PRINTED: 11/16/2020 DEPARTMENT OF HEALTH AND HUMAN ...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

11/16/2020PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

WESTFIELD, IN 46074

155841 09/30/2020

COPPER TRACE HEALTH & LIVING COMMUNITY

1250 W 146TH STREET

00

F 0000

Bldg. 00

This visit was for the Investigation of Complaints

IN00333303, IN00323753, IN00324906,

IN00328444, IN00323856 and IN00335491.

This visit included a COVID-19 Focused

Infection Control Survey.

Complaint IN00333303- Substantiated.

Federal/State deficiencies related to the

allegations are cited at F808 and F842.

Complaint IN00323753- Unsubstantiated due to

lack of evidence.


lack of evidence.


Federal/State deficiencies related to the

allegations are cited at F808.


lack of evidence.


Federal/State deficiences related to the

allegations are cited at F677.

Unrelated deficiencies are cited at F689.

Survey dates: September 28, 29 and 30, 2020.

Facility number: 013556

Provider number: 155841

AIM number: 201341880

Census Bed Type:

SNF/NF: 77

F 0000 Copper Trace Health and Living

requests paper compliance for

the following deficiencies. This

plan of correction is to serve as

Copper Trace Health and

Living’s credible allegation of

compliance.

Submission of this plan of

correction does not constitute

an admission by Copper Trace

or its management company

that the allegations contained

in the survey report is a true

and accurate portrayal of the

provision of nursing care and

other services in this facility.

Nor does this submission

constitute an agreement or

admission of the survey

allegations.

FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determined that

other safegaurds 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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: 1QHT11 Facility ID: 013556

TITLE

If continuation sheet of 24

(X6) DATE




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155841 09/30/2020


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SNF: 13

Residential: 37

Total: 127

Census Payor Type:

Medicare: 8

Medicaid: 54

Other: 28

Total: 90

This deficiency reflects State Findings cited in

accordance with 410 IAC 16.2-3.1.

Quality review was completed on October 07,

2020.

483.24(a)(2)

ADL Care Provided for Dependent Residents

§483.24(a)(2) A resident who is unable to

carry out activities of daily living receives the

necessary services to maintain good

nutrition, grooming, and personal and oral

hygiene;

F 0677

SS=D

Bldg. 00

Based on interview and record review, the

facility failed to ensure residents were provided

ADL (Activity of Daily Living) care related to

showers for 2 of 3 residents reviewed for ADL

care (Residents K and H).

Findings include:

1. During an interview, on 09/28/20 at 11:45

a.m., Resident K indicated she only received a

shower when she asked the staff to provide a

shower. When she asked for a shower,

sometimes she would get one and sometimes she

would not. She had went 3 to 4 weeks without a

shower before. About a month ago, she asked for

a shower and the staff brought her towels and

wash cloths but did not help her shower. She

F 0677 F677 ADL Care Provided for

Dependent Residents CFR(s)

483.24(a)(2)

Residents K and H have

received shower/bed bath.

All other residents have the

potential to be affected by the

alleged deficient practice. All

residents have been

offered/provided a shower/bed

bath per their stated/known

preference.

Education to nursing staff has

been provided on the system

for providing ADL assistance as

it relates to showers/bed

10/30/2020 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1QHT11 Facility ID: 013556 If continuation sheet of 24




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tried to wash herself but could not. She did not

want to fall. She had been falling at home which

led to her being admitted to the facility.

The record for Resident K was reviewed on

09/29/20 at 3:00 p.m. Diagnoses included, but

were not limited to, lack of coordination,

abnormalities of gait and mobility and

Alzheimer's disease.

A Quarterly Minimum Data Set (MDS)

assessment, dated 08/21/20, indicated Resident

K's score on the BIMS was 15 which indicated

the resident was cognitively intact. Resident K

was totally dependent for bathing and required

the assistance of 1 staff member.

During an interview, on 09/29/20 at 9:05 a.m.,

Qualified Medication Aide (QMA) 8 and

Registered Nurse (RN) 9 indicated the residents'

showers were to be documented on the ADL

sheets and kept in the ADL binder at the nursing

station.

