rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,BIRCHWOOD TERRACE REHAB & HEALTHCARE,475003,43 STARR FARM RD,BURLINGTON,VT,5408,2018-04-04,645,E,0,1,1DSP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, the facility failed to assure that a PASARR (Pre-Admission Screening And Resident Review) was conducted for 8 applicable Residents (Residents #84, #54, #53, #5, #36, #10, #4, and #83) who were admitted with a 30 day exemption and have exceeded their expected 30 day stay. Findings include: 1. Per record review, Resident #84 had a PASARR dated 1/25/16, for which the exemption was marked for an anticipated stay of less than 30 days. There is no evidence of a complete PASARR was completed after the 30 days was exceeded. Resident # 84 has [DIAGNOSES REDACTED]. On 04/03/18 at 10:04 AM, the Social Services Director confirmed that the PASARR was not done after the initial 30 day period. 2. Per record review, Resident # 5 has a PASARR screening dated 10/12/05. Part A checked yes by the physician identifies that the resident is being admitted to the facility for less than 30 days. There is no evidence of further screening after the 30 days exemption. Resident #5 has [DIAGNOSES REDACTED]. On 04/03/18 at 10:04 AM, the Social Services Director confirmed that the PASARR screening has not been updated since the initial 30 day period. 3. Per record review, Resident # 10 has a PASARR screening dated 2/12/16. Part A checked yes by the physician identifies that the resident is being admitted to the facility for less than 30 days. There is no evidence of further screening after the 30 days exemption. Resident #10 has [DIAGNOSES REDACTED]. On 04/03/18 at 10:04 AM, the Social Services Director confirmed that the PASARR screening has not been updated since the initial 30 day period. 4. Per record review, Resident # 36 has a PASARR screening dated 2/7/17. Part A was checked yes. The screening was signed by the Social Worker and identifies that the resident is being admitted to the facility for less than 30 days. There is no evidence of further screening after the 30 days was exceeded. Resident #36 has [DIAGNOSES REDACTED]. On 04/03/18 at 10:04 AM, the Social Services Director confirmed that the PASARR screening has not been updated since the initial 30 day period. 5. Per record review, Resident # 53 has a PASARR screening dated 2/6/17. Part A checked yes. The screening was signed by the Social Worker and identifies that the resident is being admitted to the facility for less than 30 days. There is no evidence of further screening after the 30 days was exceeded. Resident #53 has [DIAGNOSES REDACTED]. On 04/03/18 at 10:04 AM, the Social Services Director confirmed that the PASARR screening has not been updated since the initial 30 day period. 6. Per record review, Resident # 54 has a PASARR screening dated 11/3/16. Part A checked yes. The screening was signed by the physician and the Social Worker identifying that the resident is being admitted to the facility for less than 30 days. There is no evidence of further screening after the 30 days was exceeded. Resident #54 has [DIAGNOSES REDACTED]. On 04/03/18 at 10:04 AM, the Social Services Director confirmed that the PASARR screening has not been updated since the initial 30 day period. 7. Per medical record review Resident #4 had a 30-day exemption PASARR from the hospital, dated 4/12/17. When it was determined that Resident #4 would remain in long term care, and after the 30 days had lapsed, the facility failed to complete a Level 1 PASARR screening for the change to long term care status. The Director of Social Services confirmed during an interview on 4/4/18 at 9:17 AM, that no PASARR screening was completed after the 30-day exemption document lapsed. 8. Per medical record review Resident #93 had a 30-day exemption PASSAR from the hospital, dated 3/15/16. When it was determined that Resident #4 would remain in long term care, and after the 30 days had lapsed, the facility failed to complete a Level 1 PASARR screening for the change to long term care status. The Director of Social Services confirmed during an interview on 04/03/18 at 10:05 AM, that no PASARR screening was completed after the 30-day exemption document lapsed.",2020-09-01
2,BIRCHWOOD TERRACE REHAB & HEALTHCARE,475003,43 STARR FARM RD,BURLINGTON,VT,5408,2018-04-04,804,F,0,1,1DSP11,"Based on staff interview and record review, the facility failed to ensure that beverages were served at a safe and appetizing temperatures. Findings include: Per review of facility food temperature logs from 12/1/17 - 3/31/18, of the 363 meals served, hot beverage temperatures were checked only 58 times and cold beverage temperatures were checked only 68 times. This was confirmed by the Executive chef on 4/3/18 at 9:30 [NAME]M.",2020-09-01
3,VERNON GREEN NURSING HOME,475008,61 GREENWAY DRIVE,VERNON,VT,5354,2017-08-09,248,B,0,1,D1TH11,"Based on direct observation, medical record reviews, resident and staff interviews, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group & individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community, for the 19 residents in the memory care unit. Findings include: Per direct observation between 8/7-9/2017, at different times of the days, residents are observed seated around the perimeter of the activity room of the memory care unit, some with heads down, others, with eyes closed, sleeping in their wheelchairs or gerichairs. On 8/7/17, eleven residents are observed to be in this situation the first morning of survey. The TV is turned on, but few residents are actually aware of this. Included in the observations are that lengthy games (30-45 minutes) or events, like having residents read to as a whole group, movies or interactive games do not elicit interest on the part of the residents. Large, group activities are scheduled for 3 times a day on the memory care unit. Staff are observed reporting their memories of trips and other stories and only 1 of 11 residents verbally responds, the others continue to be seated, with eyes closed. Interactive games, intended to engage residents, were observed and staff were interacting with each other and again, residents are seated with eyes closed and not aware. During an interview on 8/09/2017, a licensed nursing assistant (LNA) reports that the facility uses Music and Memory and that residents have their own iPods with their own music list. Consistent use of this was not observed. Residents who can, report they often do not attend activities, because the activities are too babyish. The above observations are confirmed by the unit staff several times during the 3 days of survey.",2020-09-01
4,VERNON GREEN NURSING HOME,475008,61 GREENWAY DRIVE,VERNON,VT,5354,2018-08-29,880,F,0,1,S5OH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, the facility failed to 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. Findings include: Per observation on 08/29/18 at 9:22 AM, accompanied by the Licensed Practical Nurse (LPN), an open vial of [MEDICATION NAME] Purified Protein Derivative (TPPD used for testing for (TB) [MEDICAL CONDITION]) was found in the A wing refrigerator and there was no date to indicate when the vial was opened. The LPN stated that the vial was only used for newly hired staff. Upon inquiring about the TPPD used for newly admitted residents the LPN stated that they don't test the residents for TB. Interview with the Assistant Director of Nurses, s/he stated that the TB testing has not been done on residents since s/he was hired nine years ago. The Director of Nurses (DON) confirmed on 8/29/18 at 10:42 AM that the facility does not test residents for TB upon admission. The DON further stated that if a resident is admitted from another facility or from home, there is not always information available to determine if TB testing had been previously done. Reference: CDC recommendations and guidelines Morbidity and Mortality Weekly Report Centers for Disease Control and Prevention 1600 Clifton Rd, MailStop E-90, Atlanta, GA , U.S.A July 13, 1990 / 39(RR-10);7-20 Skin tests should be administered to all new residents and employees as soon as their residency or employment begins unless they have documentation of a previous positive reaction. A two-step procedure is advisable for the initial testing of residents and employees in order to establish a reliable baseline (11-13).",2020-09-01
5,VERNON GREEN NURSING HOME,475008,61 GREENWAY DRIVE,VERNON,VT,5354,2018-08-29,881,C,0,1,S5OH11,"Based on interview and review of the facility policies and procedures, the facility failed to develop a comprehensive antibiotic stewardship program. Findings include: Per review of the guidelines for the formation of an antibiotic stewardship program, the facility has not yet established a program that addresses the requirements that include antibiotic use protocols and a system to monitor antibiotic use. The Director of Nurses (DON) confirms this during interview on 8/29/2018.",2020-09-01
6,VERNON GREEN NURSING HOME,475008,61 GREENWAY DRIVE,VERNON,VT,5354,2019-09-18,657,F,0,1,XBZR11,"Based on staff interview and record review, the facility failed to provide evidence of the participation of all required Interdisciplinary Team (IDT) meeting members during care plan meetings, and for preparing comprehensive care plans for 15 of the 24 sampled residents. Residents #1, 3, 4, 5, 9, 13, 14, 22, 23, 24, 33, 39, 44, 45 and 50. Findings include: Record reviews conducted by the survey team during the re-certification survey between 9/16/19 and 9/18/19 failed to produce evidence that the IDT included all required members of the team, as required per Centers for Medicare Services (CMS), to participate in the comprehensive care plans of the above identified residents. Per interview with the Registered Nurse Unit Manager on A wing, on 09/18/19 at 11:12 AM, s/he did not think that the physician reviewed the care plans before the meetings and the physicians have not attended care plan meetings that s/he has attended. In an interview with the Director of Social Services (DSS) on 9/18/19 at 5:02 PM, s/he confirmed that there is no evidence that the physicians are part of the IDT. The DSS further stated that the physician will only attend a care plan meeting on occasion and only if something comes up as a concern that the physician needs to address, such as a discharge. The DSS confirmed at this time that the physician is not part of the IDT and they do not review the care plans and/or give input to the comprehensive care plan.",2020-09-01
7,VERNON GREEN NURSING HOME,475008,61 GREENWAY DRIVE,VERNON,VT,5354,2019-09-18,689,D,0,1,XBZR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, direct observation and staff/resident interviews, the facility failed to ensure that the environment was free of accident hazards for 1 applicable resident, (Resident #24). The findings are as follows: As the evidence demonstrates below, after Resident #24 sustained a burn from spilling hot coffee, the facility failed to adequately address all areas of potential hazards for Resident #24 to prevent further accidents. Per medical record review, Resident #24 [MEDICAL CONDITION] 08/29/19 to his/her right leg extending from the top of the resident's thigh to the back of the right knee. The resident reported spilling coffee while independently self-propelling his/her wheelchair back to his/her room. The burn was assessed by the nursing staff; the physician was notified and ordered daily of cleansing and dressing the wound until healed. Per review of the physician's progress note dated 09/03/19, reads, a few days ago resident was drinking coffee and it spilled on self, resulting in erosion of the skin on the thigh and vesicle (blister) formation. The fluid filled vesicle's opened, drained and are beginning to heal. Burn is superficial and does not extend to the dermis. Per interview on 09/17/19 at approximately 1 PM with the resident and a family member, the resident denies any pain or discomfort at present and voiced that s/he is to blame for spilling the coffee on him/herself. Per review of the Minimum Data Set assessment (MDS), a federally mandated assessment dated [DATE], the resident is identified as having cognitive deficits and often refuses to allow staff to assess him/her. S/he requires supervision with locomotion on and off the unit; and needs supervision and set up for eating. On 08/29/19, as a result of this incident, the care plan was updated and indicated that nursing is to ensure lids and straws are used at all times while drinking coffee. Education was provided to the LNA staff related to the management of transporting hot beverages for Resident #24 on 08/29/19 and on 08/30/19 regarding transporting hot liquids from one location to another by residents. Nurses notes identify on 08/29/19 at 4:30 PM (2 hours after notification about the initial burn), the resident carried his/her hot soup and coffee after supper on his/her lap back to his/her room. Staff offered to transport, but the resident refused. There is no evidence in the nurses notes that staff provided education of risks at the time of refusal of assistance. There are also instances documented in the nurses notes identifying the resident requesting soup or coffee to be heated during the overnight shift and early mornings. There is no evidence that temperatures of the heated coffee or soup were monitored or checked prior to delivery to Resident #24 during the overnight shift. The surveyors with the Administrator, Food Service Director and the Director of Nurses (DNS), checked the temperatures with a calibrated digital thermometer, of hot water and hot coffee during the evening meal on 09/16/19, on 09/17/19 all three meals were checked and on 09/18/19 breakfast and lunch liquids were checked. The results identified black coffee and hot water temperatures varied from as high as 164 degrees to as low as 142 degrees Fahrenheit. Through the investigation, it was discovered that temperatures of hot liquids are not routinely checked by facility staff prior to serving residents. On 09/17/19 at 7:37 AM, the surveyor observed twelve residents eating breakfast in the activity room across from the nurses' station on A-Wing. LNA staff were observed to be in and out of the room and the Licensed Practical Nurse (LPN) was administrating medications. At 8:00 AM, unsupervised, Resident #24 placed a full cup of water and hot coffee upon his/her lap and propelled him/her-self approximately 20-25 feet to his/her room. The surveyor witnessed the hot coffee in the resident's lap had spilled out of the lid onto his/her thigh. At 8:05 AM, the LPN confirmed that the resident's pants at the knee area was wet and removed the cup of coffee from the resident's room. The surveyor in the presence of the LPN tested the coffee with a calibrated digital thermometer and it registered 122 degrees Fahrenheit. As a result of the second incident that was brought to the facility's attention by the surveyor, Resident #24 was provided with hard plastic spill proof mugs, that enables him/her to independently transport coffee at any time without the risk of spillage.",2020-09-01
8,VERNON GREEN NURSING HOME,475008,61 GREENWAY DRIVE,VERNON,VT,5354,2019-09-18,812,E,0,1,XBZR11,"Based on observation, staff interview and record review the facility failed to ensure that food was stored in accordance with professional standards for food service safety. Findings include: 1. Per review of the facility's temperature logs for the refrigerators and freezers, it was noted that on the B-Wing unit the supplement refrigerator was consistently registering temperatures above 40 degrees from (MONTH) 2019 through (MONTH) 2019. On 9/17/19 at 4:15 PM, the surveyor accompanied the Food Service Director on a tour to the B-wing unit and observed that the refrigerator temperature was not checked on 9/1, 9/2, 9/3, 9/4, 9/16, and 9/17/19; and that when the temperature had been checked in (MONTH) of 2019, it was over 40 degrees. The refrigerator contained soda, juice, and Boost supplements. It also had an opened container of thickened dairy beverage. The Food Service Director confirmed that the thickened dairy beverage should have been kept at a temperature of 40 degrees or less; and that the refrigerator had been out of temperature range for over five months. S/he stated that s/he was unsure who was responsible for acting upon the elevated temperatures. Per interview on 4/17/19 at 4:30 PM with the Director of Nursing (DNS), s/he stated that it was the night nurse's responsibility to check the refrigerator temperature and that s/he was not aware that the refrigerator's temperature had been out range for all of these months.",2020-09-01
9,MOUNTAIN VIEW CENTER GENESIS HEALTHCARE,475012,9 HAYWOOD AVENUE,RUTLAND,VT,5701,2018-01-04,623,D,1,0,ZY0H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews and record review the facility failed to notify the resident and/or resident's representative; and the ombudsman in writing of a transfer to the hospital for 2 of 4 applicable residents (Resident #1 & Resident #3). Findings include: Per record review Resident #1 was transferred to the hospital on [DATE], readmitted to the facility on [DATE]; and then subsequently transferred back to the hospital on [DATE]. Resident #3 was transferred to the hospital on [DATE]. There was no evidence in either of the residents' medical records that the residents', residents' representatives, and/or the ombudsman were notified of the transfers in writing. During an interview on 1/3/18 at approximately 5:30 PM, this was confirmed by the Administrator.",2020-09-01
10,MOUNTAIN VIEW CENTER GENESIS HEALTHCARE,475012,9 HAYWOOD AVENUE,RUTLAND,VT,5701,2018-01-04,656,D,1,0,ZY0H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews and record review the facility failed to implement the care plan for monitoring behaviors and effects of [MEDICAL CONDITION] medication for 1 of 4 applicable residents (Resident #1). Findings include: Per record review Resident #1's care planned interventions read, Complete behavior monitoring sheet, monitor for continued need of medication as related to behavior and mood, monitor for side effects and consult physician and/or pharmacist as needed. Resident #1 received [MEDICATION NAME] (medication for anxiety) 12 times from 12/3/17 to 12/17/17. The Medication Administration Record [REDACTED]. There was no evidence in the medical record as to what was causing the resident's anxiety, what non-pharmacological methods were used to reduce the resident's anxiety, the resident's response to the medication, and the continued need of the medication. There was also no documentation to indicate that the resident had any behaviors during this time period. During an interview on 1/2/18 at approximately 3:00 PM, this was confirmed by the Administrator and Director of Nursing.",2020-09-01
