More than a dozen Indiana nursing homes cited with infection control deficiencies during pandemic

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INDIANA — As of Wednesday, 15 nursing homes in Indiana were cited with infection control deficiencies since late March. The Indiana State Department of Health sent enforcement notices to each of these facilities. All of them must submit an acceptable plan of correction for the deficiencies.

More than 120 infection control surveys have been conducted in Indiana, according to the Centers for Medicare & Medicaid Services (CMS). The remainder of the surveys found that facilities were in compliance with the infection control requirements.

On March 20, CMS announced a suspension of routine inspections, and an exclusive focus on immediate jeopardy situations and infection control inspections. 

The Division of Long Term Care of ISDH conducted these surveys to determine if the facilities were in compliance with federal requirements related to the complaint and implementing proper infection prevention and control practices to prevent the development and transmission of COVID-19.

As of Wednesday, ISDH found these facilities were not in substantial compliance:

  • Cardinal Nursing and Rehabilitation Center
  • Golden Living Center-Valparaiso
  • Washington Nursing Center
  • Golden Living Center-Richmond
  • Majestic Care of Avon
  • Rawlins House Health & Living Community
  • Golden Living Center-Merrillville
  • Exceptional Living Center of Brazil
  • Westside Retirement Village
  • Signature Healthcare of Newburgh
  • Good Samaritan Home Health Center and Residential
  • Aperion Care Marion
  • Sprenger Health Care of Mishawaka
  • Brooke Knoll Village
  • Symphony of Crown Point

The longest survey report came from Cardinal Nursing and Rehabilitation Center in South Bend. As of May 21, 17 people have died at this campus.

The survey completed on April 19 found the facility failed to follow CDC guidance during a pandemic and implement an infection control program for timely and accurate assessment of signs and symptoms of COVID-19.

Surveyors also found multiple residents were exhibiting symptoms consistent with COVID-19 but were not monitored and/or isolated.

During an interview with surveyors, the Executive Director of Operations at a local hospital indicated he contacted the facility on April 11 due to concern of a possible COVID-19 outbreak at the facility.

“He indicated the concern was brought to his attention after one patient who had arrived in the local emergency room had to be immediately intubated and another had died en route, and both had tested positive for COVID-19. He indicated the facility “seemed shocked” by the diagnosis of COVID-19 in these residents and reported to him that there were no residents that were symptomatic in the facility,” said the survey report.

It also said the Executive Director of Operations at the local hospital indicated he had provided the facility with 60 swabs to complete testing and had recommended to the facility that they swab all residents on all floors.

According to the survey report, the Executive Director of the nursing home said she had not followed through with the recommendation of testing all residents in the facility.

“She indicated there was not enough manpower to test the residents, and there was no place to move them to if they were positive,” said the report.

American Senior Communities, the company that manages this facility, said Cardinal received a deficiency-free annual licensure and recertification survey in April 2019 and has had at least twice weekly visits from the ISDH surveyor in recent weeks with no further findings.

“We are aggressively and formally disputing the findings in the state’s April 19 report from their visit,” according to a statement sent to FOX59.

State surveyors also found Westside Retirement Village in Indianapolis was not following federal requirements.

Their survey report said the facility did not ensure residents who were not showing symptoms of COVID-19 were not exposed to or roomed with residents who were positive for COVID-19.

“Due to lack of available beds, they had to place a positive female (Resident C) into a room with a female dementia resident (Resident B) who was asymptomatic and had not been tested, and a positive male resident (Resident H) into a room with a male dementia resident (Resident K) who was asymptomatic and had not been tested,” said the report.

At least six people have died at Westside Retirement Village.

Just down the block, Brooke Knoll Village was also cited for an infection control deficiency.

The survey report said four residents were exhibiting symptoms and were not isolated.

Surveys of some of the other dozen Indiana nursing homes that were cited found residents eating lunch together in a dining room and staff not wearing face masks properly.

Nursing homes across the country are required to report COVID-19 information to all residents and their families, as well as directly to the Centers for Disease Control and Prevention (CDC).

CMS and the CDC are in the process of analyzing the data that has been submitted and CMS anticipates making the data public by the end of May.

We received a statement from Brooke Knoll Village and one from American Senior Communities, who manages Cardinal Nursing and Rehabilitation Center.