The ADL binder was reviewed, on 09/29/20 at

9:05 a.m., the following ADL sheets were

observed for Resident K:

On 08/03/20, the resident was documented to

have received a shower and a shampoo.


have received a shower and a shampoo.

There was no documentation to indicate Resident

K received showers in the month of September

2020.

2. The record for Resident H was reviewed on


were not limited to, lack of coordination, morbid

baths. The systemic change

includes education for nursing

staff upon hire and annually.

The Director of

Nursing/Designee will audit

completion of showers/bed

baths as scheduled. This audit

will occur on five (5) residents

per week on various

units/shifts for 30 days, then

five (5) residents per month on

various shifts for 11 months to

total 12 months of monitoring.

Results of this audit will be

reported to the Quality

Assurance Performance

Improvement Committee

monthly to assist with

additional recommendations if

necessary.





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(severe) obesity due to excess calories, muscle

weakness and cognitive communication deficit

An Annual Minimum Data Set (MDS)

assessment, dated 04/23/20, indicated Resident

H was totally dependent for bathing and required

the assistance of 1 staff member.

A review of Resident H's "Point of Care ADL

Category Report," for the month of June 2020,

indicated the following:


have received a bed bath.


have received a partial bed bath.


have received a partial bed bath.

A review of Resident H's "Point of Care History"

for the month of July 2020, indicated the

following:

On 07/01/20, the resident received a partial bed

bath.


bath.

An ADL sheet, dated 07/21/20, indicated the

resident had refused "Bed Bath/Shower/Tub

Bath".


bath.

There was no other documentation to indicate

Resident H had received any other showers or

bed baths.

During an interview, on 09/29/20 at 2:30 p.m.,

the Director of Nursing (DON) indicated it was

her expectation the residents would receive a





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shower or bed bath 2 times a week and staff were

to document the completed task on the ADL

sheets. The ADL sheets were to be kept in the

ADL binder at the nursing station.

A current facility policy, titled "Activities of

Daily Living (ADL), Supporting," dated as revised

on 03/2018 and received from the Administrator

on 09/30/20 at 11:55 a.m., indicated

"...Residents who are unable to carry out

activities of daily living will receive the services

necessary to maintain good nutrition, grooming

and personal and oral hygiene...."

This Federal tag relates to Complaint

IN00335491.

3.1-38(b)(2)

483.25(d)(1)(2)

Free of Accident

Hazards/Supervision/Devices

§483.25(d) Accidents.

The facility must ensure that -

§483.25(d)(1) The resident environment

remains as free of accident hazards as is

possible; and

§483.25(d)(2)Each resident receives

adequate supervision and assistance devices

to prevent accidents.

F 0689

SS=D

Bldg. 00

Based on observation, interview and record

review, the facility failed to ensure a resident's

environment remained free of accident hazards

when water was observed on the floor and

medications were left unattended at the bedside

for 1 of 1 resident randomly observed (Resident

K).

Findings include:

F 0689 F689 Free of Accident

Hazards/Supervision/Devices

CFR(s): 483.25(d)(1)(2)

Resident K’s shower stall was

repaired during this survey

event. Medications were

removed from the bedside of

Resident K at the time of

10/30/2020 12:00:00AM





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1. During a tour of the facility, on 09/28/20 at

11:55 a.m., a large amount of standing water was

observed from the hallway, on the living area of

Resident K's vinyl floor. The water was observed

to cover the entire bathroom floor and extended

outward approximately 4 and a 1/2 feet into the

resident's room, encroaching into Resident K's

roommate's area. At this time, Resident K was

observed to be sitting, in a chair next to the bed,

on the other side of the pooling water. A rolling

walker was observed to be in front of Resident

K's chair. A wet floor caution sign to warn

against crossing the wet floor was not observed

to be posted. Resident K indicated "it happens all

the time." Resident K indicated the roommate

had been given a shower earlier the same

morning and the water had pooled outside the

shower and flowed into the room. Resident K

indicated there was nothing to prevent the water

from coming out of the shower, onto the floor

and into the room.