11,MOUNTAIN VIEW CENTER GENESIS HEALTHCARE,475012,9 HAYWOOD AVENUE,RUTLAND,VT,5701,2019-02-14,658,D,0,1,ZRVE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews the facility failed to assure that services provided by the facility, are provided according to professional standards regarding reconciling & following physician orders [REDACTED].#114). Findings include: Per record review Resident #114 was admitted to the facility on [DATE] with a Gastrostomy Tube ([DEVICE]). Signed physician's orders [REDACTED]. On 1/16/2019, a clarification order was written by the Registered Dietician (RD) for Glucerna 1.5 at 400 ml TID (three times a day) and signed by the Advanced Practice Registered Nurse (APRN). On 1/17/2019, another clarification order was written for Glucerna 1.5 at 400 ml TID PT (per tube). The APRN signed and dated the clarification order on 1/21/19. Resident #114's hand-written Enteral Protocol flow sheet (a form that the facility uses to document tube feeding administration) dated 1/16/19 reads Glucerna 400 ml 3 times a day. Flush tube with 200 ml of water 6x's a day total volume flush 1200 ml/24 hrs and total volume of nutrient + flush + 2400 ml/24 hrs. The hand-written Enteral Protocol flow sheet for the month of (MONTH) 2019 reads Glucerna 1.5 cal/ml (calorie per milliliter) 400 ml 4 times daily with the times documented as 0800, 1200, 1700 (only 3 times). There were 34 initialed opportunities to identify the incorrect documentation between 2/1/19- 2/12/19. On 2/12/19 at 3:30 PM during an interview with the Unit Manager, s/he confirmed that the monthly physician's orders [REDACTED]. The monthly orders are generated by the pharmacy. S/he also confirmed that the (MONTH) hand-written Enteral Protocol flow sheet indicated that the Glucerna was to be administered 4 times a day, and that the documentation on the flow sheet was only 3 times a day. S/he confirmed that this was a transcription error and that regardless of the order and directions, the nurses were giving the Glucerna three times a day. Ref: Lippincott Manual of Nursing Practice (9th Edition) Wolters, Kluwer Health/Lippincott,[NAME], & Wilkens.",2020-09-01
12,MOUNTAIN VIEW CENTER GENESIS HEALTHCARE,475012,9 HAYWOOD AVENUE,RUTLAND,VT,5701,2019-02-14,755,D,0,1,ZRVE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that the pharmacy transcribed the correct Physician's order on the Physician's order form for 1 of 30 residents in the sample (Resident # 114). Findings include: Per record review resident #114 was admitted to the facility on [DATE] with a Gastrostomy Tube ([DEVICE]). Signed Physicians orders from 1/15/19 read Glucerna (a high calorie nutrition) 1.2, special Instructions: H2O 160 ml (milliliters) flush with boluses, bolus amount (ml): 400, number of boluses/day: 3. On 1/16/19 the registered Dietician (RD) wrote a clarification order for Glucerna 1.5 at 400 ml TID (three times a day) the Advanced Practice Registered Nurse (APRN) also signed the clarification on 1/16/19. On 1/17/19, another clarification order was written for Glucerna 1.5 @ 400 ml TID PT (per tube). The APRN signed and dated the clarification on 1/21/19. Per the record the monthly Physician's orders, with a start date of (MONTH) 1, 2019, the order stated Glucerna 1.5 cal/ml liquid give bolus 400 ml four times a day (with an ordered date of 1/17/19) signed and dated on [DATE] by the Provider. These orders were also checked and signed by a nurse on 1/28/19. The monthly order forms are generated by the pharmacy. Per interview on 2/13/19 at 3:30 PM the Registered Nurse confirmed that the printed monthly physicians order from the Pharmacy for (MONTH) states four times per day and that it was signed by the Provider on 2/7/19. S/he also confirmed that the nurses who administer the Glucerna should have identified the Pharmacy's inaccurate transcription. Per interview with the Registered Dietician, (RD) on 2/13/19 at 12:44 PM s/he reported that s/he is familiar with Resident #114 from previous admissions. When Resident #114 was admitted on [DATE] both the RDs recommendation and Physician's order for Glucerna was TID and that the order should not have been changed on the (MONTH) Physician's order form. During an interview on 2/14/19 at 10:30 AM with the Pharmacy's medical supplies/billing staff s/he stated that verbal confirmation of the order had been obtained on 1/17/19 when a staff nurse on the Dogwood Unit called the Pharmacy to re-order. S/he stated that the order relayed at that time was for administration four times a day. S/he confirmed that there was no evidence of an actual Physician's order stating 4 times a day on file.",2020-09-01
13,MOUNTAIN VIEW CENTER GENESIS HEALTHCARE,475012,9 HAYWOOD AVENUE,RUTLAND,VT,5701,2019-02-14,842,D,0,1,ZRVE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that medical records were complete and accurately documented for 2 of 30 residents in the sample (Resident #92 and Resident #114). Findings include: 1. Resident #92 was admitted to the facility on [DATE] with an indwelling catheter. Signed physician's orders [REDACTED].(milliliters) of N.S. (normal saline) twice a day. Per review of a nursing progress note dated 6/12/18, new orders were received for, [MEDICATION NAME] 2% urojet (pre-filled syringe with numbing medication)-squirt the 5 (milliliter) ml into urethra (duct by which urine is moved out of the body from the bladder) prior to foley re insertion with cath changes; [MEDICATION NAME] solution (irrigation solution) 30 ml-flush foley BID (twice a day) and PRN (as needed) foley clogging to maintain foley patency; d/c (discontinue) saline flushes. Per review of Resident #92's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for (MONTH) 2019, there was no evidence that these orders were being carried out to maintain Resident #92's catheter. Per interview on 2/12/19 at 3:31 PM with a staff nurse, s/he confirmed that there were no orders on the MAR and/or TAR for Resident #92's Foley catheter care. On 2/12/19 at 3:59 PM, during an interview with the Unit Manager, s/he also confirmed that there were no orders on the MAR and/or TAR for Resident #92's Foley catheter care. 2. Resident #114 was admitted to the facility on [DATE] with a Gastrostomy Tube ([DEVICE]). Signed Physicians orders from 1/15/19 read Glucerna (a high calorie nutrition) 1.2, special Instructions: H2O 160 ml (milliliters) flush with boluses, bolus amount (ml): 400, number of boluses/day: 3. On 1/16/2019, a clarification order was written for Glucerna 1.5 at 400 ml TID (three times a day) and signed by the Advanced Practice Registered Nurse (APRN). On 1/17/2019, another clarification order was written for Glucerna 1.5 @ 400 ml TID PT (per tube). The APRN signed and dated the clarification order on 1/21/19. Per review of resident #114's Enteral Protocol flow sheet (a form that the facility uses to document tube feeding administration) for the month of (MONTH) 2019, there was a hand-written entry for Glucerna 1.5 cal/ml (calorie per milliliter) 400 ml 4 times daily with the times documented as 0800, 1200, 1700 (only 3 times). There were 34 initialed opportunities to identify the incorrect documentation between 2/1/19- 2/12/19. On 2/12/19 at 3:30 PM during an interview with the Unit Manager, s/he confirmed that the monthly physician's orders [REDACTED]. S/he also confirmed that the hand-written Enteral Protocol flow sheet indicated that the Glucerna was to be administered 4 times a day, and that the documentation on the Enteral Protocol flow sheet was 3 times a day.",2020-09-01
14,MOUNTAIN VIEW CENTER GENESIS HEALTHCARE,475012,9 HAYWOOD AVENUE,RUTLAND,VT,5701,2017-02-15,441,E,0,1,WNOM11,"Based on observation and interview the facility failed to ensure that the Infection Control program is designed to provide a safe, sanitary and comfortable environment to prevent the transmission of infection for residents residing on 3 of the 4 units. For Residents #90, #123, #281 and #411 the findings include the following: Per observation during the initial tour on 2/13/17 on 3 of 4 units, for Residents # 90, #123, #281 and #411, nebulizer equipment to include oxygen tubing, medication chamber connected to mouth pieces and nasal cannulas/masks, were discovered uncovered and unprotected in resident rooms stored on bedside tables. Per review of the policy titled Nebulizer dated 1/1/04, page #2 identifies Upon completion of the treatment, rinse the mouthpiece and T piece with tap water and dry. Place in treatment bag labeled with the patient name and date. Replace and date the set up every seven days. Per facility tour on 2/13/16 at 4 PM in the presence of the Co-Administrator and the Unit Mangers, confirmation was made that the Nebulizer equipment was not stored properly, facility policy was not followed nor was the equipment protected from contamination.",2020-09-01
15,MOUNTAIN VIEW CENTER GENESIS HEALTHCARE,475012,9 HAYWOOD AVENUE,RUTLAND,VT,5701,2018-03-22,641,B,0,1,CMTT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to maintain accurate MDS (Minimum Data Set) documentation for 3 of 33 sampled residents, Resident #37, #81 and #89. Findings include: 1.) Per record review on 3/20/18, the MDS dated [DATE] indicated that Resident #37 did not have restraints and the MDS dated [DATE] indicated that restraints were used less than daily. Per interview with the Licensed Practical Nurse (LPN) at 10:13 AM confirmation was made that the resident does not have restraints and the bed rails do not restrict movement and are used to assist with mobility. Per the side rail assessment completed by the facility, Resident #35 had requested the bed rail and they are used as an enabler in bed mobility. Per observation of the resident's bed, there were 2 upper half rails and they are non-restrictive to the resident's movement or mobility. Per interview with the MDS coordinator on 3/20/18 at 10:18 AM, s/he thought that the bed rails were restraints and confirmed at this time that the MDS was inaccurately documented. 2.) On 3/20/18, per observation, Resident #89 did not have side rails on his/her bed and per review of the medical record, there was MDS documentation dated 11/29/17 that the resident had no restraint. Further review of the medical record presented that the MDS dated [DATE] indicated that the resident had a restraint (side rails) that were used less than daily. Per interview with the LPN, charge nurse on 3/19/18 at 2:52 PM, the resident doesn't have a restraint and doesn't use side rails. Confirmation at 10:18 AM on 3/20/18 from the MDS coordinator that the MDS was inaccurately documented. 3. Medical record review for Resident #81 identified a Minimum Data Set (MDS) assessment dated [DATE] identified that the resident received an anticoagulant medication for 5 of the last 7 days. The MDS assessment is a Federal mandated assessment, used to determine the resident's health and emotional needs. Confirmation was made by the MDS Coordinator, on 3/20/18 at approximately 8:43 AM that s/he thought [MEDICATION NAME], was an anticoagulant. [MEDICATION NAME] is classified as an anti-platelet medication.",2020-09-01
16,MOUNTAIN VIEW CENTER GENESIS HEALTHCARE,475012,9 HAYWOOD AVENUE,RUTLAND,VT,5701,2018-03-22,657,E,0,1,CMTT11,"Based on staff interview and record review, the facility failed to provide evidence of the participation of all required Interdisciplinary Team (IDT) meeting members during care plan meetings and for preparing comprehensive care plans for 23 of 33 residents. Residents #32, 73, 42, 101, 138, 22, 57, 117, 341, 24, 6, 15, 48, 29, 81, 133, 238, 102, 44, 112, 37, 89 and 66. Findings include: Record reviews conducted by the survey team during the re-certification survey between 3/19 and 3/22/18 failed to produce evidence that the IDT included all required members of the team, as required per Centers for Medicare Services (CMS), to participate in the comprehensive care plans of the above identified residents. Interview with the Director of Nursing and Social Services on 3/22/18, confirmed that there is no evidence that Licensed Nursing Assistants, who are responsible for the specific resident are part of the IDT. It was further stated that a member of food and nutrition service staff is not part of the comprehensive care plan unless there is a nutritional concern.",2020-09-01
17,MOUNTAIN VIEW CENTER GENESIS HEALTHCARE,475012,9 HAYWOOD AVENUE,RUTLAND,VT,5701,2018-03-22,804,E,0,1,CMTT11,"Based on observation and interviews, the facility failed to assure that foods were served at a safe, appetizing and palatable temperature. Findings include: Per interview in the resident Council special meeting on 3/20/18 at 1 PM, Residents in attendance stated that food served in resident rooms is always cold, especially the eggs in the morning. The majority of the 9 residents attending were from Dogwood Drive but there were other residents from other units as well. The residents stated that the eggs were always cold and that other meals were not hot either. This surveyor raised the question because a review of the Resident Council minutes for the past 3 months showed complaints of cold food. During lunch on 3/21/18 two surveyors, on Dogwood Drive, sampled test trays and also checked the temperatures of the foods. The following observations were made: Liver & Onions and Chicken were found to be at 100 degrees, Mashed Potatoes were at 106 degrees, Scalloped Potatoes were at 105 degrees, California Mixed Vegetables were at 100 degrees on one tray and 97 degrees on the second tray, and coffee was at 160 degrees. The chocolate milk was at 60 degrees and the ice cream was soft but not melted. According to the Dietary Manager, in an interview, the food has temperature readings checked once when the food arrives on the unit. Food is delivered to the unit in pans on Dogwood Drive. The US Food and Drug Administration states, Be aware that some warmers only hold food at 110 F (Fahrenheit) to 120 F, so check the product label to make sure your warmer has the capability to hold foods at 140 F or warmer. This is the temperature that is required to keep bacteria at bay. Foods to be served cold must be held and served at temperatures of 40 degrees F or less to prevent bacteria growth.",2020-09-01
18,MOUNTAIN VIEW CENTER GENESIS HEALTHCARE,475012,9 HAYWOOD AVENUE,RUTLAND,VT,5701,2018-03-22,880,E,0,1,CMTT11,"Based on observation and confirmed by staff interview the facility failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections on 1 of 4 nursing units. The findings include the following: Per initial tour on 3/19/18, the surveyor identified oxygen masks, nebulizer masks (with connected medication chambers) and a C-Pap mask not in use by the residents and resting at the bedside without protective coverings. During a Unit tour with the infection control Registered Nurse on 3/21/18 at 2:30 PM, confirmation was made that three resident rooms on Beech Tree unit were observed as follows: An oxygen mask with attached medication chamber, connected to a portable oxygen tank in a carrier next to the resident's bed was unprotected; a nebulizer mask with the medication chamber attached to the nebulizer machine was unprotected at the bedside; and an oxygen cannula resting on the oxygen concentrator were unprotected. Per facility policy titled Nebulizer dated 1/1/04, page #2 identifies, Upon completion of the treatment, rinse the mouthpiece and T piece with tap water and dry. Place in a treatment bag labeled with the patient name and date. Previously cited on 2/16/17.",2020-09-01
19,MOUNTAIN VIEW CENTER GENESIS HEALTHCARE,475012,9 HAYWOOD AVENUE,RUTLAND,VT,5701,2019-09-23,602,E,1,0,I8IS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews and record review, the facility failed to assure that several residents were free from misappropriation of 28 (twenty-eight) medications as identified by the admission of a Licensed Practical Nurse. Findings include: A concern was raised when there was an investigation conducted by the Attorney General's office in regards to possible drug diversion. The facility conducted audits of all the controlled substance logs and the medical records of the residents that were to receive these type of medications. It was found that on 28 separate occasions, for several different residents in the facility and on various units, a Licensed Practical Nurse (LPN) had not followed the procedure for having a witness to the wasting/destruction of a controlled medication that had been dropped, refused or spit out by a resident and was therefore not administered. These medications included [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME]. During the process of conducting the facility internal investigation, the facility questioned licensed nursing staff regarding the policy for destruction of controlled medications if they are refused or dropped. During the investigation the (LPN) was questioned and his/her answers regarding policies, raised concerns about other nurses that may or may not have been following the policies. The LPN was involved in 28 incidents of wasting medications that were either dropped, refused or spit out, and the LPN was placed on leave until an internal investigation could be completed. When the LPN was informed of his/her termination s/he admitted to taking medications from the residents. During the onsite investigation on 9/23/19, it was confirmed that the facility had written strategy plans and completed multiple corrective actions in response to this incident of 8/9/19. These corrective actions included: termination after suspension, policy revision and education to staff, nursing competencies, audits, initiated a QA (Quality Assurance) project. These corrective actions were completed and will be on-going. Based on corrective actions completed prior to the onsite, this citation is designated as past noncompliance.",2020-09-01
20,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-01-29,607,D,1,0,4VXC11,"> Based on interview and record review the facility failed to ensure that screening for abuse was completed according to their policy for 1 of 10 employees reviewed (Employee #1). Findings include: Per record review on 1/16/19, there was an allegation of sexual abuse of a resident involving Employee #1. Upon review of Employee #1's personnel file, there was no evidence that a screening was done for adult abuse. Per interview on 1/29/19 at 4:30 PM with the Administrator, s/he confirmed that there was no screening done for adult abuse for Employee #1. Per review of the Abuse Prohibition policy (revised 7/1/18) under the Process section it read, 2. The Center will screen potential employees for a history of abuse, neglect, or mistreating patients, including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries.",2020-09-01
21,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-01-29,758,D,1,0,4VXC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to to ensure that residents drug regimens were free from unnecessary [MEDICAL CONDITION] drug use for 1 of 4 residents in the applicable sample (Resident #1). Findings include: Per record review, a physician's orders [REDACTED]. On 11/8/18, the pharmacy consultation report identified that Resident #1's [MEDICATION NAME] was ordered for greater than 14 days without a stop date. Per regulation, providers are required to document the indication for use, the intended duration of therapy, and the rationale for the extended time period. There was no evidence in the record that the provider acted upon this recommendation. Per review of Resident #1's Medication Administration Record [REDACTED]. Per interview on 1/29/19 at 4:38 PM with the Director of Nursing (DNS), s/he confirmed that the medication was not stopped after the 14 day period; and that there was no evidence of physician justification for extending the medication beyond the 14 day period in the medical record.",2020-09-01