Statement from Brooke Knoll Village:

Early in the pandemic, facilities were receiving guidance almost daily from CDC, ISDH, WHO and other organizations.  Brooke Knoll Village continued, and still yet continues, to follow new directives as information is received and to implement best practices as they are revised and released.  As seen in the media, these practices are evolving and being revised as the pandemic continues.

Brooke Knoll Village is a facility which immediately transfers any resident testing positive for COVID-19 to a sister facility which has a segregated specialized unit caring for residents who are COVID positive. This is done in an effort to ensure the resident receives specialized care and to deter the risk of transmission to residents who are COVID negative.
Early in the pandemic, ISDH strike teams were assigned the duty to visit long term care facilities and to conduct COVID testing. These teams were limited as to number of residents which could be tested and the number of visits which would be made to a facility. Brooke Knoll Village had requested and utilized the strike team on two prior occasions, and had been advised the strike team would not be available to return for future visits to test specifically for COVID.
It was after this time when ISDH visited the facility in April.  There were three residents with diagnostic tests ordered by the physician to fully assess the varied symptoms exhibited and to rule out or to diagnose the likelihood of COVID, as Brooke Knoll Village had previously been advised that COVID testing would not again be available through ISDH.  PPE was being utilized for those residents and was available to staff.   A group of comprehensive diagnostic testing was being conducted to assess each resident’s overall clinical status, and results were pending.  The surveyors determined those residents undergoing the diagnostic testing should have been provided additional precautions above and beyond those precautions which were in place.  Those additional precautions were seen by the surveyors as best practice preventative measures until the time at which a definitive determination of COVID status could be made.   There was no harm to any resident.  From an abundance of caution, Brooke Knoll Village revised its practices to presume any resident with any respiratory symptom to be potentially positive until determined otherwise.
Brooke Knoll Village continues to revise practices with any new/revised information provided by the CDC, ISDH and/or CMS.

Statement from American Senior Communities:

As long term care facilities nationwide continue to feel the devastating impact of COVID-19, our team at Cardinal Nursing and Rehabilitation remains focused on our top priority – the health and safety of residents and employees. Given the unprecedented critical needs of residents during this pandemic, we enhanced our standard infection control protocols and trained our staff on COVID-19-specific infection control protocols. We have tested 100% of the residents at Cardinal Nursing and Rehabilitation.

Cardinal received a deficiency free annual licensure and recertification survey in April 2019 and has had at least twice weekly visits from the ISDH surveyor in recent weeks with no further findings. We are aggressively and formally disputing the findings in the state’s April 19 report from their visit. 

American Senior Communities is partnering with the community to address the heightened needs of residents, families and staff caused by the pandemic. Uniquely and early on, we created its own testing strike team, which includes nurses from ASC and Eskenazi Health. The organizations are collaborating with the IU Health Lab, which is providing test kits and rapidly reading the results. This strategy enhances our ability to quickly identify positive cases and implement isolation protocols. Early detection of the virus is imperative to reducing the exposure risk to other residents and to staff. Long term care communities conducting extensive testing may report higher numbers of COVID-19 positive cases than other communities that do not prioritize testing or have access to tests. 

From the outset of the COVID-19 pandemic, we have sought to be ahead of the curve, implementing safety and infection control procedures prior to guidelines issued by the Centers for Disease Control (CDC) and the Indiana State Department of Health (ISDH). We continue to go beyond CDC and ISDH recommendations for clinical care:

  • Testing 100% of all residents in facilities where there is reason to believe a resident or staff member has contracted the virus.
  • Testing 100% of residents in high-risk facilities where there are no known cases of the virus.
  • Restricting visitors at all facilities.
  • Retesting residents who were COVID-19 positive to ensure proper care.
  • Screening each resident for illness daily.
  • Screening and taking the temperature of all staff, clinical partners, vendors and all others as they enter our communities.
  • Requiring all staff to wear PPE at all times.
  • Cancellation of large group activities.
  • Exercising best practices for infection control.
  • Quarantining and cohorting residents and staff who are COVID-19 positive.
  • Requiring all residents to wear masks if they are able to tolerate it while outside of their room, and in their room when a staff member or visitor is present.

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