During observation of Resident K's bathroom at

this time, the entrance of the shower was

observed to have a rubber threshold dam affixed

to the left side of the shower floor. The

remainder of the threshold dam was observed

unsecured to the floor and to be in a curled

position. Water was observed to flow freely onto

the floor of the bathroom and out into the

resident living area.

On 09/28/20 at 12:05 p.m., Housekeeper 3 was

observed to come to Resident K's room and

attempted to push the water from outside the

bathroom towards the bathroom and into the

shower area with a flat ended dust broom.

Housekeeper 3 indicated there was too much

water and he would need to mop up the water.

identification, and QMA was

provided with education

immediately.



alleged deficient practices. All

resident room showers have

been audited, and repairs

completed as indicated.

Resident records have been

audited for the indication of

self-administration of

medication, and assessments

completed as indicated.

Education has been provided to

all staff on the indication to

report water leaks to the

Maintenance Department for

timely repairs. Systematic

change includes education on

the process of reporting safety

concerns to the Maintenance

Department upon hire and

annually. Education has been

provided to all licensed nurses

and QMA’s on the policy for

self-administration of

medication. Systematic change

includes education for licensed

nurses and QMAs upon hire

and annually.

The Director of

Maintenance/Designee will audit

resident showers through direct

observation. The Director of


through direct observation of the

administration of medications.

Both audits will occur on five (5)

random residents/rooms per week





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Housekeeper 3 returned to a housekeeping cart

parked outside the resident's room and retrieved

a string mop. Housekeeper 3 was observed to

mop up the water with the string mop. During an

interview, at this time, Housekeeper 3 indicated

this "happens all the time" and Resident K's room

was "not the only one."

The record for Resident K was reviewed on


were not limited to, lack of coordination and

abnormalities of gait and mobility.

A care plan, dated as last reviewed on 09/21/20,

addressed the problem the resident was at risk

for falling and fall related injuries related to

impaired mobility. The goal was to minimize the

risk of injury.

2. On 09/29/20 at 9:05 a.m., Resident K was

observed in her room, seated in a chair next to

the bed, holding a cup of liquids. In front of the

chair was a rolling walker and a white tissue was

observed laying on the bench seat of the walker.

On the tissue the following was observed:

1 large dark blue capsule

1 medium size turquoise capsule

1 medium size scored, white tablet

The resident indicated the capsules and tablet

were a portion of her morning medications. The

resident indicated she took "about 14 -15 pills in

the morning" and she preferred to take them one

at a time. The resident indicated staff "always"

left the medications in the room for Resident K

to take. During this interview, Resident K

indicated she did not know what the medications

were and added the same medications were

brought to her every morning and left in the

on various shifts for 30 days, then

five (5) residents/rooms per month

on various shifts for 11 months to

total 12 months of monitoring.

Results of these audits will be

reported to the Quality assurance

Performance Improvement

Committee monthly to assist with


necessary.





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room.

On 09/29/20 at 9:10 a.m., Qualified Medication

Aide (QMA) 8 was observed standing at the

mediation cart on the unit. When questioned,

QMA 8 indicated she had passed the medications

to Resident K on this morning. When questioned

regarding the medications being left in resident

K's room, QMA 8 indicated the resident was

"independent". When questioned if the resident

had an order to self administer medications,

QMA indicated she did not know. When asked

how the QMA knew the resident had taken all the

medication left in the room, the QMA 8 again

stated the resident was "independent". Resident

K's morning medications were observed to have

been documented as given on 09/29/20.

During an interview, on 09/29/20 at 9:15 a.m.,

RN 9 indicated she was unaware of a physician

order for the resident to self-administer

medications.

During review of Resident K's record, on

09/29/20 at 11:00 a.m., indicated there was no

documentation of a physician's order for the

resident to self administer medications or a self

medication assessment.

On 09/30/20 at 11:05 a.m., QMA 12 was

requested to assist to identify the dark blue and

turquoise capsules and the white tablet seen on

09/29/20 at 9:05 a.m. Upon opening the

medication cart drawer, the following was

observed to have been scheduled to be given

during morning medication pass for Resident K:

a. A large, dark blue capsule was identified to be

Potassium Chloride (a medication used to treat

low blood potassium) 10 milliequivalents.