22,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2020-01-29,609,D,1,0,GCF111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and confirmed by staff interview the facility failed to report to the State Licensing Agency, within the required time frame, injuries of an unknown source for 1 applicable resident, (Resident #1). This citation is a repeat that was cited on [DATE]. The findings include the following: Per medical record review for Resident #1, nurses' notes and an interaction communication form completed by the Registered Nurse (RN) on [DATE] at 07:00 identify a change in condition with a large bruise noted over the right eye, right scalp, forehead, in the morning. The RN evaluated the resident and identified the injuries as an unobserved event/injury. Per review of the RN documentation on the narrative event summary dated [DATE] at 7 AM, evidences (a small purple area on the right side of scalp, late Saturday evening, [DATE]. Today it is noted with a bruise above the right eye and scattered across his/her forehead and the bruise on his/her scalp is a lot larger in size). Circumstances of the event documented on the same narrative summary form evidences (possibilities may include resident bumping his/her head against the Hoyer (mechanical lift), and possibly when Licenses Nurse Aides (LNA's) were turning him/her, they may have bumped his/her head against the wall.) Per review of the nurses' notes dated [DATE] at 1500, the Licensed Practical Nurse (LPN) documents, (continues with forehead bruising and starting to spread to eyes. Has a bump on the right side of his/her head). Per phone interview on [DATE] at approximately 3:15 PM, confirmation was made by the RN that s/he did not make a report of injuries of unknown source to the licensing agency. S/he confirms that s/he has no understanding of how to make a report. S/he voiced that s/he reported the incident to the Director of Nurses (DNS). In-service documentation identifies that the RN has completed an in-service education at the facility on abuse reporting in (MONTH) 2019. Confirmation was made by the DNS on [DATE] at approximately 3:30 PM, that the injuries reported to him/her at the time of the notification were not described as documented. The facility did not suspect abuse, rather an unobserved event/injury. The facility policy titled Abuse Prohibition identifies that injuries of unknown source are defined as an injury with both of the following conditions: 1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident and 2) the injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular time. The Summary Report dated [DATE] confirms that both above conditions were met. Per review of the Chief Medical Examiner's preliminary report identifies that Resident #1 died on [DATE] with an immediate cause of death being generalized medical deconditioning. Other significant conditions are identified as [MEDICATION NAME] impact of the head identified as scalp and facial contusions.",2020-09-01
23,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2020-01-29,610,D,1,0,GCF111,"> Based on interview and record review the facility failed to complete a thorough investigation of injuries of an unknown source and report the result of the investigation to the State Licensing Agency for 1 applicable resident sampled, (Resident #1). The findings include the following: Per medical record review both nurses notes and interaction communication form completed by the Registered Nurse (RN) on 01/05/20 at 07:00 identify a change in condition with a large bruise noted over right eye, right scalp, forehead, in the morning. The RN evaluated the resident and identified the injuries as an unobserved event/injury. Per review of the RN documentation on the narrative event summary dated 01/05/20 at 7 AM, evidences (a small purple area on the right side of scalp, late Saturday evening, 01/04/20. Today it is noted with a bruise above the right eye and scattered across his/her forehead and the bruise on his/her scalp is a lot larger in size). Circumstances of the event documented on the same narrative summary form evidences (possibilities may include resident bumping his/her head against the Hoyer (mechanical lift), and possibly when Licenses Nurse Aides (LNA's) were turning him/her, they may have bumped his/her head against the wall.) Per review of the nurses' notes dated 01/05/20 at 1500, the Licensed Practical Nurse (LPN) documents, (continues with forehead bruising and starting to spread to eyes. Has a bump on the right side of his/her head). Confirmation was made by the Director of Nurses on 01/29/20 at approximately 3:30 PM that the investigation is not completed for the incident of unknown injuries that occurred to Resident #1 on 01/05/20. The summary of the event form identifies ongoing investigation and no report has been sent to the Licensing Agency as required. Per review of facility policy titled Abuse Prohibition that includes Injuries of Unknown Source identifies the following: 7.4 Report allegations involving injuries of unknown source within 24 hours if the event does not result in serious bodily injury; 7.8 The investigation will be thoroughly documented in the Risk Management System (RMS). Ensure that documentation of witnessed interviews are included; 9.2 Report findings of all completed investigations within five (5) working days to the agency.",2020-09-01
24,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2020-01-29,656,D,1,0,GCF111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and confirmed by staff interview the facility failed to ensure that the Resident Centered Comprehensive Care Plan was implemented for 1 of 3 sampled residents, (Resident #1). This citation is a repeat that was cited on 10/24/18. The findings include the following: Per record review Resident #1 was admitted to the facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. The resident began receiving Hospice Services (health care that focuses on the terminally ill resident) in (MONTH) 2019. Per record review a significant change Minimum Data Set (MDS) assessment was conducted on 10/04/19 (State mandated assessment). The assessment identified that the resident was an extensive assist with 2 staff members for care. The Resident centered-care plan initiated on 06/01/19 identifies that the resident requires assistance for Activities of Daily Living (ADL's) with 2 staff for bed mobility. The resident is incontinent of urine and requires incontinence care every 2-3 hours and s/he is identified to be resistive to care, can become combative at times. According to the Resident Assessment Instrument manual, bed mobility is defined as how the resident moves from lying position, turns side to side and positions body while in bed. Per interview with Employee #1 on 01/29/20 at approximately 1 PM, confirmation was made that during the overnight shift on 01/04/20 through 01/05/20, Resident #1 was provided incontinent care at 6 AM only. Employee #1 confirms that the resident doesn't drink much during the evening shift, therefore s/he is only incontinent once during the night shift. The employee stated (all resident care plans are the same. Residents are checked and changed with one staff member during the overnight shift). Resident #1's care plan was provided to the employee evidencing the need for 2 staff members for bed mobility. The employee confirmed s/he was unaware of that need or that the resident was to be checked every 2-3 hours. Confirmation was made by the Director of Nurses on 01/29/20 at approximately 3 PM that staff are expected to know the needs of the residents as identified on the care plan. Staff did not utilize two staff members for bed mobility nor did the staff provide incontinence care every 2-3 hours as directed.",2020-09-01
25,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2020-01-29,842,B,1,0,GCF111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and confirmed by staff interview the nursing staff failed to ensure that 1 of 3 sampled resident's medical record had accurate documentation identifying the date and time of injuries of unknown origin and the timely notification to the appropriate resident represtentative of those injuries, (Resident #1). This citation is a repeat that was cited on 06/26/19. The findings include the following: 1. Resident #1's record inaccurately documented notification of an emergency contact. Per record review Resident #1 was admitted to the facility in (MONTH) 2019 with an identified Emergency Contact #1 Health Care Representative. The resident's Contact #2 who was recently admitted to another health care organization for long term care services and suffers with [MEDICAL CONDITION]. Per review of nurses notes, documentation identifies that on 01/05/20 at approximately 07:00, Resident #1 was identified with large bruise noted over right eye, right scalp, and forehead. Nurses' notes dated 01/05/20 at 7:15 AM identify the Contact #2 was notified of the findings. Per phone interview on 01/29/20 at approximately 3:45 PM, confirmation was made by the Registered Nurse (RN) that s/he did not notify Contact #2. S/he had documented that the call had been made. However, later realized that the task was not completed and asked the Unit Manger to inform the appropriate contact. There is no evidence in the medical record identifying that the injuries of unknown origin were communicated to Contact #1 or #2 as requested by the RN. 2. Resident #1's record contains conflicting or inaccurate dates regarding the first appearance of an injury of unknown origin. Per review of the Risk Management System (RMS) Event Summary Report completed by the RN on 01/05/20 at 7 AM, identifies that Resident #1 had an unobserved event/injury/bruise. The narrative description on the RMS report, describes a small purple area on the right side of scalp late Saturday evening, 01/04/20. On 01/05/20 the RN identifies a bruise above the resident's right eye, scattered across his/her forehead and the scalp bruise is a lot larger in size. Per review of the nurses notes, there is no evidence that identifies that the bruising on the right side of scalp was first identified on Saturday evening 01/04/20. Interview with Employee #1 on 01/29/20 at approximately 1 PM, confirms that he/she did not observe any bruising on the resident's head, right eye or forehead during personal care provided on 01/04-01/05/20 during the overnight shift. Per phone interview with the RN on 01/29/20 at approximately 3:15 PM confirmation was made that s/he evaluated the resident on 01/05/20 at 7 AM and identified the injuries as an unobserved event/injury. The above information was shared with the Director of Nurses on 01/29/20.",2020-09-01
26,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2018-02-05,684,J,1,0,V3D211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure that 1 applicable resident (Resident # 1) received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan regarding implementation of diet orders. Findings include: Per interview and record review, Resident #1 was given the wrong meal on [DATE] and left unattended. Per review of internal investigation information and per interviews, Resident #1 choked on whole grapes and subsequently expired at the facility on [DATE]. Resident #1 had a [DIAGNOSES REDACTED]. There is a physician's orders [REDACTED]. There is a care plan for risk for impaired swallowing that includes an intervention to provide a dysphagia pureed diet as ordered. The care plan for Activities of daily living (ADLs) stated that Resident #1 required extensive assist of 1 person for eating. Per interview with the Center Nurse Executive (CNE) on [DATE] at 12:57 PM, a staff member brought another resident's tray to Resident #1's room on [DATE]. Resident #1's roommate stated that this person was a tall woman later identified by staff as a facility Registered Nurse (RN). A staff Licensed Nursing Assistant (LNA) brought the correct meal tray to Resident #1 a while later as described by Resident #1's roommate. This LNA discovered Resident #1 in distress and alerted nursing staff. In a written statement by the RN that delivered the incorrect tray to Resident #1, the RN stated Resident #1 refused the potatoes and asked for fruit so I placed the cup of grapes on (his/her) lap so (s/he) could reach them better. The RN then wrote that h/she left the room. The CNE confirmed that this RN was the person that delivered the incorrect meal tray to the Resident #1 and that Resident #1 was an extensive assist of 1 for eating and should not have been left alone with grapes. In a [DATE] interview at 3:03 PM, a facility LNA stated that h/she set up the regular diet tray that was delivered to Resident #1 that was meant for a resident 5 doors down from Resident #1's room. The LNA confirmed that h/she observed whole grapes on the table in front of Resident #1 on [DATE]. The LNA also confirmed that the aforementioned RN said that h/she gave Resident #1 the grapes. This citation will be considered past non-compliance. The facility has taken significant steps to correct the issues. Staff have been educated, management has audited meal tickets and resident photographs are now on meal tickets. Per observation of the noon meal on [DATE], staff were observed following proper procedures regarding meal trays.",2020-09-01
27,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2018-02-05,800,J,1,0,V3D211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure that 1 applicable resident (Resident # 1) received their physicia-ordered therapeutic diet and adequate dining assistance. Findings include: Per interview and record review, Resident #1 was given the wrong meal on [DATE] and left unattended. Per review of internal investigation information and per interviews, Resident #1 choked on whole grapes and subsequently expired at the facility on [DATE]. Resident #1 had a [DIAGNOSES REDACTED]. There is a physician's orders [REDACTED]. There is a care plan for risk for impaired swallowing that includes an intervention to provide a dysphagia pureed diet as ordered. The care plan for Activities of daily living (ADLs) stated that Resident #1 required extensive assist of 1 person for eating. Per interview with the Center Nurse Executive (CNE) on [DATE] at 12:57 PM, a staff member brought another resident's tray to Resident #1's room on [DATE]. Resident #1's roommate stated that this person was a tall woman later identified by staff as a facility Registered Nurse (RN). A staff Licensed Nursing Assistant (LNA) brought the correct meal tray to Resident #1 a while later as described by Resident #1's roommate. This LNA discovered Resident #1 in distress and alerted nursing staff. In a written statement by the RN that delivered the incorrect tray to Resident #1, the RN stated Resident #1 refused the potatoes and asked for fruit so I placed the cup of grapes on (his/her) lap so (s/he) could reach them better. The RN then wrote that h/she left the room. The CNE confirmed that this RN was the person that delivered the incorrect meal tray to the Resident #1 and that Resident #1 was an extensive assist of 1 for eating and should not have been left alone with grapes. In a [DATE] interview at 3:03 PM, a facility LNA stated that h/she set up the regular diet tray that was delivered to Resident #1 that was meant for a resident 5 doors down from Resident #1's room. The LNA confirmed that h/she observed whole grapes on the table in front of Resident #1 on [DATE]. The LNA also confirmed that the aforementioned RN said that h/she gave Resident #1 the grapes. This citation will be considered past non-compliance. The facility has taken significant steps to correct the issues. Staff have been educated, management has audited meal tickets and resident photographs are now on meal tickets. Per observation of the noon meal on [DATE], staff were observed following proper procedures regarding meal trays.",2020-09-01
28,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-02-13,725,E,1,0,BMZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff, resident and family interviews, the facility failed to ensure there was sufficient nursing staff to provide nursing and related services assuring resident safety and maintaining the highest practicable physical, mental and psychosocial well-being of each resident. Consideration for the number of residents who reside in the home, the resident assessments, individual care plans, the acuity and [DIAGNOSES REDACTED]. This is a repeat deficiency having been cited during the last 3 recertification surveys on (MONTH) 26, (YEAR), (MONTH) 14, (YEAR) and (MONTH) 24, (YEAR) and again during a follow-up survey on (MONTH) 4, (YEAR). The findings include the following: 1. During a Resident Council group meeting that was held on 2/13/19, several residents (who wish to remain anonymous) reported they have not seen any improvement of wait times for staff to respond to call lights since the facility was cited for staffing in (MONTH) and (MONTH) (YEAR). They still report that Licensed Nursing Assistant staff (LNAs) report being short staffed. 2. During the 3 days of survey (2/11, 2/12, and 2/13/2019), multiple staff including Registered Nurses (RN), Licensed Practical Nurses (LPN) and LNAs, both facility employed, as well as agency staff voiced concerns about resident safety and putting their licenses on the line related to staff shortages. They report having to rush through resident care and that residents have to wait a long time for their call lights to be answered. In reviewing the staffing schedule for 2/13/19 on one of the rehab units there were 2 LPN's and 1 LNA scheduled from 2:45 PM to 7 PM for 17 residents. From 7 PM until 11:15 PM there is 1 LPN and 2 LNA's scheduled. Of the 17 residents, 1 is a Hoyer lift and 2 others are 2-person assists. 3. Per interview on 2/13/19 at 4:20 PM a resident on the rehab unit (who wishes to remain anonymous) reported that on the morning of our interview s/he was left on the toilet for 15 or 20 minutes and was very uncomfortable in that position. After using the call light and also yelling to staff, s/he self-transferred to their walker and then again self-transferred to a chair in their room. The resident stated, I know I'm supposed to wait for someone to help, but I just couldn't sit there any longer. In reviewing the resident's care plan and the most recent Minimum Data Set (MDS) the resident is a 2-person extensive assist. Family members of the resident were in the room during the interview and reported that staff is scare on the weekend. 4. Per interview with another resident on 2/13/19 at 4:45 PM on the rehab unit (who wishes to remain anonymous) reported that earlier in the week s/he put on their call light to use the toilet, s/he waited 45 minutes and by the time someone responded s/he had been incontinent. S/he reported that the week before s/he put on their call light because s/he wanted something for pain. By the time someone responded it was over 30 minutes and by then s/he was in excruciating pain.",2020-09-01
29,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2018-04-03,689,G,1,0,ZOGT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, direct observation, staff and resident interviews between 4/2-3/2018, the facility failed to ensure that the environment was free of accident hazards for 1 of 7 residents (Resident # 1). The specifics are detailed below: Per medical record review on 4/2/2018, Resident # 1 suffered second [MEDICAL CONDITION] 01/31/2018 on his/ her abdomen, chest and upper left thigh after spilling a cup of coffee. Wounds on the abdomen and chest healed quickly. Wound assessments of the left thigh by both the physician and nursing staff resulted in daily dressing protocols being changed 3 different times, before the area healed on 4/3/2018. Resident # 1 is observed in bed on 4/2/2018 with a dressing in place over the left thigh, denying any pain or discomfort. Resident # 1 is able to articulate that it happened from coffee. Resident # 1 requires assistance and supervision with meals and eats all meals in the main dining room. Unit staff confirm during interview on 4/2 and 4/3/2018 that Resident # 1 was having breakfast in the dining room on 1/31/2018 when the injury occurred. Interview with the food service director on 4/3/2018 in the late afternoon confirms that liquid temps were not being taken before the coffee urn was taken to the unit dining room, but that after being notified that an incident happened, the coffee temperatures were checked and ranged between 170 and 190 degrees. As a result of this incident, temperatures of hot liquids are now taken prior to serving the residents. The food service director further states that Resident #1's meal ticket indicates that a cup with lid is to be used for liquids. This is confirmed by unit staff and on the care plan. The cup with the lid is a sturdy, hard plastic cup with a secure lid and large handle for residents to hold. Protocols were put in place after the injury that include taking temperatures of hot liquids, providing covered cups to residents to minimize injuries if cups are dropped and directions to not leave residents unsupervised who are at risk for spilling liquids/food. There have been no further injuries of this nature throughout the facility since (MONTH) (YEAR). This tag is cited as past non-compliance.",2020-09-01
