4
had a mask on and indicated she was unsure
what isolation precautions the resident was on
and she was only required to wear a mask when
she provided care for the resident.

Qualified Medical Assistant (QMA) 6 indicated all
residents were on standard precautions and staff
wore masks when resident care was provided.
She was not aware of any droplet precautions for
any residents. Her duties consisted of medication
pass to residents.
1. Resident B's record was reviewed on 4/9/20 at

3:10 p.m. A progress note, dated 4/8/20 at 12:00
p.m., indicated the resident presented with a low
grade fever of 99.2. The NP was notified and new
orders received for urinalysis (UA) with culture
and sensitivity (C&S), complete blood count
(CBC) with differential (a measure of the number
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of red blood cells, white blood cells, and platelets
in the blood), reticulocyte hemoglobin (content
testing in diagnosis of iron), comprehensive
metabolic panel (CMP) (chemical balance and
metabolism in the body), d-dimer (protein
fragments produced when a blood clot gets
dissolved in the body), respiratory swab (used for
detection of respiratory viruses such as RSV,
influenza A & B). Resident B was placed on
droplet isolation as a precaution.
A progress note, dated 4/8/20 at 4:00 p.m.,

indicated all laboratory tests were collected and
sent out. The facility was currently awaiting
results.
A physician's telephone order, dated 4/8/20,

indicated droplet isolation.
A progress note, dated 4/9/20 at 11:00 a.m.,

indicated the resident had been notified she
would be transferred to a COVID-19 treatment
center facility.
A hall report sheet, dated 4/8/20, indicated the

resident shared a room with Resident M.
Resident M's record was reviewed, on 4/11/20 at
3:02 p.m., and a progress note, dated 4/8/20 at
2:30 p.m., indicated the resident was being
transferred to a COVID-19 treatment center
facility.
2. Resident C's record was reviewed on 4/9/20 at

p.m., indicated the resident was noted to have a
cough and bilateral rhonchi and respiratory
wheezes. The NP was notified and new orders
received.
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AVON, IN 46123

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DEFICIENCY)

A review of physician's telephone orders lacked
documentation of a physician's order on 4/9/20.

indicated the resident had been notified she
would be transferred to a COVID-19 treatment
center facility.
A hall report sheet, dated 4/3/20, indicated the

resident shared a room with Resident N. Resident
N's record was reviewed, on 4/11/20 at 3:00 p.m.,
and a progress note, dated 4/3/20 at 10:00 a.m.,
indicated the resident's laboratory results had
been reviewed and a new order was received to
send resident to a COVID-19 treatment center
facility.
3. Resident D's record was reviewed on 4/9/20 at

a.m., indicated the resident had been seen by the
NP due to complaint of cough and shortness of
breath. New orders for CBC, CMP, d-dimer to be
drawn in the morning, and 2 view chest x-ray.

indicated the resident had reported some
improvement in shortness of breath and cough.

indicated the resident reported not feeling well.
A physician's telephone order, dated 4/9/20,

indicated to transfer resident to COVID-19
treatment center facility. No documentation was
found the resident was in isolation precautions.
During an interview, on 4/9/20 at 1:33 p.m., the

ICP indicated if a resident had just a cough, a
fever, or shortness of breath they would not be
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DEFICIENCY)

put on droplet precautions. A protocol of
laboratory testing would be ordered by the
physician to rule out all other disease processes
especially with residents who had co-morbidities.
The facility was unable to get any additional
COVID-19 specific tests so that was why this
protocol had been implemented. If laboratory
results reflected an elevated d-dimer, decreased
white blood cell count, a negative respiratory
panel, and negative chest x-ray those patients
with respiratory symptoms and temperatures
would be presumed positives for suspected
COVID-19. Any other resident who had not met
this criteria would be classified as "unable to rule
out" for COVID 19 and not be placed on droplet
precautions. At 2:46 p.m., he indicated due to
PPE limitations the facility had to ration supplies
and only presumed or suspected cases of
COVID-19 would be placed on droplet
precautions. If a resident had signs or symptoms
of COVID-19, respiratory concerns, or if they had
been placed on any type of isolation precautions
staff would pass in report to the oncoming shift of
those findings. He was unsure why droplet
precautions had not been implemented, a sign
was not posted outside of the resident's room,
and why it was not passed on in report for
Resident B. But the resident had not required
droplet precautions and should have been
classified as "unable to rule out" COVID-19.
Standard precautions were used for every
resident at this time and included use of a mask
by staff. If a resident was placed on transmission
based precautions, such as droplet precautions, a
sign would be posted outside of the resident room
that indicated to see the nurse. The nurse would
provide staff at that time with what type of
precautions would be used, and a sign would not
be used for standard precautions.
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AVON, IN 46123

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DEFICIENCY)
4. During an initial tour observation, on 4/9/20 at

10:23 a.m., Residents F's room was observed to
have a stop sign on the door.

Certified Nursing Assistant (CNA) 10 indicated
there were no residents on isolation precautions
on the unit Resident F was on and only standard
precautions with the use of a mask by staff were
being used.