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b. A medium, turquoise capsule was identified to

be Omeprozole (a medication used to treat

gastroesophageal reflux disease) 20 milligrams

(mg).

c. A medium, scored white tablet was identified

to be Acetaminophen (a medication used to treat

pain and fever) 500 mg.

A current facility policy, titled "Bedside

Medication and Self-Administration of

Medications," received from the Administrator

on 09/30/20 at 11:40 a.m., indicated "...1. Each

resident is offered the opportunity to

self-administer his/her medications during the

routine assessment by the facility's

interdisciplinary team (IDT). 2...If the resident

desires to self-administer medications, an

assessment is conducted by the IDT of the

resident's cognitive, physical and visual ability to

carry out this responsibility...8. The DON

(Director of Nursing) instructs all staff to report

to the charge nurse on duty any medications

found at the bedside..."

3.1-11(a)

3.1-45(a)(1)

483.60(e)(1)(2)

Therapeutic Diet Prescribed by Physician

§483.60(e) Therapeutic Diets

§483.60(e)(1) Therapeutic diets must be

prescribed by the attending physician.

§483.60(e)(2) The attending physician may

delegate to a registered or licensed dietitian

the task of prescribing a resident's diet,

including a therapeutic diet, to the extent

allowed by State law.

F 0808

SS=D

Bldg. 00


review, the facility failed to provide the correct F 0808 F808 Therapeutic Diet

Prescribed by Physician CFR(s): 10/30/2020 12:00:00AM





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therapeutic diet as prescribed by the physician to

support the resident's treatment, plan of care, in

accordance with the resident's goal and family

preferences for 1 of 3 residents reviewed for

therapeutic diets (Resident J).

Finding includes:

On 09/28/2020 at 12:00 p.m., Resident J was

observed in the dining room eating lunch. She

had pork which was cut up in cubes on her lunch

plate.

The record for Resident J was reviewed on

09/28/2020 at 11:20 a.m. Diagnoses included,

but were not limited to, Diabetes Mellitus,

pneumonia due to inhalation of food and

dysphagia (difficulty swallowing).

A current physician's order, dated 09/2/2020,

indicated the resident was to receive a regular

diet with mechanically altered ground meat.

The resident's meal ticket, provided by the

Kitchen Manager on 09/28/2020 at 12:30 p.m.,

indicated the resident was to have a regular

mechanically altered diet with ground meat.

A current care plan, dated 01/16/17, indicated

the resident was nutritional at risk related to her

mechanically altered therapeutic diet.

Interventions included, but were not limited to,

provide diet per physician order.

A current care plan, dated 06/21/18, indicated

the family chose to have the resident remain on a

mechanically altered diet with ground meat

against speech therapy recommendations of

puree solids with double swallows and sips of

thin liquids. Interventions included, but were not

483.60(e)(1)(2)

The diet served to Resident J

was replaced at the time of

identification, and prior to the

start of consumption of the

meal.

All other residents with orders

for therapeutic diets have the


alleged deficient practice. Each

therapeutic diet has been

audited to ensure that it is

reflected correctly in the

medical record and on the diet

slip.

Education to dietary staff has

been provided on facility policy

“Protocol for Following

Physician’s Orders”.

Systematic change includes

education for dietary and

nursing staff on the indication

to verify the accuracy of the

plated diet prior to serving the

meal tray to the resident. This

education will be provided upon

hire and annually.

The Director of Dining

Services/Designee will audit

through direct observation of

meal service. This audit will

occur for five (5) resident trays

per day at various meals for 30

days, then five (5) residents

trays per week for 8 weeks,

then five (5) resident trays

monthly for 9 months to total

12 months of monitoring.

Results of audit will be reported





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limited to, provide diet per family's request.

During an interview, on 09/28/2020 at 10:45

a.m., Resident J's family member indicated the

resident received a roast beef sandwich last week

despite the staff knowing the resident was to have

her meat ground up.


p.m., the Director of Nursing indicated the

resident's current diet order was a mechanically

altered diet with ground meat and the pork on the

resident's plate was not ground up as it should

have been.


a.m., the Kitchen Manager indicated she would

not consider pork cut up in cube size pieces as

mechanically altered ground meat.