30,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-05-01,561,J,1,0,IOQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews with the resident and facility staff, the facility failed to promote and support the resident's choice (1 of 4 sampled, Resident #1) to participate in preferred activities and interact with members of the community, both inside and outside the facility, leading to an unsafe discharge. Findings include: Per record review, Resident #1 entered the facility on 6/27/18, following [MEDICAL CONDITION] (paralyzed in the lower body), caused by trauma. There was also a clear history of [MEDICAL CONDITION] among the admitting diagnoses. Resident #1 had a medical order allowing 1 beer per day. A note on 1/21/19 relates that Resident #1 was non-compliant with the 1 beer per day order, and thus the order was discontinued. Resident #1 had a written plan of care which outlined risk of adjustment issues related to isolation, difficulty accepting placement in center, loss of status and/or freedom associated with transition, loss of support network, coping with decline in overall health status, including functional decline. Additionally the care plan stated, It is important for me to go outside when the weather is good. Family and staff to assist outdoors, weather permitting. The facility could show no evidence that mental health or medically-related social services were engaged to assist Resident #1 with adjustment issues, or with abrupt withdrawal of alcohol use. On 4/18/19, the facility held a meeting with Resident #1 and informed him/her of their intent to enforce their requirement that all residents sign out and back in whenever leaving the facility. The facility had been allowing Resident #1 to leave and go off site to visit friends down the street. When Resident #1 went off premises on 4/19/19 without signing out, the facility called the police. This experience resulted in Resident #1 exhibiting increased efforts to assert independence and a right to autonomy. When questioned on 4/29/19 at 3:30 PM, Resident #1 stated, they let me go out and took it back; I can have a beer and a cheeseburger. In the wake of this further restriction, Resident #1 verbalized intent to leave the facility whenever s/he wanted, per Interdisciplinary Team (IDT) notes of 4/24/19. Resident #1 had been in discussions regarding autonomy and choices from January, 2019 through 4/24/19, and disagreed with restrictions the facility put in place regarding independence. There is no written evidence that the facility notified the ombudsman or issued a 30 day notice of discharge during the period prior to the 4/24/19 alleged AMA (against medical advice) discharge. Per interview with the Long Term Care ombudsman on 5/1/19 at 8:40 AM, the facility had never contacted him/her about this resident's issues surrounding independence or desire to leave the facility AMA until 4/25/19, the day after discharge. Due to the disagreement regarding rights to engage in activities outside the facility, the Administrator and other facility staff had Resident #1 sign an AMA document at 1:00 PM on 4/24/19. That afternoon, Resident #1 left the premises twice, and subsequently returned both times, indicating to the DNS s/he made a mistake. Per interview with a facility staff member who was a witness to the events during the second return to the facility, s/he stated that when the resident returned, the facility DNS (Director of Nursing Services) asserted the AMA status and refused re-admission to the facility. After asserting the AMA status and refusing re-entry to the resident despite clear needs surrounding care, the administration ordered a maintenance staff person to transport the resident to a hotel and paid for one night. Per observation at hospital at 3:30 PM on 4/29/19, and confirmed by hospital documents dated 4/25/19, Resident #1 deteriorated during the hotel stay and required emergency transport to hospital for treatment of [REDACTED].",2020-09-01
31,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-05-01,600,J,1,0,IOQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and resident interview, the facility failed to provide goods and services to the resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress for 1 of 4 residents sampled (Resident #1). Findings include: Per medical record review 4/29-5/1/19, Resident #1 is paraplegic (paralyzed in the lower body) due to a (YEAR) trauma, with other [DIAGNOSES REDACTED]. S/he was assessed and care planned to require staff assistance of 1-2 for bed mobility, transfers from bed to chair, personal hygiene, and catheter care. S/he could eat a regular diet with provision and setup by staff. Leading up to an unsafe discharge on 4/24/19, Resident #1 had known psychosocial and mental health needs that were not addressed by the facility. The facility failed to ensure that the resident received appropriate treatment and services to address his/her alcohol dependence, risk of isolation, feelings of loss of freedom and independence, and coping with an overall decline in health and function, as stated in the written plan of care and diagnoses. The resident, age 64, was rendered paraplegic by trauma and was admitted to the facility 6/27/18. Record review shows no evidence that the resident was referred for professional mental health assessment and/or professional, medically-related social services to address these issues of trauma, loss, addiction, and adjustment, from admission through discharge on 4/24/19. During interview on 4/29/19 at 12:30 PM, the social worker described only having routine care conferences and doing some research to find placement closer to family. On 4/30/19 at 9:00 AM, the Director of Nursing and Administrator related difficulty finding an alternate placement closer to home. Per interview with the Nurse Practitioner (NP), 4/30/19 at 9:35 AM, s/he confirmed that s/he was unaware of any psychological referral. Record review showed that at least 3 facilities had refused admission. The nearest family lives 2 hours away. During the above interviews, the Administrator, DNS, and NP referred to Resident #1 as non-compliant with various aspects of care and services. From admission through 1/22/19, Resident #1 was allowed 1 beer per day, and had a medical order for this. Due to an incident on 1/21/19 where staff observed Resident #1 allegedly having more than 1 beer with 2 other people, the medical order for 1 beer per day was discontinued. There was no evidence that Resident #1 received referral or treatment for [REDACTED]. Resident #1 did show a change in behaviors from that time until 4/24/19. This included an elopement (leaving the building without signing out) on 4/19/19 to assert his/her right to leave the premises. When Resident #1 again left the premises on 4/24/19, an AMA (against medical advice) process was initiated by the facility. Facility staff, not the resident, initiated the discussion about discharge AMA when the resident was adamant about wanting to socialize independently outside the facility that day. There is no facility policy that requires residents to sign out AMA when they wish to go on a therapeutic leave. The facility thought the resident was leaving the building to go to a friend's to live, but took no steps to ensure care/services at that discharge location, nor confirm that as an option. The facility discharged the resident and ordered a maintenence staff person to transport him/her to a local hotel, paying for a one-night stay, on 4/24/19. The facility knew at that time that the family did not intend to care for him/her that evening. The facility knew that the resident could not get from wheelchair to bed, had difficulty dialing a phone, and needed help with catheter care, stool incontinence, all personal hygiene, and could not acquire food, drink, medications or future housing without assistance. The resident was known to have a history of serious UTI [MEDICAL CONDITION], and a current deep tissue pressure sore on the buttocks which could become infected without regular hygiene and care. The facility did not notify the family until some time on 4/25/19 of the hotel location. The facility did not do a Visiting Nurse Association referral by fax until midday, 4/25/19, per copy of fax transmission. This was confirmed by the Administrator and Director of Nursing (DNS) on 4/30/19 at 9:00 AM. Significant harm and risk of death resulted from this discharge, per review of hospital documents. Per interview of 2 maintenance staff, on 4/29/19 at 11:25 AM, Resident #1 was moved into a hotel room with belongings and medications, and 911 was called from the hotel room at approximately 6:30 PM on 4/24/19. The maintenance person who did the transport was not a caregiver and noted that s/he needed to dial the phone for the resident because Resident #1 gets shaky when tries to zero in with hands. Per hospital records, dated 4/25/19, Resident #1 reported to the physician that his/her hand tremors increased previously as a heralding (warning symptom) to UTI. Resident #1 had a history of [REDACTED]. Per interview of Resident #1 on 4/29/19 at about 3:30 PM, the rescue squad summoned by the maintenance person transferred the resident to bed, removed a soiled brief, and emptied the catheter bag, which had leaked on the resident's clothing. On 4/25/19, at approximately noon, an anonymous concerned facility staff person, per interview on 4/29/19, called the resident at the hotel. The resident did not know how to use the phone to reach hotel staff, so the staff person called the police and asked for a welfare check. It was later on 4/25/19 that hotel staff called 911 and ambulance response transported the resident to University of Vermont Medical Center (UVMMC) at approximately 6:12 PM, arriving 6: 34 PM, per dispatch records. Per review of hospital records of 4/25/19, upon emergency department assessment, Resident #1 was not oriented to time, saying s/he had been at the hotel for three days vs the actual 24 hours. The exam revealed the following: Mildly tremulous, unstageable ulcer of coccyx, covered in feces, arrives unable to care for self at motel, ruptured foley (catheter) bag, leukocytosis (high white blood cell count) and fever (100.5 F), abnormal urine dipstick with urine brown and cloudy. Given 1 gram Tylenol for reported headache, and hydrated with intravenous (IV) bolus 1 Liter [MEDICATION NAME] ringers. Attending (physician) attests to failure to thrive after sudden discharge from rehab, associated AKI (acute kidney infection) in addition to leukocytosis and fever, with UA (urinalysis) consistent with complicated UTI (urinary tract infection). Attending notes that patient reports similar heralding of increased hand tremors with previous UTI. admitted to hospitable for further UTI care and placement/housing. Per observation of Resident #1 by this surveyor, on 4/29/19 at 3:30 PM at UVMMC, the resident was receiving IV (Intra-venous) treatment for [REDACTED]. The resident therefore is confirmed to have declined to a level of serious harm and potentially life-threatening status of septic UTI during the 24 hour hotel stay, subsequent to sudden discharge by the facility, with no care rendered after 1:00 PM on 4/24/19, despite the resident returning to the facility twice during the afternoon of 4/24/19 clearly in need of care/assistance and indicating to the DNS that s/he made a mistake. The facility did not make any attempt to contact the resident at the hotel or secure caregivers except to fax a VNA referral at 1:30 PM on 4/25/19, with no check of follow through by the VN[NAME] Per interview on 4/30/19 at 9:00 AM, the Administrator and DNS confirmed that the resident was considered discharged after the AMA was signed, 1:00 PM on 4/24/19, and that they had arranged the transport and paid for a one night hotel stay. See also F0561, F0622, F0626, F0656, F0660, F0742 and F0745.",2020-09-01
32,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-05-01,622,J,1,0,IOQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and resident interview, the facility failed to permit 1 of 4 residents sampled (Resident #1) to remain in the facility, and not transfer or discharge. Findings include: Per record review and staff interviews on 4/29-30/19, the facility alleged that there was a resident initiated AMA (against medical advice) discharge on 4/24/19. This was confirmed by the administrator and Director of Nursing (DNS) on 4/30/19 at 9:00 AM, based on the signature of Resident #1 on an AMA document, signed at 1:00 PM on 4/24/19, and verbal expression of desire to leave the facility during an Interdisciplinary Team (IDT) meeting just prior (per Social Services notes of 4/24/19 and interview on 4/29/19 at 12:30 PM). On 4/29/19 at 2:15 PM, the Recreation Assistant, who was present at the IDT meeting of 4/24/19, stated that Resident #1 had described that s/he simply wanted to go downtown that day. Facility staff, not the resident, initiated the discussion about discharge AMA when the resident was adamant about wanting to socialize independently outside the facility that day. Based on the behavior of Resident #1, returning to the facility twice on the afternoon of 4/24/19 and verbalizing that s/he made a mistake, this could also be viewed as a therapeutic leave on the part of the resident, and an unsafe decision related to potential cognitive changes caused by brewing bacterial urinary tract infection [MEDICAL CONDITIONS]. The unit manager witnessed Resident #1 in the building at approximately 3:30 PM on 4/24/19 on 4th floor unit, per interview on 4/29/19 at 12:05 PM. The Administrator and DNS stated on 4/30/19 at 9 AM, that on 4/24/19 around 3:30-4 PM they brought Resident #1 into the conference room and allowed phone use to call the daughter and others. It was stated that a staff person had to dial the phone related to hand tremors of Resident #1. Per review of the comprehensive care plan regarding discharge planning, it is clear that a discharge to the community was not the plan. Per Occupational Therapy assessment dated [DATE], the resident required supervision outside of the building and per interview on 4/29/19 at 12:45 PM, the OT stated that the resident had poor judgement and safety awareness. The health status was declining at the time of discharge 4/24/19 (diagnosed [DATE] as septic with UTI, requiring hospital admission and intravenous antibiotics). In hospital documents of 4/25/19, Resident #1 reported having been at the hotel for 3 days, when in fact it had been approximately 24 hours from entry to the hotel 4/24/19 6:30 PM, per statement of maintenance person who did the transport in facility van, 4/29/19 at 11:25 AM. This statement of 3 days in the hotel represents evidence of lost orientation to time. Both the maintenance person, who called 911 from the hotel, and the DNS, mentioned that on 4/24/19 Resident #1 needed assistance to dial the phone related to hand tremors. Per hospital records, dated 4/25/19, Resident #1 reported to the physician that his/her hand tremors increased previously as a heralding (warning symptom) to UTI. Resident #1 had a history of [REDACTED]. An additional factor is that Resident #1 had a recent history of going off the premises on 4/19/19, per record review and confirmed by the administrator, DNS, and social worker during interviews on 4/29/19. The facility called the police and sent a staff person to bring Resident #1 back to the facility, and re-entry was permitted on 4/19/19. Resident #1 had been in discussions regarding autonomy and choices from January, 2019 through 4/24/19, and disagreed with restrictions the facility put in place regarding independence. There is no written evidence that the facility notified the ombudsman or issued a 30 day notice of discharge during the period prior to the 4/24/19 alleged AMA discharge. Per interview with the Long Term Care ombudsman on 5/1/19 at 8:40 AM, the facility had never contacted him/her about this resident's issues surrounding independence or desire to leave the facility AMA until 4/25/19, the day after discharge.",2020-09-01
33,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-05-01,623,D,1,0,IOQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed prior to discharge to notify 1 of 4 sampled residents (Resident #1) in writing and in a language and manner they understand. The facility also failed to send a copy of any notice to a representative of the Office of the State Long-Term Care Ombudsman. Findings include: Per interview 4/29/19 at 2:20 PM, the Admissions Director stated that s/he did not provide a transfer/discharge notice with appeal rights and required contact information to Resident #1 on 4/24/19, nor did s/he mail the notice to Resident #1 or the representative. The facility alleged that this was a resident initiated AMA (against medical advice) discharge on 4/24/19. This was confirmed by the administrator and Director of Nursing (DNS) on 4/30/19 at 9:00 AM, based on the signature of Resident #1 on an AMA document, signed at 1:00 PM on 4/24/19, and verbal expression of desire to leave the facility during an Interdisciplinary Team (IDT) meeting just prior (per Social Services notes of 4/24/19 and interview on 4/29/19 at 12:30 PM). Per interview on 4/29/19 at 2:15 PM, the Recreation Assistant (who attended the IDT meeting of 4/24/19) reported that Resident #1 simply wanted to go downtown that day. Based on the behavior of Resident #1, returning to the facility twice on the afternoon of 4/24/19 and verbalizing that s/he made a mistake, this could also be viewed as a therapeutic leave on the part of the resident, and an unsafe decision related to potential cognitive changes caused by brewing bacterial urinary tract infection [MEDICAL CONDITIONS]. There is no evidence that Resident #1 initiated the AMA discharge process. Refer to F622.",2020-09-01
34,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-05-01,625,D,1,0,IOQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to provide a written notice of the duration of the bed hold for 1 of 4 residents sampled (Resident #1) prior to therapeutic leave, or discharge. Findings include: Per the Admission Director, 4/24/19 2:20 PM, no bed hold notice was issued to Resident #1 or the representative prior to or reasonably thereafter on 4/24/19. Per the Administrator and Director of Nursing during interview on 4/30/19 at 9:00 AM, Resident #1 was considered discharged against medical advice when transported from the facility to a hotel on 4/24/19. Based on the behavior of Resident #1, returning to the facility twice on the afternoon of 4/24/19 and verbalizing that s/he made a mistake, this could also be viewed as a therapeutic leave on the part of the resident, and an unsafe decision related to potential cognitive changes caused by brewing bacterial urinary tract infection [MEDICAL CONDITIONS]. Refer to F622.",2020-09-01