Licensed Practical Nurse (LPN) 11 indicated
Resident F was not on any type of isolation
precautions, standard precautions with staff
wearing a mask were being used. The resident
had reported shortness of breath that morning but
during her assessment she found the resident's
vital signs to be normal and no observation of
respiratory distress. She indicated the sign on the
door had been placed for the resident's
roommate who at some point returned from the
hospital. Resident O had no concerns and was
not symptomatic and was on standard
precautions as well. The sign was only placed to
monitor the Resident O since he had been out of
the facility.
Resident F's record was reviewed on 4/10/20 at

a.m., indicated the resident had a temp of 100
degrees Fahrenheit.

indicated the resident reported not feeling well.
The document lacked signs or symptoms. New
orders received for NP.
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DEFICIENCY)

indicated the resident was reviewed by the NP
and remained afebrile (no fever), no signs or
symptoms of cough or shortness of breath, and
denied pain. Per NP may discontinue droplet
precautions.

indicated the resident reported shortness of
breath and oxygen saturation was 88%. The
resident was placed on 2 liters per minute (lpm)
oxygen via nasal cannula and oxygen saturation
improved to 95%. No fever noted. NP was
notified and the resident was transferred to a
single room and placed on droplet isolation
precautions.

DON indicated Resident F was scheduled to be
tested for COVID-19 on 4/11/20.

Assistant Director of Nursing (ADON) indicated
the Resident F was put on droplet precautions on
4/3/20. She rounded with the NP, on 4/9/20 at
10:30 a.m., and according to her nurses' note the
resident reported he had no cough or shortness
of breath. The resident was afebrile, droplet
precautions were discontinued at that time. She
was unaware the resident had reported shortness
of breath to LPN 11 on 4/9/20 because he had
reported no complaints to her and the NP that
morning.
During an interview on 4/13/20 at 11:30 a.m., the

Assistant Director of Nursing (ADON) indicated
Resident F was tested for COVID on 4/12/20 and
she had been informed on 4/13/20 that he was
positive for COVID. Resident F was in isolation
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DEFICIENCY)

and would be transferred to a sister facility's
COVID unit
5. During an interview, on 4/9/20 at 11:56 a.m.,

the DON indicated she had spoken with someone
from the Indiana State Department of Health
(ISDH) on 4/3/20 and had been advised since
they had four positive COVID-19 cases, Resident
P, Resident Q, Resident R, and Resident S, in
the facility at that time they should treat every
resident in the facility as presumptive for
COVID-19. The four residents' were transferred
to a COVID-19 facility on 4/2/20. At that time, she
implemented droplet precautions for every
resident. On the evening of 4/7/20 droplet
precautions were removed because signs and
symptoms of COVID-19 had calmed down and
many resident's had not shown signs or
symptoms of COVID-19, they had a low stockpile
of PPE, and they had empty rooms to put
residents in who had signs or symptoms of
COVID-19.

Director of Nursing (DON) indicated when a
resident was sent to one of the COVID 19
treatment center facilities the roommate still at
the facility would stay in a single room and be
monitored for an increased temperature, cough,
shortness of breath, and any changes from
baseline. Staff would keep a 6 foot distancing
from the resident and when direct care was
provided staff would wear a mask and gloves.
The gown would not be included because the
resident would not be required to be on droplet
precautions.
On 4/9/20 at 10:31 a.m., the Administrator

provided a document, dated 03/2020, and titled,
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"Pandemic Covid-19 Emergency Preparedness
Plan," and indicated it was the policy currently
being used by the facility. The policy indicated,
"...Supplies and Resources: This facility shall
provide supplies necessary to adhere to
recommended IPC practices including: ...Signs
shall be posted immediately outside of resident
rooms indicating appropriate transmission-based
precautions, as applicable, and required personal
protective equipment (PPE)...General Guidance:
The following are principles to be followed for
care of the resident with a confirmed or
suspected case of Covid-19. 1. Place resident in
contact-droplet precautions with proper PPE-
gown, glove, mask with face shield or eye
protection...."
The ISDH Guidance for out-of-hospital facilities,

dated 3/29/20, indicated, "The following is
guidance for out of hospital facilities who house
patients with a confirmed or suspected case of
COVID-19. There are a few guiding principles: 1.
Placement of patient /resident in contact-droplet
precautions with proper PPE, including gown,
glove, mask with face shield or eye protection. 2.
Proper donning and doffing of personal protection
equipment when in contact with
COVID-19residents ....Reduce the movement of
staff between patients with and without COVID-19
precautions with proper PPE- gown, glove, mask
with face shield or eye
protection...Patients/residents with known or
suspected COVID-19 should be cared for in a
single-person (private) room with the door closed.
Airborne infection isolation rooms (AIIR) are not
required. Patients/residents with known or
suspected COVID-19 should not share
bathrooms with other patients/residents. All
patients/residents returning from the hospital with
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DEFICIENCY)

suspected or confirmed COVID-19 should be
cared for in a private room, or Cohorted with
other patients of the same status in the same
unit, wing, hallway, or building. Patients with close
contact with a confirmed COVID-19 patient (e.g.,
roommate or infected staff without wearing PPE)
should be isolated and follow 14 day
self-monitoring guidelines. If they develop
symptoms, and are confirmed or suspected to
have COVID-19, they should remain isolation until
at least 7 days after symptom onset and 72 hours
after resolution of fever, without use of antipyretic
medication, and improvement in symptoms (e.g.,
cough), whichever is longer ..."
The CDC guidance - Preparing for COVID-19:

Long-term Care Facilities, Nursing Homes,
indicated, "If COVID-19 is suspected, based on
evaluation of the resident or prevalence of
COVID-19 in the community, Residents with
known or suspected COVID-19 do not need to be
placed into an airborne infection isolation room
(AIIR) but should ideally be placed in a private
room with their own bathroom. Room sharing
might be necessary if there are multiple residents
with known or suspected COVID-19 in the facility.
As roommates of symptomatic residents might
already be exposed, it is generally not
recommended to separate them in this scenario.
Public health authorities can assist with decisions
about resident placement ...If a resident requires
a higher level of care or the facility cannot fully
implement all recommended precautions, the
resident should be transferred to another facility
that is capable of implementation. Transport
personnel and the receiving facility should be
notified about the suspected diagnosis prior to
transfer. While awaiting transfer, symptomatic
residents should wear a facemask (if tolerated)
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DEFICIENCY)

and be separated from others (e.g., kept in their
room with the door closed). Appropriate PPE
should be used by healthcare personnel when
coming in contact with the resident ..."
The Immediate jeopardy that began on 4/9/20

was removed on 4/12/20 when the facility
implemented a revised procedure where
residents with respiratory symptoms, such as
cough or shortness of breath or demonstrating a
change in condition in which COVID-19 is not
immediately eliminated as a potential diagnosis
were placed in private rooms. All nursing staff on
duty received in-service training on the initiation
of transmission-based precautions when
determined appropriate by the clinical team, and
adherence with said precautions via
Transmission-Based Precaution sign placed on
the applicable resident's closed door and
available PPE per precautions. The
noncompliance remained at the lower scope and
severity level of no actual harm with the potential
for more than minimal harm that is not immediate
jeopardy because of the facility's need for
continued monitoring
This Federal tag relates to Complaint

IN00324083.
3.1-18(a)

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PRINTED: 05/20/2020

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

1108 KINGWOOD DRIVE

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 000 INITIAL COMMENTS F 000

This visit was for the Investigation of Complaint

This visit was in conjunction with the Investigation

Complaint IN00324083 - Substantiated.

Complaint IN00324229.- Substantiated.No

Survey dates: April 9, 10, 11, 12, and 13, 2020.

Facility number: 012901

Census Bed Type:

Census Payor Type:

These deficiencies reflect State Findings cited in

Quality review completed on April 20, 2020.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

1108 KINGWOOD DRIVE

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 880 Continued From page 1 F 880

§483.80 Infection Control

§483.80(a) Infection prevention and control

§483.80(a)(1) A system for preventing, identifying,

§483.80(a)(2) Written standards, policies, and

1108 KINGWOOD DRIVE

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 880 Continued From page 2 F 880

§483.80(a)(4) A system for recording incidents

§483.80(f) Annual review.

The immediate jeopardy began on 4/8/20 when

1108 KINGWOOD DRIVE

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 880 Continued From page 3 F 880

On 4/9/20 at 10:30 a.m., the Administrator

During an observation, on 4/9/20 at 10:40 a.m.,

During an observation, on 4/9/20 at 10:41 a.m.,

During an observation, on 4/9/20 at 10:42 a.m.,

1108 KINGWOOD DRIVE

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 880 Continued From page 4 F 880

During an interview, on 4/9/20 at 10:45 a.m.,

During an observation, on 4/9/20 at 11:16 a.m.,

During an interview, on 4/9/20 at 11:20 a.m.,

1. Resident B's record was reviewed on 4/9/20 at

1108 KINGWOOD DRIVE

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 880 Continued From page 5 F 880

A progress note, dated 4/8/20 at 4:00 p.m.,

A physician's telephone order, dated 4/8/20,

A progress note, dated 4/9/20 at 11:00 a.m.,

A hall report sheet, dated 4/8/20, indicated the

2. Resident C's record was reviewed on 4/9/20 at

1108 KINGWOOD DRIVE

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 880 Continued From page 6 F 880

A progress note, dated 4/9/20 at 10:45 a.m.,

A hall report sheet, dated 4/3/20, indicated the

3. Resident D's record was reviewed on 4/9/20 at

A progress note, dated 4/8/20 at 8:30 a.m.,

A progress note, dated 4/9/20 at 8:45 a.m.,

A physician's telephone order, dated 4/9/20,

During an interview, on 4/9/20 at 1:33 p.m., the

1108 KINGWOOD DRIVE

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)