A current undated policy, titled "Protocol for

Following Physician Orders," provided by the

Executive Director on 09/28/20 at 3:00 p.m.,

indicated "...It is the policy of [name of

corporation] that we will provide the appropriate

physician prescribed care to residents in our

communities. The facility patient care...services

will reflect the orders and plan of care of the

prescribing physician...All...staff will...follow the

physician orders as written...."

This Federal tag relates to Complaints

IN00333303 and IN00328444.

3.1-21(a)(3)

to the Quality Assurance

Performance Improvement

Committee monthly to assist

with additional

recommendations if necessary.

483.20(f)(5), 483.70(i)(1)-(5)

Resident Records - Identifiable Information

§483.20(f)(5) Resident-identifiable

information.

F 0842

SS=E

Bldg. 00





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(i) A facility may not release information that

is resident-identifiable to the public.

(ii) The facility may release information that

is resident-identifiable to an agent only in

accordance with a contract under which the

agent agrees not to use or disclose the

information except to the extent the facility

itself is permitted to do so.

§483.70(i) Medical records.

§483.70(i)(1) In accordance with accepted

professional standards and practices, the

facility must maintain medical records on

each resident that are-

(i) Complete;

(ii) Accurately documented;

(iii) Readily accessible; and

(iv) Systematically organized

§483.70(i)(2) The facility must keep

confidential all information contained in the

resident's records,

regardless of the form or storage method of

the records, except when release is-

(i) To the individual, or their resident

representative where permitted by applicable

law;

(ii) Required by Law;

(iii) For treatment, payment, or health care

operations, as permitted by and in

compliance with 45 CFR 164.506;

(iv) For public health activities, reporting of

abuse, neglect, or domestic violence, health

oversight activities, judicial and administrative

proceedings, law enforcement purposes,

organ donation purposes, research

purposes, or to coroners, medical

examiners, funeral directors, and to avert a

serious threat to health or safety as permitted

by and in compliance with 45 CFR 164.512.





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§483.70(i)(3) The facility must safeguard

medical record information against loss,

destruction, or unauthorized use.

§483.70(i)(4) Medical records must be

retained for-

(i) The period of time required by State law;

or

(ii) Five years from the date of discharge

when there is no requirement in State law; or

(iii) For a minor, 3 years after a resident

reaches legal age under State law.

§483.70(i)(5) The medical record must

contain-

(i) Sufficient information to identify the

resident;

(ii) A record of the resident's assessments;

(iii) The comprehensive plan of care and

services provided;

(iv) The results of any preadmission

screening and resident review evaluations

and determinations conducted by the State;

(v) Physician's, nurse's, and other licensed

professional's progress notes; and

(vi) Laboratory, radiology and other

diagnostic services reports as required

under §483.50.

Based on interview and record review, the

facility failed to maintain complete

documentation of meal consumption in the

residents' medical record for 4 of 4 residents

reviewed for documentation of meal

consumption. (Residents B, J, L, and N)

Findings include:

1. The record for Resident B was reviewed on


F 0842 F842 Resident Records –

Identifiable Information CFR(s):

483.20(f)(5), 483.70(i)(1)-(5)

Nursing staff were educated on

the indication to complete

documentation for meal

consumptions.



alleged deficient practice, and

10/30/2020 12:00:00AM





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cerebral infarction (stroke) and dementia.

A document, titled "Vitals Report," provided by

the Executive Director on 09/30/2020 at 4:00

p.m., indicated from 07/11/2020 through

7/16/2020, the resident's meal consumption was

not completely documented on the following

days:

a. On 07/11/2020- breakfast, lunch and dinner's

meal intakes were not documented.

b. On 07/12/2020- breakfast, lunch and dinner's


c. On 07/13/2020- breakfast, lunch and dinner's


d. On 07/14/2020- breakfast, lunch and dinner's


e. On 07/15/2020- dinner's meal intakes were

not documented.

f. On 07/16/2020- dinner's meal intakes were not

documented.