35,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-05-01,626,J,1,0,IOQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and resident interviews, the facility failed to permit return to the facility after a therapeutic leave for 1 of 4 residents in the sample (Resident #1). Findings include: Per record review, staff and resident interviews, Resident #1 returned to the facility 4/24/19 at least twice after having been considered discharged against medical advice (AMA) by the facility (signature on 4/24/19 at 1:00 PM, per AMA document). The facility thought the resident was leaving the building to go to a friend's to live, but took no steps to ensure care/services at that discharge location, nor confirm that as an option. At 3:30-4 PM, Resident #1 was observed in the building on the 4th floor, per interviews with the nurse unit manager (4/29/19 at 12:05 PM), the Nurse Practitioner (4/30/19 9:35 AM), as well as by both the Administrator and Director of Nursing/DNS (4/30/19 at 9:00 AM). Per facility records, and these interviews, Resident #1 again left the premises, allegedly going to the hospital (where he presented as homeless needing housing and was turned away) and returned again to the facility at approximately 5:00 PM, clearly in need of care, indicating to the DNS s/he made a mistake. During the above interviews, witnesses placed Resident #1 in the building again, meeting in the ground floor conference room with administrator, DNS, Assistant DNS, and Business Manager regarding funds. The Assistant DNS was confirmed having dialed the phone for Resident #1 to talk with his/her daughter and others because the resident could not independently dial the phone due to hand tremors. At approximately 5:30 PM on 4/24/19, the Occupational Therapist (OT) confirmed having talked to Resident #1 from a window, as s/he was outside near the rear of the building, and asked Resident #1 to meet him/her at the entrance. Confirmed during this interview on 4/29/19 at 12:45 PM, the OT described that s/he went to the DNS and advised that Resident #1 was not safe and capable of living alone in the community. The DNS stated clearly to the OT, per this interview, that Resident #1 was AMA and not to receive medical care nor allowed to stay at the facility that night. S/he stated that when the resident returned, the facility DNS (Director of Nursing Services) asserted the AMA status to the resident and refused re-admission to the facility. When interviewed at the hospital on [DATE] at 3:30 PM, the resident said s/he did not specifically ask for re-admission because the DNS told me (s/he) would call the cops; they did that before so I knew they would. The facility had called the police on 4/19/19 and allowed return to the facility after Resident #1 left the premises in a perceived elopement (notes of 4/19/19, confirmed by administrator and DNS 4/30/19 at 9:00 AM). The facility then arranged for the one-night stay at a hotel for the night of 4/24/19 instead of readmitting the resident who had extensive care needs, and had a maintenance person transport the resident, with plastic bags of clothing, belongings, and medications, and a list of area healthcare providers, along with the electric wheelchair. The facility did not permit the resident to re-admit to the facility after a therapeutic leave and mis-understanding of the AMA discharge due to possible altered mental status and brewing infection. After spending approximately 24 hours in the hotel, and having 3 emergency 911 responses for care and welfare checks, Resident #1 was admitted to the hospital on [DATE]. Hospital records showed a multi-drug resistant urinary tract infection which represented substantial health risk to Resident #1. The facility not only did not permit return, but failed also to provide community services to a vulnerable person who could not, by their assessment and care plan, transfer him/herself from chair to bed, had an indwelling urinary catheter, was dependent on caregivers for hygiene, and had trouble using a telephone. A fax was sent by the facility to the Visiting Nurse Association at 1:30 PM on 4/25/19, with no evidence of any effort to check on Resident #1, and knowing the family was not coming promptly to assist (per interview administrator and DNS, 4/30/19 at 9:00 AM).",2020-09-01
36,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-05-01,656,J,1,0,IOQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to implement the written plan of care for 1 of 4 residents in the sample (Resident #1). Findings include: After admission 6/27/18 with [MEDICAL CONDITION] due to trauma, and a history of [MEDICAL CONDITION], the facility developed a care plan based on the assessed needs and preferences of Resident #1. This included a preference to go outside, weather permitting, and risk of social isolation related to change in customary lifestyle, difficulty accepting placement in the center, loss of status and/or freedom, loss of support network, and coping with decline in overall health and functional decline. Staff were directed in the written plan of care to: evaluate mood state or behavioral symptoms impacting social isolation; encourage to make decisions independently and provide positive feedback; encourage expression of thoughts and feelings associated with the change or loss of customary lifestyle/routines; encourage to participate in activity preferences; family and staff to assist outdoors, weather permitting. On 4/18/19, a care plan was also developed for risk of elopement related to history of leaving grounds without signing out. This directed staff to notify the physician, observe location when out of bed, remind to sign out/in when leaving. Additionally the care plan included risk for [MEDICAL CONDITION] activity related to tremors. Monitor for signs/symptoms of impending [MEDICAL CONDITION]. Resident #1 stated during interview on 4/29/19 at 3:30 PM that s/he expressed to facility staff that s/he had not been out of the building all year, that rehab means getting out and mingling with people.Contrary to the care plan which states that staff or family will support the resident to go outside, Resident #1 was allowed to go outside and off the premises a few times alone. On 4/19/19 when Resident #1 left the premises, the facility called police. During the care plan meeting of 4/24/19, Resident #1 asserted the desire to go downtown that afternoon. This was confirmed by a staff witness during interview at 2:15 PM on 4/29/19. The facility did not implement care strategies to safely allow such community activity.The facility instead initiated an Against Medical Advice (AMA) discharge on 4/24/19. Per record review, staff and resident interviews, the resident left the facility and returned on 4/24/19 at least twice after having been considered discharged against medical advice (AMA) by the facility (signature on 4/24/19, 1:00 PM, per AMA document). First the resident was documented as leaving the building to go to a friend's to live. Later, Resident #1 was observed in the building and on the 4th floor at 3:30-4 PM, per interviews with the nurse unit manager (4/29/19 at 12:05 PM) and by the Nurse Practitioner (4/30/19 9:35 AM), as well as by both the administrator and Director of Nursing/DNS (4/30/19 at 9:00 AM). Per facility records, and these interviews, Resident #1 again left the premises, allegedly going to the hospital (where he presented as homeless in need of housing and was turned away) and returned at approximately 5:00 PM. During the above interviews, witnesses placed Resident #1 in the building again, meeting in the ground floor conference room with administrator, DNS, Assistant DNS, and Business Manager regarding funds. The Assistant DNS was confirmed having dialed the phone for Resident #1 to talk with his/her family and others due to hand tremors preventing the resident from dialing the phone independently. At approximately 5:30 PM on 4/24/19, the Occupational Therapist (OT) confirmed having talked to Resident #1 from a window, as s/he was outside near the rear of the building, and asked Resident #1 to meet him/her at the entrance. Confirmed during this interview on 4/29/19 at 12:45 PM, the OT described that Resident #1 said they would not let him/her back in the building and s/he had no place to go. The resident stated I made a mistake. The OT went to the DNS and advised that Resident #1 was not safe and capable of living alone in the community. The DNS stated clearly to the OT, per this interview, that Resident #1 was AMA and that's too bad; I'll get him/her a hotel. When interviewed at the hospital on [DATE] at 3:30 PM, the resident said the DNS told me you've got to get out of here; we'll call the cops. The facility had called police on 4/19/19 and allowed return to the facility after Resident #1 left the premises in a perceived elopement (notes of 4/19/19, confirmed by administrator and DNS 4/30/19 at 9:00 AM). The facility then arranged for the one-night stay at a hotel for the night of 4/24/19, and had a maintenance person transport the resident, with plastic bags of clothing, belongings, and medications, and a list of area healthcare providers, along with the electric wheelchair. The facility did not permit the resident to re-admit to the facility after a therapeutic leave due to possible altered mental status and brewing infection. After spending approximately 24 hours in the hotel, and having 3 emergency 911 responses for care and welfare checks, Resident #1 was admitted to hospital on [DATE]. Hospital records showed a multi-drug resistant urinary tract infection which represented substantial health risk to Resident #1. The facility not only did not permit return, but failed also to provide community services to a vulnerable person who could not, by their assessment and care plan, transfer him/herself from chair to bed, had an indwelling urinary catheter, and had trouble using a telephone. A fax was sent by the facility to the Visiting Nurse Association at 1:30 PM on 4/25/19, with no evidence of any effort to check on Resident #1, and knowing the family was not coming promptly to assist (per interview administrator and DNS, 4/30/19 at 9:00 AM). Refer to F561.",2020-09-01
37,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-05-01,657,D,1,0,IOQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review and interview, the facility failed to assure the plan of care was revised to reflect the care and services provided to one of two residents (Resident #2). Findings include: 1. Per record review, Resident #2's care plan completed by the Social Worker (SW) dated 4/8/19, did not accurately reflect the resident's mental status. The care plan states Resident #2 has impaired/decline in cognitive function or impaired thought processes related to a condition other than [MEDICAL CONDITION]. The interventions include monitor conditions that may contribute to cognitive loss/dementia, including metabolic causes, respiratory problems, [MEDICAL CONDITION], delusions, hallucinations, psychiatric disorder, poor nutrition, hearing or vision impairment, new/acute heath problem, head injury, pain fever, dehydration or alcohol withdrawal. Evaluate needs for psych/behavioral health consult. Per record review of the Brief Interview for Mental Status (BIMS), which was completed upon admission by the SW states Resident # 2 has a score of 15. BIMS is used to obtain a snapshot of how well a person is functioning at the moment. A score of 13-15 is cognitively intact. Per staff interview, SW confirmed on 4/30/19 at 8:15 AM that the care plan for Resident #2 was inaccurate as written on 4/8/19 and the resident was mentally alert and cognitively intact. SW did not revise the care plan prior to the resident's discharge on 4/25/19. SW stated the computer generated care plan auto populates and staff completing the care plan need to make adjustments as needed. Stated she/he should have revised the care plan from has cognitive impairment to has the potential for cognitive impairment. 2. Per record review, Nursing note dated 4/11/19 states, Noted two 1 centimeter by 1 centimeter to patient mid-spine after patient complained of soreness. Noted redness with mild drainage. Applied 3 by 3 inch [MEDICATION NAME] dressing. Per staff interview and confirmed with with the Unit Manager on 4/29/19 at 12:57 PM, Resident #2's care plan for Has actual skin breakdown dated 3/25/19 related to surgery was not revised to include skin breakdown noted on 4/11/19 to mid [MEDICATION NAME] spine in 2 areas. 3. Per record review, Resident #2's care plan dated 3/25/19 states resident requires assistance/is dependent for Activities in Daily Living (ADL) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion. Interventions include extensive assist of 2 for transfers using a walker. Per staff interview and confirmed with Unit Manager on 4/29/19 1:08 PM, Resident # 2 was admitted post surgery and was dependent for assistance in bathing, grooming personal hygiene, dressing, eating, bed mobility transfers, locomotion, toileting and extensive assistance with transfer, and the care plan was not revised to include the 4/8/19 the care conference review which indicated the Resident #2 was upper body moderate assist, lower body maximum assist, transfers moderate assist. Ambulation minimum assist with Contact Guard Assist (CGA).",2020-09-01
38,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-05-01,660,J,1,0,IOQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, and confirmed by interviews, the facility failed to consider need for care and capacity, and to inform and consult the office of the State Long Term Care Ombudsman, regarding the desire of 1 of 4 residents sampled (Resident #1) to discharge. Findings include: Resident #1 was admitted for care on 6/27/18 after [MEDICAL CONDITION], caused by trauma and complicated by [MEDICAL CONDITION]. The facility developed a plan of care which included discharge planning for a desire to move to a facility closer to family on the New Hampshire border, and indicated the resident is dependent on staff for care, assistance with a urinary catheter, a pressure ulcer, adjustment concerns, and other issues. At the time of alleged discharge against medical advice (AMA), 4/24/19, the facility failed to consider the caregiver/support person availability, capacity, and capability to perform required care unassisted in the community. Resident #1 was also assessed and care planned as needing staff support for fecal incontinence, lower body [MEDICAL CONDITION] with inability to transfer without 1-2 person assistance, and hand tremors which impaired ability to dial a telephone. The facility thought the resident was leaving the building to go to a friend's to live, but took no steps to ensure care/services at that discharge location, nor confirm that as an option. Per interview with the Long Term Care ombudsman on 5/1/19 at 8:40 AM, the facility failed to contact the ombudsman and involve him/her in exploration of alternative options for placements, transfers or discharges. The facility made a hasty discharge arrangement 4/24/19, to transport the resident to a hotel and paid for one night, knowing that the family did not intend to care for him/her. This was confirmed by Administrator interview of 4/30/19 at 9 AM. Per hospital documents dated 4/25/19, the resident required Emergency Medical Services for transport to hospital from the hotel. [DIAGNOSES REDACTED]. The resident was admitted for UTI hospital care and homeless status. Per review of the comprehensive care plan regarding discharge planning, it is clear that a discharge to the community was not the plan. Per Occupational Therapy assessment dated [DATE], the resident required supervision outside of the building and per interview on 4/29/19 at 12:45 PM, the OT stated that the resident had poor judgement and safety awareness.",2020-09-01
39,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-05-01,742,J,1,0,IOQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interviews, the facility failed to ensure 1 of 4 residents sampled (Resident #1) received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being, related to trauma, new [MEDICAL CONDITION] with loss of independence, adjustment problems, and a history of [MEDICAL CONDITION]. Findings include: Per record review, the facility failed to ensure that the resident received appropriate treatment and services to correct his/her alcohol dependence, risk of isolation, and feelings of loss of freedom and independence, and coping with an overall decline in health and function, as stated in the written plan of care and diagnoses. The resident, age 64, was rendered paraplegic by trauma and was admitted to the facility 6/27/18. Record review shows no evidence that the resident was referred for professional mental health assessment and treatment to address these issues of trauma, loss, addiction, and adjustment from admission through discharge 4/24/19. During interview on 4/29/19 at 12:30 PM, the social worker described having routine care conferences and doing some research to find placement closer to family. On 4/30/19 at 9:00 AM the Director of Nursing and administrator related difficulty finding an alternate placement. Per interview with the nurse practitioner, 4/30/19 at 9:35 AM, s/he confirmed that s/he was unaware of any psychological referral. Record review showed that at least 3 facilities had refused admission. The nearest family lives 2 hours away. From admission through 1/22/19, Resident #1 was allowed 1 beer per day, and had a medical order for this. Due to an incident on 1/21/19 where staff observed Resident #1 allegedly having more than 1 beer with 2 other people, the medical order for 1 beer per day was discontinued. There was no evidence to suggest that Resident #1 received referral or treatment for [REDACTED]. Resident #1 did show a change in behaviors from that time until 4/24/19. This included an elopement on 4/19/19 to assert the right to leave the premises. When Resident #1 again left the premises on 4/24/19, an AMA (against medical advice) process was initiated by the facility. Facility staff, not the resident, initiated the discussion about discharge AMA when the resident was adamant about wanting to socialize independently outside the facility that day. Despite leaving and returning to the facility that afternoon at least twice, the facility moved forward with a less than orderly discharge to a hotel, alone and without care. This culminated in emergency services and transport to hospital for treatment of [REDACTED].",2020-09-01
40,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-05-01,745,J,1,0,IOQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to provide professional, medically related social services to ensure 1 of 4 residents sampled (Resident #1) attained their highest practicable physical, mental and psychosocial well-being related to trauma, new [MEDICAL CONDITION] with loss of independence, adjustment problems, and a history of [MEDICAL CONDITION]. Findings include: Per record review, the facility failed to ensure that the resident received appropriate treatment and services to correct his/her alcohol dependence, risk of isolation, feelings of loss of freedom and independence, and coping with an overall decline in health and function, as stated in the written plan of care and diagnoses. The resident, age 64, was rendered paraplegic by trauma and was admitted to the facility 6/27/18. Record review shows no evidence that the resident was referred for professional mental health assessment and/or professional, medically-related social services to address these issues of trauma, loss, addiction, and adjustment from admission through discharge 4/24/19. During interview on 4/29/19 at 12:30 PM, the social worker described having routine care conferences and doing some research to find placement closer to family. On 4/30/19 at 9:00 AM the Director of Nursing and Administrator related difficulty finding an alternate placement closer to home. Per interview with the Nurse Practitioner (NP), 4/30/19 at 9:35 AM, s/he confirmed that s/he was unaware of any psychological referral. Record review showed that at least 3 facilities had refused admission. The nearest family lives 2 hours away. During the above interviews, the Administrator, DNS, and NP referred to Resident #1 as non-compliant with various aspects of care and services. From admission through 1/22/19, Resident #1 was allowed 1 beer per day, and had a medical order for this. Due to an incident on 1/21/19 where staff observed Resident #1 allegedly having more than 1 beer with 2 other people, the medical order for 1 beer per day was discontinued. There was no evidence to suggest that Resident #1 received referral or treatment for [REDACTED]. Resident #1 did show a change in behaviors from that time until 4/24/19. This included an elopement on 4/19/19 to assert his/her right to leave the premises. When Resident #1 again left the premises on 4/24/19, an AMA (against medical advice) process was initiated by the facility. Despite leaving and returning to the facility that afternoon at least twice, indicating s/he had made a mistake, the facility moved forward with a less than orderly discharge to a hotel, alone and without care. This culminated in emergency services and transport to hospital for treatment of [REDACTED].",2020-09-01
41,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-05-01,842,D,1,0,IOQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review and interview, the facility failed to assure that 1 of 2 resident health records was accurately documented by the social work staff. (Resident #2). Finding include: 1. Per record review, Resident #2's care plan completed by the Social Worker (SW) dated 4/8/19, states Resident #2 has impaired/decline in cognitive function or impaired thought processes related to a condition other than [MEDICAL CONDITION]. The interventions include monitor conditions that may contribute to cognitive loss/dementia, including metabolic causes, respiratory problems, [MEDICAL CONDITION], delusions, hallucinations, psychiatric disorder, poor nutrition, hearing or vision impairment, new/acute heath problem, head injury, pain fever, dehydration or alcohol withdrawal. Evaluate needs for psych/behavioral health consult. Per record review of the Brief Interview for Mental Status (BIMS), which was completed upon admission by the social worker, states Resident # 2 has a score of 15. BIMS is used to obtain a snapshot of how well a person is functioning at the moment. A score of 13-15 is cognitively intact. SW stated that Resident #2 was mentally alert and cognitively intact. Per staff interview, the SW confirmed on 4/30/19 at 8:15 AM that the care plan for Resident #2 was inaccurate as written on 4/8/19 and the resident was mentally alert and cognitively intact. The SW did not correct the inaccurate documentation in the care plan prior to Resident #2's discharge on 4/25/19. SW stated the computer generated care plan auto populates and staff completing the care plan need to make adjustments as needed. Stated she/he should have revised the care plan.",2020-09-01
42,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-05-15,725,F,1,0,YQQB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, resident, family and staff interviews, reviews of medical records and staffing patterns throughout the facility, and personnel record review, the facility failed to assure that sufficient staff is present on all units during all shifts to safely meet the acuity levels of the residents living in the facility. This is a repeat deficiency, having been cited during the last 3 recertification surveys on (MONTH) 26, (YEAR), (MONTH) 14, (YEAR) and (MONTH) 24, (YEAR), again during a follow-up survey on (MONTH) 4, (YEAR), and most recently cited during a complaint investigation completed (MONTH) 13, 2019. Specifics are detailed below: Per interviews with 2 family members, 3 residents, 13 line staff members and the complainants from 8 reports to the Department of Licensing (DLP), comments and concerns from them to 3 surveyors who conducted the investigations, indicate that the facility does not have enough staff to meet the needs of residents. In an interview with with a family member on the 2nd floor on 5/12/2019 as supper was finishing, s/he reports that there is not enough staff to provide the necessary care to residents on that unit at mealtimes and on the evening and night shifts. S/he further reports that food preparation at the steam table and delivery of meals to residents is not efficient, and often the food is cold when it is served. Two residents, seated nearby, nodded in agreement. Per observation on 5/12/2019 at 5:30 PM, seven residents are eating dinner in the dining room, 1 is being fed by staff when a resident seated at the same table, is trying to eat but his/her dish has fallen into his/her lap, resulting in attempts by the resident to scoop fallen food from the table into eating utensils. This is not observed by staff until the surveyor commented. This resident is hunched over in his/her wheelchair, with their head nearly on the table. The resident does not respond when asked if they are in need of help. In an interview on 5/12/2019 at 5:30 PM on the 4th floor, 2 residents who wish to remain anonymous stated that the facility has, and has had for quite a while, trouble keeping staff. The first resident states that you have to wait when you need something and it's worse at mealtime. The resident continues that it's never like this when you (surveyors) are not here (commenting on the number of staff in the dining area). Additionally, both residents commented on how difficult it is that so many staff are contracted (traveling) staff. They say that while they try hard, the [MEDICATION NAME] don't know them and that some don't have their hearts in it. They also say that the facility continues to lose regular staff. In an interview on the same unit at 7:30 PM a resident stated that recently, the call light was on for 25 minutes when s/he really needed to use the bathroom, I almost didn't make it. In an interview on the 3rd floor on 5/12/2019 at 4:45 PM a Licensed Nursing Assistant (LNA) stated that it is difficult when so many staff are [MEDICATION NAME] because they are too busy to really get to know the residents. The elderly residents need a routine and get stressed with so many different faces. In an interview on 5/12/2019 7:05 PM an LNA, who generally works on the 4th floor, stated that Things are the worst they've ever been and continued to state that management doesn't pay attention and things never get resolved. Staffing is awful. It's not consistent. [MEDICATION NAME] need more orientation. Residents aren't happy because they aren't getting what they need. They have long waits for care. In interview on 5/12/2019 at 8 PM, an LNA stated it's very stressful and we're very short staff. At one time there were 2 LNA's assigned to the 3rd floor and there were 3 residents who needed 1:1 staffing and 5 residents who were 2 assist with only 2 LNAs on the unit. When asked how the LNAs managed to do everything, the LNA stated we put the 1:1's in recliners at the nurses station. The LNA stated I've had nurses tell me to transfer a person who is a 2 assist, alone. We can't ask another floor because they're short staffed too. Housekeepers answer call lights. On 5/13/2019 at 9:50 AM an LNA stated I do mostly 12 hour shifts. I've worked in other places but this place is different than most I've seen. Last week I worked a 7 AM to 3 PM shift and then came back for a 7 PM to 7 AM shift. During the 4 hours I was gone the residents in one of the rooms I worked in (on 4th floor) hadn't been changed and one was wet and the other was wet and had a bowel movement (BM). Neither had been changed in the 4 hours I was gone. I have been told by another LNA just turn the call lights off and get back when you get to it because you get in trouble if the call lights stay on. During meals the food gets cold while 2 people help set the residents up and serve the trays. There are never as many people helping when you (surveyors) are not here. On 5/13/2019, in the afternoon, an LNA stated a few weeks ago we had 3 residents who needed 1:1 and there were only 2 LNAs. We took them out by the nurses stations in chairs so whoever was there could watch them. On Easter I was on the 4th floor and I was the only LNA on that unit because of call outs. The On-call person refused to come in to help. Sometimes residents don't get the right food or what they want because the [MEDICATION NAME] don't know them. Currently, the facility utilizes 27 [MEDICATION NAME] to staff the 4 units: 16 LNAs (Licensing Nursing Assistants) and 11 LPNs (Licensed Practical Nurses.) 17 of these were on duty, throughout the facility, on 5/12/2019, working 8, 12 or 16 hour shifts. Staff who were interviewed indicate that they often work 16 hour shifts. The Matrix used on 5th floor to determine resident needs indicates that 14 of 32 residents have dementia/ [MEDICAL CONDITION], 7 have experienced a fall, 5 are on Hospice, 5 have pressure ulcers and 28 receive either diuretics, anti anxiety medications, antipsychotics, hypnotics, antibiotics or a combination of several of these. This is provided by the charge nurse on that unit, who also confirms that usual staffing for evening hours on 5th floor is 2 nurses, one for each med cart and, 3 LNAs (but with split hours there are some evenings where only 2 LNAs are on duty after 9:15) The night staffing on 5th floor is 1 nurse and 2 LNAs. Per observation, the acuity log that the facility is using to determine staff needs does not include input from the LNAs and does not contain numbers to indicate how many residents are on a toileting program or those who are incontinent. Nor does it contain transfer needs, how much assistance is needed for ambulation or position changes while residents are in bed. This is confirmed by the assistant director of Nursing, during interview on 5/15/2019 in the late afternoon. S/he indicates that they are working on putting that aspect into place. The facility has a monitoring system housed on the 5th floor that is used to monitor entry into the building after hours. It does not have the capacity to monitor the driveway, beyond the mid point heading towards the road. Besides their regular duties of caring for residents, staff on the 5th floor are responsible to respond when the front doorbell rings.",2020-09-01
43,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-05-15,730,B,1,0,YQQB11,"> Based on staff interview and record review, the facility failed to complete a performance review at least once every twelve months for four of seven nurse aides in the sample. Findings include: During review of a random selection of seven employee records on (MONTH) 15, 2019, four of the records did not have evidence of an annual performance review. Licensed Nursing Assistant (LNA) #1 was hired (MONTH) (YEAR) and the last performance evaluation was (MONTH) (YEAR). LNA #2 was hired in (MONTH) (YEAR) and LNA #3 was hired in (MONTH) (YEAR) with no evidence of performance evaluations for either being conducted since hire date. In review of the record for LNA #4, who was hired in (YEAR) and there was no evidence of an annual performance review. The Human Resource Director confirmed, during interview on (MONTH) 15, 2019, that the four employees did not have annual performance evaluations completed.",2020-09-01
44,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-06-26,609,D,1,0,NSOU11,"> Based on observations, record review, and interviews the facility failed to assure that a report of sexual abuse was made to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for Residents #2 & #3. Findings include: Per observations conducted during the survey both Residents #2 & #3 were observed to be fully mobile. Resident #3 has a BIMS of 15 and is his/her own decision maker and Resident #2 has Dementia and his/her Daughter is the decision maker for this resident. The residents were observed by both surveyors (separately) to spend time together and they interact playfully. Per record review Resident #2 was the Alleged Perpetrator in the intake which initiated this investigation. The accusation is that Resident #2 slapped Resident #3 in the face. In a second incident Resident #2 became upset and grabbed R#3's upper arm causing bruising. The facility reported the incident and it was investigated during this visit. When reviewing the record a progress note was found dated 6/2/19. The note stated that the residents were found seated in the back sitting area and Resident #2 had his/her hand up the shirt of Resident #3. Both residents were laughing and they were separated. There is no evidence that this incident was reported to the State Survey Agency. Additionally the facility Executive Director and the Director of Nursing Services stated that they were unaware of the incident.",2020-09-01
45,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-06-26,655,D,1,0,NSOU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 1 applicable resident (Resident #1) that included the minimum healthcare information necessary to properly care for the resident. Findings include the following: Per review of the medical record on 6/24/19 for Resident #1, the resident was admitted to the facility on [DATE] for hospice respite care. The care plan developed on 3/30/19 does not contain all the required topics to be addressed. The baseline care plan included some basic information on caring for this resident, however, it does not contain information regarding medications to be prescribed, physician orders, dietary information, social service needs and nothing related to hospice care needs. There was also no evidence that a summary of this plan of care was provided to the resident or resident representative. Confirmation was made by the Director of Nursing (DNS) on 6/24/19 at 1:45 PM, that the care plan did not address all the required aspects of care that are required in the regulation and that they did not document that a copy of or summary of the baseline care plan was given to the resident or their representative.",2020-09-01
46,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-06-26,658,D,1,0,NSOU11,"> Based on record review and staff interview the facility failed to assure that services provided meet professional standards of quality regarding doumentation of a health event, for Resident #4. Findings include: Per record review Resident #4 is very limited in speech due to cognition, and has a BIMS (a cognition assessment tool) of 3 indicating severe cognitive impairment. According to documentation the resident's speech was limited to 1-2 word statements. During the evaluation the resident was found to have a fractured right humerus. According to a written statement on 6/6/19 by the LNA, on 5/28/19 at approximately 5 am, the resident complained of pain when a Licensed Nursing Assistant (LNA) lifted the Right Arm to assist in dressing. The LNA immediately stopped moving the arm and went to report the complaint of pain to the 11 pm-7am nurse (the Licensed Pratical Nurse (LPN) on duty) as it was not usual for that resident. The LPN's written statement indicates that on 5/28/19 the resident was evaluated and when asked about the presence of pain would simply say my butt. The statement dated 6/4/19 indicates there was no bruising or discoloration in the Right shoulder/ arm. There was no grimacing or report of pain when the arm was touched' according to the statement. An LNA statement by a Day Shift LNA states that on 5/28/19 s/he went to get Resident #4 out of bed. When the LNA was trying to put the resident's shirt on the resident complained of pain. The LNA stopped and immediately went to get the LPN assigned to that resident's corridor on the day shift. The day LPN wrote in a statement that at 7-7:30 am on 5/28/19 that the LNA had come to have the nurse check Resident #4. Upon checking the resident the LPN found that the resident's R shoulder was lower than the other shoulder. It was also swollen and cold to the touch. The resident repeated hurt and my arm. The note also said, 'Spoke to the night nurse. No report of pain. Notified the NP {Nurse Practitioner} and RN {Registered Nurse} Both in to assess. The resident was sent to the ER (emergency room ) at 8 am. The written statement by the RN on Day shift states that the LPN called her to assess the resident. The resident showed non-verbal signs of pain. The APRN (Advance Practice Registered Nurse) saw the resident, ice applied, the MD (Medical Doctor) notified. In a review of the medical record for Resident#4 on 6/24-26/19 there are no progress notes by the facility LPN's or the facility RN regarding the events of the early morning hours of 5/28/19 when Resident # 4 complained of pain and was transferred to the ER. Upon transfer to the ER for evaluation the resident was found to have a fracture of her Right Humerus (long bone in the upper arm). In an interview on 6/24/19 at 9:30 am the LPN from the day shift stated that there had been nothing during morning report that indicated there had been an issue with Resident#4. S/he stated that when the LNA reported at 7 am the complaint of pain when Resident #4 was being assisted s/he asked the 11 pm-7 am LPN if there was anything different during the night for Resident #4 and s/he responded no there wasn't. The day LPN also stated that s/he had not documented anything regarding the incidents described for Resident #4 on 5/28/19. On 6/25/19 at 8 am, via telephone interview the RN on the Day shift confirmed that s/he had not documented her assessment of the resident or any other information in the resident record for the incident on 5/28/19. In an interview on 6/26/19 at 7:05 am the 11 pm-7 am LPN stated that her description of the events in her statement were accurate but she did not find any issues so she didn't write a progress note or mention what happened in report. In an interview on 6/26/19 at 10:45 am the Director of Nurses (DNS) confirmed that it is expected that nursing staff would have documented that events regarding the event on 5/28/19 for Resident #4.",2020-09-01
47,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2019-06-26,842,D,1,0,NSOU11,"> Based on record review and interviews the facility failed to assure that the medical record for Resident #4 were complete and accurately documented. Findings include: Per record review Resident #4 is very limited in speech due to cognition, and has a BIMS (a cognition assessment tool) of 3 indicating severe cognitive impairment. According to documentation the resident's speech was limited to 1-2 word statements. According to a written statement on 6/6/19 by the LNA, on 5/28/19 at approximately 5 am, the resident complained of pain when a Licensed Nursing Assistant (LNA) lifted the Right Arm to assist in dressing. The LNA immediately stopped moving the arm and went to report the complaint of pain to the 11 pm-7am nurse (the Licensed Pratical Nurse (LPN) on duty) as it was not usual for that resident. The LPN's written statement indicates that on 5/28/19 the resident was evaluated and when asked about the presence of pain would simply say my butt. The statement dated 6/4/19 indicates there was no bruising or discoloration in the Right shoulder/ arm. There was no grimacing or report of pain when the arm was touched' according to the statement. An LNA statement by a Day Shift LNA states that on 5/28/19 s/he went to get Resident #4 out of bed. When the LNA was trying to put the resident's shirt on the resident complained of pain. The LNA stopped and immediately went to get the LPN assigned to that resident's corridor on the day shift. The day LPN wrote in a statement that at 7-7:30 am on 5/28/19 that the LNA had come to have the nurse check Resident #4. Upon checking the resident the LPN found that the resident's R shoulder was lower than the other shoulder. It was also swollen and cold to the touch. The resident repeated hurt and my arm. The note also said, 'Spoke to the night nurse. No report of pain. Notified the NP {Nurse Practitioner} and RN {Registered Nurse} Both in to assess. The resident was sent to the ER (emergency room ) at 8 am. The written statement by the RN on Day shift states that the LPN called her to assess the resident. The resident showed non-verbal signs of pain. The APRN (Advance Practice Registered Nurse) saw the resident, ice applied, the MD (Medical Doctor) notified. In a review of the medical record for Resident#4 on 6/24-26/19 there are no progress notes by the facility LPN's or the facility RN regarding the events of the early morning hours of 5/28/19 when Resident # 4 complained of pain and was transferred to the ER. Upon transfer to the ER for evaluation the resident was found to have a fracture of her Right Humerus (long bone in the upper arm). In an interview on 6/24/19 at 9:30 am the LPN from the day shift stated that there had been nothing during morning report that indicated there had been an issue with Resident#4. S/he stated that when the LNA reported at 7 am the complaint of pain when Resident #4 was being assisted s/he asked the 11 pm-7 am LPN if there was anything different during the night for Resident #4 and s/he responded no there wasn't. The day LPN also stated that s/he had not documented anything regarding the incidents described for Resident #4 on 5/28/19. On 6/25/19 at 8 am, via telephone interview the RN on the Day shift confirmed that s/he had not documented her assessment of the resident or any other information in the resident record for the incident on 5/28/19. In an interview on 6/26/19 at 7:05 am the 11 pm-7 am LPN stated that her description of the events in her statement were accurate but she did not find any issues so she didn't write a progress note or mention what happened in report. In an interview on 6/26/19 at 10:45 am the Director of Nurses (DNS) confirmed that it is expected that nursing staff would have documented that events regarding the event on 5/28/19 for Resident #4.",2020-09-01