A care plan, dated 07/13/2020, indicated the

resident had a potential for diabetic

complications related to Diabetes Mellitus.


monitor and record intake of food.

2. The record for Resident J was reviewed on



congestive heart failure and vitamin deficiencies.






days:

nursing staff were educated on

the indication to complete

documentation for meal

consumptions.

Education to the nursing staff

has been provided on facility

policy “Charting and

Documentation”. The

systematic change includes

education for nursing staff

upon hire and annually to

maintain timely documentation

of meal consumption.

The Director of


through direct observation of

the documentation of meal

consumptions. This audit will

occur on five (5) residents per

day at various meals for 30

days, then five (5) residents per

week at various meals for 8

weeks, then five (5) residents

per month at various meals for

9 months to total 12 months of

monitoring. Results of audit

will be reported to the Quality

Assurance Performance

Improvement Committee

monthly to assist with


necessary.





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a. On 09/16/2020- lunch and dinner's meal

intakes were not documented.



c. On 09/23/2020- dinner's meal intakes were

not documented.

d. On 09/25/2020- breakfast and lunch's meal



not documented.

A care plan, dated as revised on 09/24/2020,

indicated to accurately document intakes.


document for breakfast, lunch and dinner.

A nutritional care plan, dated as revised on

09/24/2020, indicated the resident had a history

of significant weight loss. Interventions

included, but were not limited to, record meal

consumption's.

3. The record for Resident L was reviewed on


but were not limited to, chronic kidney disease,

depression and gastro-intestinal reflux.



a.m., indicated from 09/16/2020 through



days:

a. On 09/16/2020- lunch and dinner's meal


b. On 09/17/2020- dinner's meal intakes were

not documented.






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d. On 09/19/2020- dinner's meal intakes were

not documented.


not documented.

f. On 09/21/2020- breakfast, lunch and dinner's


g. On 9/22/2020- dinner's meal intakes were not

documented.

h. On 09/23/2020- dinner's meal intakes were

not documented.

i. On 09/24/2020- breakfast's meal intakes were

not documented.

j. On 09/25/2020- breakfast's meal intakes were

not documented.

k. On 09/26/2020- breakfast, lunch and dinner's


l. On 09/27/2020- breakfast, lunch and dinner's


m. On 09/28/2020- dinner's meal intakes were

not documented.


01/20/2020, indicated the resident was on a

regular diet and would not have a significant

weight change. Interventions include, but were

not limited to, record meal consumption.

4. The record for Resident N was reviewed on


but were not limited to, dysphagia (difficult

swallowing), gastric varices (enlarged or swollen

veins in the stomach) and Alzheimer's Disease.






days:





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a. On 09/16/2020- dinner's meal intakes were

not documented.





d. On 09/18/2020- breakfast, lunch and dinner's


e. On 09/20/2020- lunch's meal intakes were not

documented.

f. On 09/21/2020- breakfast, lunch and dinner's


g. On 09/22/2020- breakfast, lunch and dinner's


h. On 09/23/2020- breakfast, lunch and dinner's


i. On 09/24/2020- breakfast, lunch and dinner's


j. On 09/25/2020- lunch and dinner's meal


k. On 09/26/2020- breakfast, lunch and dinner's


l. On 09/27/2020- breakfast and lunch's meal


m. On 09/28/2020- breakfast, lunch and dinner's


n. On 09/29/2020- breakfast, lunch and dinner's


o. On 09/30/2020- breakfast, lunch and dinner's



09/02/2020, indicated the resident was

nutritionally at risk. Interventions included, but

were not limited to, encourage oral intake of

51% or more with each meal.

A care plan, dated as revised on 09/14/2020,

indicated the resident required a mechanically





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altered diet related to difficulty swallowing.


monitor and record intake of food.


the Director of Nursing indicated a resident did

not need an order to document meal intakes. It

was a standard intervention included in any

nutritional care plan and the Certified Nurse Aide

was responsible for documenting the amount in

the resident's record.

A current facility policy, titled "Charting and

Documentation," dated July 2017 and provided

by the Administrator on 09/30/2020 at 12:30

p.m., indicated "...The medical record should

facilitate communication between the

interdisciplinary team regarding the resident's

condition and response to care...2. The following

information is to be documented the resident

medical record...f. Progress toward care plan

goals and objectives...."

This Federal tag relates to complaint

IN00333303.

3.1-50(a)(1)

3.1-50(a)(2)

483.80(a)(1)(2)(4)(e)(f)

Infection Prevention & Control

§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

F 0880

SS=E

Bldg. 00





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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 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





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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.


review, the facility failed to implement their

infection prevention and control program when

one staff member failed to wear a surgical

(medical grade) face mask properly in resident

care areas and failed to perform proper hand

hygiene during resident care. This deficient

practice had the potential to spread infections,

including COVID-19, to 25 of 25 residents

residing on 1 of 4 units in the health care

(Heritage Court unit).

Finding includes:

During an observation, on 09/29/20 at 12:35

p.m., meal service was being provided to the

residents on the Heritage Court unit by Certified

Nurse Aide (CNA) 4 and two other staff

members. CNA 4's surgical mask was below her

F 0880 F880 Directed POC

The directed plan of correction

(DPOC) is to serve as Copper

Trace’s credible allegation of

compliance.

Submission of this plan of

correction does not constitute an

admission by Copper Trace

Community or its management

company that the allegations

contained in the survey report is a

true and accurate portrayal of the

provision of nursing care and

other services in this facility. Nor

does this provision constitute an

agreement or admission of the

survey allegations.

The facility respectfully

requests desk review for the

10/30/2020 12:00:00AM





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nose and mouth when she walked out of a

resident's room and down the common hallway

toward the dining room of the unit.


when asked where her mask was, CNA 4

indicated it was "here" as she adjusted her mask

to above her nose.

During the continued observation, on 09/29/20 at

12:35 p.m., CNA 4 walked to the steam table,

pulled her mask down below her nose and mouth,

wiped her nose with the front and back of her

hands, pulled the mask back up above her nose

and pulled up her pants. She then washed her

hands, at the nearby sink, for less than ten

seconds, covering only the front and back

surfaces of her hands. She turned off the faucet

with her bare hands. Without further washing or

sanitizing her hands, she picked up a lunch tray at

the steam table and carried it into a resident's

room. CNA 4's surgical mask was again observed

below her nose when she set up the resident's

lunch tray and stood over the resident to remove

the plastic wrap from the two drinking cups.

After setting up the resident's tray, the CNA

adjusted her mask to above her nose. She did not

sanitize her hands and continued to provide care

to the resident, including handing her the bedside

remote and adjusting her bedside table.


the Director of Nurses indicated her expectation

for staff was a mask should be worn above the

nose in resident care areas at all times. If staff

members got mask fatigue, especially in a warm

resident's room, they were expected to step away

from the resident and take a break in a bathroom

or other non-resident area. The outside of the

mask was considered "dirty" (contaminated). If

following citation.

F880 Infection Prevention and

Control

S/S E

I. The corrective

actions to be accomplished for

those residents found to have

been affected by the practice.

There were no residents affected

by the alleged practice. Staff

member was immediately

educated on proper utilization of

PPE including when and how to

wear face masks and hand

hygiene including proper hand

washing technique.

II. The facility will

identify other residents that

may potentially be affected by

practice.

Other residents residing on this

same unit (Heritage Court), have

the potential to be affected by the

alleged deficient practice.

Rounds were made to ensure

associates were utilizing their

masks appropriately and

performing hand hygiene/ hand

washing using proper technique.

The residents who reside on the

unit were screened for and are

not showing any signs or

symptoms of Covid-19. The

residents continue to reside in

their green zone rooms.

III. The facility will put





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the staff member touched the mask, the staff

member was expected to hand sanitize or wash

their hands following the Centers for Disease

Control and Prevention (CDC) guidelines.


the Regional Corporate Nurse indicated the

facility's COVID-19 Response Plan, dated March

2020 and provided on 09/29/29, was also their

general policy for infection control and indicated

the flyer included in the policy reflected the

current content of their handwashing policy. The

policy provided did not include directions on

when and how face masks should be worn.