48,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2017-08-14,247,B,1,0,DTTL11,"> Based on record review and staff interview, the facility failed to provide a written notice, including reasons for the change prior to receiving a roommate and/or a room change for 2 of 4 residents in the applicable sample (Resident #2 & Resident #3). The findings include the following: 1.) Per record review, Resident #2 had received a new roommate at the beginning of (MONTH) (YEAR). There was no evidence that a written notice was given to Resident #2 regarding receiving a new roommate. Per interview with Resident #2 s/he stated that s/he did not receive any notice regarding receiving a new roommate. Per interview on 8/14/17 at 11:18 AM with the Director of Social Services, s/he confirmed that there was no written notification for Resident #2 regarding receiving a new roommate. 2.) During record review it was found that Resident #3 had been temporarily transferred to a different room on a different unit while his/her room was being worked on. This transfer occurred on 6/16/17 and during an interview with Social Services at 2:38 PM, s/he confirmed that the transfer had been discussed with the guardian for Resident #3. S/he further stated that written notice was not given to the resident because s/he doesn't understand and there was no written notification given to the guardian. The social worker stated that the room change was only for a few days and that is why notification was not given in writing.",2020-09-01
49,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2017-08-14,356,C,1,0,DTTL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and confirmed by staff interview the facility failed to post nurse staffing information as required. The findings include the following: Upon arrival to the facility on [DATE] at 8 AM, the daily staffing information posted in the lobby, (available for public review), is dated 8/2/17. Per interview with the Director of Nurses at approximately 8:35 AM, confirmation was made that the staffing has not been posted daily as required and that the last information available for the public is dated 8/2/17.",2020-09-01
50,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2017-08-14,514,C,1,0,DTTL11,"> Based on observation, staff interview and record review the facility failed to ensure that 1 of 5 sampled residents' medical records met acceptable professional standards and practices. For Resident #1 the findings include the following: Per medical record review, Resident #1 had a straight Catheterization on 5/15/17 at approximately 1:47 AM by the Licensed Practical Nurse (LPN). After two unsuccessful attempts a final attempt was conducted by the resident. The LPN confirms that 300-400 cc's of urine was obtained. Per review of the Treatment Administration Record, the LPN initialed the treatment as completed at that time. Per review of the progress notes, there is no documentation that evidences that the Catheterization took 3 attempts before Resident #1's bladder was relieved. Per interview with the LPN on 8/14/17 at approximately 11:45 AM, confirmation was made that h/she does not recall writing a progress note, nor can the LPN offer any explanation as to why the note was not written The Director of Nurses confirmed at the time of the telephone interview that there is no evidence in the Electronic Medical Record that a progress note was written. Per review of the facility policy titled Intermittent Catheter Insertion documentation identifies staff to document the reason for use of intermittent catheter; date and time; color, odor, amount, and description of urine; and patient's response.",2020-09-01
51,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2018-08-22,600,D,1,0,IWGT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > The facility failed to assure the resident's right to be free from sexual abuse for one resident, Resident # 1. Findings include: Per record review, on 8/10/18 Resident #1 was seated in a wheelchair by the nurses station. Resident #2 was noted to approach the resident, with a pillow in hand, and stand by the resident. Staff observed and noted that Resident #2 had exposed his penis and had rested it upon Resident #2's arm. Resident #2 was described as stroking his penis as it lay on Resident #1's arm. Both residents have cognitive impairment. The residents were separated and Resident #2 was returned to his room. Resident #2 had documentation in the electronic medical record (EMR), which reflected two previous incidents of exposing himself in public areas and incidents of urinating in public areas. Resident #2 was first care planned for Inappropriate Sexual Behaviors on 2/12/2018. The facility plan to prevent any further incidents included every 15 minute checks and for Resident #2 not to be within arms reach of other residents. The facility failed to provide the supervision to implement the care plan regarding not being within arms reach of other residents. In interview, the Director of Nursing Services stated that Resident #2 had a history of [REDACTED]. Using the reasonable person concept per CMS guidelines, having this type of non-consensual sexual contact occur would cause mental anguish to a reasonable person.",2020-09-01
52,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2018-08-22,656,D,1,0,IWGT11,"> Based on record review and staff interview the facility failed to assure the implementation of the comprehensive person-centered care plan for each resident, consistent with the resident rights for one resident, Resident #1. Findings include: Per record review, on 8/10/18, Resident #1 was seated in a wheelchair by the nurses station. Resident #2 was noted to approach the resident, with a pillow in hand, and stand by the resident. Staff noted that Resident #2 had exposed his penis and had rested it upon Resident #2's arm. The residents were separated and Resident #2 was returned to his room. Resident #2 had documentation in the electronic medical record (EMR), which reflected two previous incidents of exposing himself in public areas and incidents of urinating in public areas. Resident #2 was first care planned for Inappropriate Sexual Behaviors on 2/12/2018. The facility plan to prevent any further incidents included every 15 minute checks and for Resident #2 not to be within arms reach of other residents. In a review of the documentation of every 15 minute checks, care planned on 8/13/18, there are gaps in the checks as follows: No checks documented 5 PM-11 PM on 8/13/18; No checks documented 11:15 AM-11:15 PM on 8/14/18; Last documented check (from Midnight) on 8/15/18 is 7 AM; First documented check on 8/16/18 is at 3:15 PM; No checks documented for the 3-11 shift on 8/17/18 and 8/18/18; No checks documented on the 11-7 shift on 8/18/18; Last checks documented are on 8/19/18 on the 7-3 shift. There is another sheet dated 5/21/18 in this resident's binder but it does not have a name on it. Of note no resident's name appears on 5 of 10 pages of checks. In interview the Director of Nursing Services stated that no other documentation of 15 minute checks was available and staff wasn't always good about documenting the checks. In addition the DNS stated that 15 minute checks were discontinued on 8/21/18.",2020-09-01
53,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2018-10-24,655,D,0,1,73OO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to assure that a baseline care plan was developed for 1 resident (#312) who is on [MEDICAL TREATMENT] in a sample of 31. Findings include: Per record review, Resident #312 was admitted on [DATE]. The resident has [MEDICAL TREATMENT] every Tuesday/Thursday/Saturday related to End Stage [MEDICAL CONDITION]. The resident was admitted after a fall at home on 9/30/18 which resulted in a [MEDICAL CONDITION] femur. S/he is very alert and is aware of her/his fluid restrictions, stating there is an 1800 ml fluid restriction in place. The resident has been in the facility for 11 days, so no Comprehensive Care Plan is yet due or in place. There is no care plan for [MEDICAL TREATMENT] found in the initial baseline care plan. The unit Registered Nurse on duty confirmed, on the morning of 10/23/18, that there was no care plan for [MEDICAL TREATMENT] for this resident.",2020-09-01
54,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2018-10-24,656,E,1,1,73OO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, the facility failed to develop a written comprehensive care plan for 5 of 27 residents in the applicable sample (Residents #4, 18, 62, 72, 101). Findings include: 1. Per observation during initial tour of the unit on the morning of 10/22/18, the room of Resident #101 is posted with a sign asking visitors to check with a nurse, and a cart containing personal protective equipment is stationed near the door. During record review and staff interview, it is confirmed that Resident #101 has an infectious disease [DIAGNOSES REDACTED]. The written comprehensive care plan for Resident #101 does not contain specific strategies to direct staff in providing care with infectious disease precautions. On 10/23/18 at 4:03 PM, the Director of Nursing confirmed that no care plan section was developed for infectious disease precautions for Resident #101. 2. Per record review for Resident # 62, staff failed to include daily weights in the care plan. There is a physician order [REDACTED]. Per review of the weight log in the electronic medical record (EMR), there were 13 missed weights between 9/29/18 - 10/22/18. Additionally, the order for daily weights is not reflected in the resident's plan of care. This was confirmed by the Unit Manager on 10/23/18 at 1:47 P.M. 3. Per record review and observation during survey, Resident #4 is in a wheelchair and totally dependent on staff for activities of daily living. According to the medical record, the resident developed a pressure ulcer on their heel on 6/17/18. Although treatment was initiated and continued until it healed, a plan of care was never developed to reflect the actual skin breakdown. Per interview on 10/24/18 at 11:59 AM, the Unit Manager confirmed that there was a care plan for Skin Integrity risk, however that there was not a care plan developed for actual skin breakdown after the resident developed a pressure ulcer. 4. Per record review, Resident #72 had a care plan in place for being at high risk of skin breakdown with interventions in place. The resident developed a Stage 2 pressure ulcer on the coccyx on 9/21/18. The care plan did not reflect the development of the pressure ulcer. Per interview on 10/24/18 at 11:15 [NAME]M., the Unit Manager confirmed that the care plan had not been revised to indicate that Resident #72 had developed a pressure ulcer. 5. Per record review, Resident #18 is on precautions for [MEDICAL CONDITIONS] and the personal protective equipment for staff is noted at the door of the room. There is no care plan present in the record for precautions and/or [MEDICAL CONDITION]. The facility Director of Nursing Services (DNS) confirmed on the afternoon of 10/23/18 that there was no care plan available for Infection Control/ Precautions available for this resident.",2020-09-01
55,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2018-10-24,658,F,0,1,73OO11,"Based on record review and staff interview the facility failed to assure that the care plans for residents were developed, revised or reviewed and approved by a Registered Nurse for 22 of 31 residents (Residents# 312, 18, 61, 87, 108, 49, 62, 311, 309, 72, 31, 57, 25, 4, 101, 34, 6, 93, 20, 43, 42, 9) reviewed in the sample, and this has the potential to affect all residents of the facility. Findings include: 1). During the record reviews of care plans it was noted that for a majority of the care plans reviewed in the Electronic Medical Record (EMR), there were either entire care plans initiated or partially initiated by Licensed Practical Nurses (LPN's), or revisions by LPN's throughout the care plans reviewed. These care plans were for Residents# 312, 18, 61, 87, 108, 49, 62, 311, 309, 72, 31, 57, 25, 4, 101, 34, 6, 93, 20, 43, 42, 9. In an interview on the afternoon of 10/23/18, the Director of Nursing (DNS) confirmed that LPN's create and revise care plans. Further, there is no sign off by RN's approving the care plan and no process for RN's to review the care plans when completed or revised by LPN's. In the State Board of Nursing Scope of Practice & Decision Tree for RN, APRN, and LPN the following is stated: LPN role in assessment, planning, and implementation of a strategy of care: -LPNs may not independently assess the health status of an individual or group and may not independently develop or modify the plan of care. LPNs may contribute to the assessment and nursing care planning processes; however, patient assessment and care plan development or revision remain the responsibility of the RN/APRN/licensed physician/licensed dentist. -LPNs may not modify a patient care protocol. If the situation and/or data collected by the LPN are not clearly consistent with a protocol, the LPN must consult with the supervising professional or authorized provider before taking action or making a recommendation to a patient.",2020-09-01
56,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2018-10-24,690,D,0,1,73OO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that a resident with an indwelling catheter had complete physician orders [REDACTED].#25). Findings include: Per record review, Resident #25 was admitted to the facility at the end of (MONTH) (YEAR) with an indwelling Foley Catheter in place. Per review of the monthly physician orders [REDACTED]. There were also no orders to indicate how frequently to change the catheter. The doctor ordered a twice daily flush of the catheter by nursing to keep it patent and to clear sediment. Per review of the plan of care for this resident, there was no mention of the twice daily flushes, the size of the catheter, or how frequently to change it. The nurse on floor stated that they were the last one to change the catheter, and that they used the catheter and balloon size indicated by hospital notes, and confirmed that there were no orders from the primary care physician for these specifics in the resident's record. Per interview on 10/24/18 at 9:35 AM, the Unit Manager confirmed that the primary care physician had not written specific orders for the parameters of the Foley catheter since the resident was admitted , and that the plan of care had not been revised to reflect current treatment regarding the catheter.",2020-09-01
57,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2018-10-24,725,E,1,1,73OO11,"> Based on observation, record review and interview, the facility failed to ensure there was sufficient nursing staff to maintain the highest practicable physical, mental, and psychosocial well-being of each resident on at least two of four units reviewed. This is a repeat violation for the third consecutive re-certification survey. Sufficient nursing staff was also cited during the re-certification surveys on (MONTH) 14, (YEAR) and (MONTH) 26, (YEAR). Findings include: During the Resident Council group meeting held during survey, multiple residents (who wished to remain anonymous) complained of long wait times for staff to answer call bells. There were two residents who claimed to have had incontinence episodes due to an extended wait time for staff response to call bells. One resident complained that it was very difficult to find staff to assist if they had to use the bathroom during meal times. Other interviews were conducted with residents who are dependent on staff for basic activities of daily living. One resident stated that they had to wait 45 minutes to get assistance when they were in an uncomfortable position in bed and unable to reposition independently. Multiple residents reported long wait times to get into bed, especially those who needed a two person assist to transfer. Besides specific examples listed, a number of residents and family members (from four (4) family interviews) stated that there was not enough staff at the facility, including hearing frequent complaints from the Licensed Nursing Assistants that they were short staffed. Per review of the log of electronic call bell wait times for Units C & D (fourth and fifth floors), call light waits of 20 minutes or more were noted. Since these two units accounted for the majority of complaints of long waits, these were the units reviewed for the 24 hours of each day: On Unit C (4th floor): 10/20- Waits noted (minutes)- 27, 24, 35, 43, 68, 21, 26, 23, 58, 47; 10/21- Waits noted (minutes)- 23, 21, 23, 21, 43, 46, 25, 23, 38; 10/22 Waits noted (minutes)- 29, 20, 39, 31, 58, 22, 24, 23; 10/23 Waits noted (minutes)- 22, 21, 34, 24, 28; (note this is a partial day of survey) On Unit D (5th floor): 10/21-Waits noted (minutes)- 27, 37, 32, 25, 49, 56, 27, 30, 44, 50, 27, 32, 37, 36, 43, 37, 62, 27, 38, 32, 33, 38, 49, 66, 55, 34; 10/22 -Waits noted (minutes)- 28, 44, 40, 64, 23, 43, 40, 28, 58, 22, 26, 26, 27, 26, 52, 38, 47; Per observation on 10/22/18 at 10:30 AM Resident #309, who is recovering from a pelvic fracture, was seated in a bedside chair when the surveyor entered the room. The resident stated I had to get into my chair alone because I was hurting and no one came. The resident further stated, I know I'm supposed to wait for someone to come but I was on the commode and I was hurting too bad to wait anymore. At that point a Licensed Nursing Assistant (LNA) entered the room and observed Someone helped you out. I'm sorry I was so long. I was caring for another resident. The resident stated s/he had not been assisted but just couldn't wait and asked the LNA to put the slide board away, stating I didn't use it. The LNA did as asked and left the room. In reviewing the plan of care, the resident requires assistance to transfer and should use a slide board. The Registered Nurse (RN) on the unit stated that the resident should have had an assist to move to her/his chair.",2020-09-01