The facility's policy included the following

instructions regarding hand sanitation.

- "Ensure employees clean their hands according

to CDC guidelines, including before and after

contact with residents, after contact with

contaminated surfaces or equipment, and after

removing personal protective equipment (PPE)."

- An undated flyer from the CDC, "Stop Germs!

Wash Your Hands," indicated the following: "Wet

your hands with clean, running water (warm or

cold), turn off the tap, and apply soap. Lather

your hands by rubbing them together with the

soap. Be sure to lather the backs of your hands,

between your fingers and under your nails. Scrub

your hands for at least 20 seconds...Rinse hands

well under clean, running water. Dry hands using

a clean towel or air dry them."

The CDC guideline, "Hand Hygiene in Healthcare

Settings," dated 01/31/20

(https://www.cdc.gov/handhygiene/providers/inde

x.html, accessed 10/01/20), reflected the

following: "Techniques for Washing Hands with

into place the following

systemic changes to ensure

that the practice does not

recur.

· Administrator is

participating in weekly CMS Q10

webinars.

· CMS-CDC Fundamentals

of Covid-19 Prevention Training

Self-Assessment Questionnaire

completed indicating need for

“Hand Hygiene and PPE Training”

which was implemented for facility

staff. (Attachment A)

· Root Cause Analysis

(RCA) with facility consultant

Infection Preventionist, including

input from the facility Medical

Director/DON/IP was completed

(See Attachment B)

· The facility Coronavirus

Disease 2019 (Covid-19)

Preparedness Checklist for

Nursing Homes and other

Long-term Care Settings form was

reviewed with the consulting

Infection Preventionist resulting in

an update being completed with

input from the Consultant

IP/Medical Director and DON

(See Attachment C)

· Consultant Infection

Preventionist educated

IDT/Leadership team on “Hand

Hygiene and PPE Training”

utilizing CDC and WHO guidelines

(Attachment D)

· Staff were educated





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Soap and Water. When cleaning your hands with

soap and water, wet your hands first with water,

apply the amount of product recommended by

the manufacturer to your hands, and rub your

hands together vigorously for at least 15

seconds, covering all surfaces of the hands and

fingers. Rinse your hands with water and use

disposable towels to dry. Use towel to turn off

the faucet. Avoid using hot water, to prevent

drying of skin. Other entities have recommended

that cleaning your hands with soap and water

should take around 20 seconds. Either time is

acceptable. The focus should be on cleaning your

hands at the right times.

3.1-18(a)

regarding how & when to don and

doff PPE, with return

demonstrations including masks,

gloves, gown and eye protection

utilizing CDC guidance

(Attachment E)

· Staff were educated on

how to wear masks including

maintaining coverage of nose and

mouth while in resident care areas

and hand hygiene using proper

hand washing technique. (See

Attachment F)

IV. The facility will

monitor the corrective action

by implementing the following

measures.

· The IP/DON or designee

will observe the staff to ensure

proper use of face masks, daily

for 4 weeks, then weekly for 8

weeks, then monthly for 9 months

for a total of 12 months of

monitoring using the Quality

Improvement Tool F-880 (1) audit

tool. (See Attachment G)

· The IP/DON or designee

will observe the staff to ensure

hand hygiene is being performed

using proper technique, daily for

4 weeks, then weekly for 8 weeks,

then monthly for 9 months for a

total of 12 months of monitoring

using the Quality Improvement

Tool F-880 (2) audit tool (See

attachment H)

The results of these reviews will be





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discussed at the monthly facility

Quality Assurance Committee

meeting monthly for 6 months and

then quarterly thereafter once

compliance is at 100%.

Frequency and duration of

reviews will be increased as

needed, if compliance is below

100%.

V. Plan of correction

completion date.

Date of compliance: 10/30/2020

The Administrator will be

responsible for ensuring the

facility is complying by date of

compliance listed. The plan of

correction is to serve as Copper

Trace’s credible allegation of

compliance.


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