58,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2018-12-04,660,D,1,0,UZ5V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals for 1 of 8 sampled residents, (Resident #2). The findings include the following: Per record review Resident #2 was admitted to the facility on [DATE] after suffering a brain hemorrhage. A care plan meeting took place on 10/26/18 with resident and family present. Meeting notes identify that the resident plans to return home at his/her prior level of functioning. Per review of the resident centered care plan on 12/4/18, there is no evidence that a discharge plan has been developed that would assist Resident #2 in meeting the goal to return home. The Licensed Nursing Home Administrator, who is currently managing Discharge Planning, confirms on 12/5/18 at approximately 1 PM, that a discharge plan has not been developed.",2020-09-01
59,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2018-12-04,687,D,1,0,UZ5V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and confirmed by staff interview the facility failed to ensure that 1 applicable sampled resident (Resident #5) received proper treatment to maintain good foot health to prevent complications from the resident's health conditions. The findings include the following: Per review of medical record for Resident #5, identifies [DIAGNOSES REDACTED]. Physician orders dated 11/22/17, direct staff to conduct Diabetic Foot Care/Check daily observation of feet, toes ankles, soles noting any alteration in skin integrity, color, temperature and cleanliness. Inspect shoes for proper fit and excessive wear, check pedal pulses every night shift. Physician orders also identify, evaluation/treatment for [REDACTED]. Podiatry consult for mycotic nail debridement and treatment dated 5/11/16 as needed. Per review of the Treatment Administration Records (TAR) for the past three months, evidence that the nightly reviews have been conducted. Nurses progress notes reviewed back to (MONTH) (YEAR) document the following: -10/23/18: right foot nails thick/long and sore to touch, middle toe is twisted and into the back of toe. Left foot great toe thick/long and sore to touch, able to trim other four toes; -10/26/18: Diabetic Foot Care daily observation completed; -11/9/18: Diabetic Foot Care daily observation completed; -11/14/18: Care Plan meeting minutes: Identify that family had concerns related to toenails need clipping, podiatry appointment scheduled and was evaluated by attending physician, who sent notes to podiatry; -11/21/18: Licensed Practical Nurse (LPN) spoke with the attending physician relating family concern for the need for more immediate care for toe nails and feet assessment then the (MONTH) podiatry appointment. MD suggested family contact podiatry; -11/21/18: Family notified of Nurse Practitioner (NP) clipping of Resident #5's toe nails that will take place on 11/27/18 and family plan to keep (MONTH) podiatry appointment; -11/27/18: Family update regarding toe clipping. NP clipped nails except right fourth toe, identified possibility of a diabetic ulcer. Family requests a plan for regularly scheduled podiatry visits; Per review of physician progress notes [REDACTED]. Assessment questions diabetic ulcer, needs referral to foot clinic, needs debridement, and ulcer. Per review of NP progress note dated 11/27/18 at 9:45 AM, identifies toe nails trimmed successfully. Right 4th toe avoided, secondary to underlying possibility of ulcer on the tip of that toe connected adjacently to her thickened nail. Assessment identified severe Onychomycosis and diabetic history. Needs regular foot care. Per review of Resident #5's care plan that was last updated on 8/10/18, identifies the need for assistance for bathing, grooming and personal hygiene, who is a diabetic and requires a daily foot check. There is no evidence of a focus on the management of Onychomycosis, the possibility of a Diabetic ulcer and/or the need for regular foot care. Confirmation was made by the Unit Manager and the unit nurse on 12/3/18, that the unit secretary attempted to make an earlier podiatry appointment but was unsuccessful. There are few Podiatrists in the area and they are scheduling beyond the (MONTH) appointment. The UM had little knowledge regarding the foot problems of Resident #5 and required the assistance of the nurse who was included in the interview. Neither nurse identified that a referral had been scheduled to a foot clinic as suggested by the attending progress note dated 11/13/18. Per review of the Foot Care policy dated 3/1/18 identifies that the facility will provide foot care and treatment in accordance with professional standards of practice to prevent complications from the resident's medical condition(s). Per review of the facility policy titled Toe Nail Trimming, dated 3/1/18 identifies that toe nail trimming for those residents with diabetes, neurological disorder, [MEDICAL CONDITION] or [MEDICAL CONDITION] may only be conducted by a physician, mid-level provider, or a podiatrist.",2020-09-01
60,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2018-12-04,745,E,1,0,UZ5V11,"> Based on observation, record review and confirmed by staff interview the facility has failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of 4 of 8 residents sampled, (Resident #2, #3, #4, and #5). The findings include the following: Per review of the medical records for Residents #2, #3, #4, and #5 have various medical and psycho-social needs identified on their resident-centered care plans. Interventions also vary depending on the focus identified, some examples are to support residents and families, honor resident wishes, monitor for changes in behavioral patterns, assisting with coping mechanisms related to cultural differences, advanced directive management and assisting in the transition after hospitalization . Social Service notes were reviewed for the past quarter and do not support evidence that the social worker(s) delivered the interventions as identified in the care plans. Confirmation was made by the Nursing Home Administrator on 12/3 and 12/4/18 that there is no documented evidence that Social Services has provided medically-related social services as identified on each resident centered care plan.",2020-09-01
61,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2018-12-04,850,C,1,0,UZ5V11,"> Based on observation and confirmed by resident and staff interviews the facility has failed to have a qualified Social Worker on a full-time basis since 11/15/18. The findings include the following: Per intake information provided through 3 anonymous complaints, identified that social services have not been provided to residents since the abrupt resignation of the Social Service Director on 11/15/18. Confirmation was made by the Nursing Home Administrator on 12/3 and on 12/4/18 that the Director of Social Service contacted the facility on 11/15/18 via text message after being out for three (3) days, communicating that s/he would not be returning. The Administrator is in the process of replacing the Social Service Director and adding a Registered Nurse Discharge Planner. There is an assistant social work currently in the department, but does not meet the qualifications of Social Worker. The facility has obtained assistance of a qualified Social Service Worker, from a sister facility, but not on a full time basis. Per phone conversation on 12/5/18, the LNHA confirms that the plan is that the Social Worker will be at the facility approximately twenty-four (24) hours a week.",2020-09-01
62,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2018-12-04,921,D,1,0,UZ5V11,"> Based on observation and staff interview, the facility failed to provide a sanitary environment for 1 applicable resident (Resident # 1). Findings include: Per observation on 12/4/18 at 11:03 AM, there is brown colored matter on the toilet seat, inside the toilet, and on the raised toilet seat (with handles), in Resident # 1's bathroom. Both staff and Resident # 1 confirm that the Resident has not used the bathroom since admission on 11/2/18. Licensed Nurses Aide (LNA) staff stated that they empty the Resident's bedpan into the toilet. The LNAs also stated that they had not emptied the bedpan today and that the bathroom is cleaned weekly. This was confirmed by the unit nurse at the time of the observation.",2020-09-01
63,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2017-12-14,552,D,0,1,0QUX11,"Based upon record review and interview the facility failed to ensure that 1 of 3 newly admitted residents in the sample was informed in a timely manner of the care and services and consent to treatment that would be provided. (Resident #143) Findings include: 1. During record review, Resident #143's Electronic and hard copy medical record did not demonstrate that the resident was informed and provided, in a timely manner, a signed admission agreement for consent to treatment, care plans and Advanced Directives. The admission paperwork denotes that the resident was admitted the end of (MONTH) (YEAR), however, the admission paperwork was signed approximately one week later on 10/06/17. Per interview on 12/11/17 at 3:57 PM, the Social Worker (MSW) acknowledged that there should be a copy of the Advanced Directive in the chart and there would be documentation of the attempts to get a copy. The MSW stated the family member was out of town around the time of admission and normally there is follow up attempts. However, there is no evidence that the family was alerted for the need to bring in a copy if possible. The MSW confirmed the above. In addition, per interview with Admission Director on 12/13/17 at 4:01 PM, explained the expectation is that the Client Services Representative is given the admission packet to go over with the newly admitted resident. All paper work is expected to be signed at the time of admission. Resident #143 was identified as being able to sign the admission paperwork. The Admission Director was able to show a reminder via email on 09/29/17 to obtain this information. However, the chart and the hard copy folder demonstrated the admission paperwork was signed on 10/06/17, (the admission folder showed being completed on 10/07/17). The Admission Director at this time, confirmed the informed consent for treatment and information for services was not given in a timely manner.",2020-09-01
64,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2017-12-14,576,C,0,1,0QUX11,"Based upon interviews the Facility failed to assure that all residents have reasonable access to mail per their choice. This has the potential to effect all residents. Findings include: 1. During interview on 12/12/17 at 10:06 AM, eight active members of the Resident Council voiced concerns regarding not having access to their personal mail on Saturdays. Several residents stated it would be nice to get (mail) over the weekend and they were aware that U.S. postal service (USPS) mail delivery services happens elsewhere on Saturday. One resident stated that the mailman has been observed near the building. When asked why the mail is not delivered, one resident stated because I think there is no (facility) staff to sort the mail. Per interview on 12/13/17 at 1:20 PM the receptionist explained that when mail is delivered by the USPS, it is sorted unopened, by the type I.E. the resident's business mail is given to the Social Worker who then distributes it to the residents and all other resident's mail is sorted by the Activity department and with the help of volunteer residents then gets delivered to the resident. The receptionist stated mail is delivered for the residents, Monday though Friday but not on Saturday. When asked if residents can get their mail if they would like to, the receptionist acknowledged we asked the postal system, years ago, not to bring (resident mail) on Saturdays as there is no one is in this office to sort the mail, (by the respective departments).",2020-09-01
65,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2017-12-14,656,D,0,1,0QUX11,"Based on observation, record review and confirmed by staff interview the facility failed to implement the person-centered care plan for 2 of 23 sampled residents. The care plan has not been developed to maintain Resident #45's safety and prevent falls and Resident #27, for toileting needs. The findings include the following: 1). Per review of Resident #45's medical record, it identifies that the resident is at end stage Kidney Disease and has been receiving Hospice services. The resident is at risk for falls. In the month of (MONTH) (YEAR), falls have occurred on 12/1/17 and 12/11/17. The Interdisciplinary Care Plan identifies that Resident #45 is to be in a supervised area when out of bed. Per observation on 12/13/17 at 1:05 PM, Resident #45 was in the TV lounge, in a recliner and sitting upright with both legs elevated. No staff presence identified. At 1:07 PM an Licensed Nurse Aide (LNA) enters the lounge and removes lunch trays. At 1:15 PM an LNA walks through the area. At 1:30 PM, the Registered Nurse (RN) staff educator enters the lounge and sits with Resident #45. Fluids that have been sitting on the table in front of the resident, are offered. The RN provides the resident with a blanket and leaves the area. At 1:33 PM, the resident is sound asleep in the TV lounge unattended. At 1:40 PM the RN directs staff to assist the resident to bed. Per interview with the RN at 1:40 PM, confirmation was made. that the Resident #45, has been left unattended in the TV Lounge. S/He also confirms that care plan does identify that the resident is to be attended when out of bed. 2). Per observations, record review and an anonymous voiced concern, Resident # 27's care needs for toileting, per the care plans, were not implemented. Review of the care plan and Kardex denotes the following: Adhere to toileting plan every 2 hours upon arising .Provide (Resident #27) with extensive, assist of 1 for toileting .Use grab bar in bathroom for transfer When it is time for toileting (Resident) may respond better to telling (resident) that it is time to go to the bathroom rather than do you have to go to the bathroom. Per observation on 12/12/17 at 4:30 P.M., Resident #27 was being wheeled down to small dining area by the Activity staff. The activity person stated the resident was in a music activity (downstairs) plus another activity (on this floor) since before 2 P.M. Per interview at 5: 07 P.M., LNA #1 & LNA #2 acknowledged that since they came on the floor/shift at 2:45 P.M. they have not checked nor toileted the resident. They were aware of the 2 hour toileting plan but thought the resident was changed by LNA #3, who was working during the day and this evening. During interview, a short time late, LNA #3 stated that for this resident, per family wishes, other LNAs are assigned for perineal-care and like services and did not provide toileting LNA #3 was not aware of who provided the toileting care between 2:00 P.M. and 5:00 P.M. Per interview on 12/13/17 at 8:20 [NAME]M., the Activity Director (AD) acknowledged the resident had been in activities the day before, from just before 2 P.M.(music downstairs), and went to another activity from 3:00 P.M. to 4:30 P.M. (upstairs). Per continued observations on 12/13/17 the following occurred: 9:15 [NAME]M. resident observed on the Unit, wheeled to up a table in the TV area. 9:22 Resident looking around trying to signal nurse surveyor and asked go to the bathroom. There was no call bell or other method to alert staff if needed. The resident was unable to demonstrate the ability to self-propel. Nurse Surveyor was unable to find available LNAs at this time. All busy providing morning care in other resident's room. 9:35 [NAME]M.- LNA #1 acknowledged ''will be right there, almost finished here''. (In another resident's room) 9:54 [NAME]M. Activity Staff arrived and asked resident if (s/he) wanted to go to activity, which the resident replied yes and started to wheel her towards the nursing station. The nurse surveyor at this time stated that the resident has been waiting greater than half an hour for assistance to go to the bathroom. The Activity person then brought the resident back to the room and found another LNA #2. 10:00 [NAME]M. LNA #1 stated that (s/he) as well as LNA #2 were late today (weather) and didn't get in until 8:00 [NAME]M Neither LNA stated that they toileted resident #2 since they started work. 10:17 [NAME]M. The DNS was aware that staff did go around and do the toileting around 730ish but acknowledged that Resident #27 had no way to ask for assistance and staff were late in providing care according to the care plan, (greater than 2 hours).",2020-09-01
66,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2017-12-14,657,E,0,1,0QUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, record review and interview the facility failed to assure that the plan of care for 3 residents (80, 51 & 143) was revised to reflect necessary care and services. Findings include: 1). Per observation and interview on 12/11/17 at 2:45 P.M., Resident #143 had a bandage on the left foot near the great toe. The resident stated that the toe nail got ripped off when staff were putting on ([NAME]) stockings, but had seen the physician and is healing. Per record review, on 11/06/17 the nursing progress note stated that therapy alerted nursing staff of dried blood surrounding the left great toe. A new order to cleanse, apply triple antibiotic ointment and Band-Aid every day shift until healed was issued. Resident had stated I don't know when my stockings have not been taken off. A new order was placed to remove stockings at bedtime. The Resident was made aware of new orders. On 11/18/2017, a Skilled Nursing Therapy progress note states ''Rx per MD order to right foot great toe which is presenting as a nail off with scant amount of serosanguinous drainage. It is tender to the touch. PT (physical therapy) and nursing is in agreement that TED hose should not be worn until wound completely heals . Two days later on 11/20/17 at 10:37 [NAME]M. entry in eMAR progress notes states Apply Jobst stocking in the AM and remove at HS .Rinse stockings and hang up to dry every day and evening shift for [MEDICAL CONDITION] Resident states 'My toenail is going to come off with those on. I don't think I should have them on.' Resident elevates bilateral legs in chair in room. Trace of [MEDICAL CONDITION] present. Per record review of the current (and recently revised) care plan demonstrates that the resident is to use TEDS stockings. Per interview on 12/12/17 at 3:28 P.M., the Unit Manager was unable to answer if the stockings were applied as indicated by the 11/20/17 eMar PN entry note, although acknowledged there was an order not use the stockings at that time. Additionally, the Unit Manager confirmed that the care plan and Kardex needed to be revised to reflect that the resident is not using compression stockings to ensure all staff follow the written plan of care. 2). Per record review of a note written by the Registered Dietician (RD), Resident #51 was changed to a Liberalized Renal Diet on 11/22/17 from a Liberalized Regular Diet. The resident is also on an 1,100 milliliter fluid restriction. There is no nutrition care plan found in the comprehensive care plan. There is no mention in any section of the plan of care of the change in diet, including in the End Stage [MEDICAL CONDITION] segment containing [MEDICAL TREATMENT] information. In an interview on 12/12/17 the RD stated that she does not complete a nutrition care plan on every resident, the diet change was requested by the [MEDICAL TREATMENT] RD, and that the resident is cognizant and is able to follow and direct her restrictions. 3) Per record review, the care plan for Resident #80 states to assess and record blood glucose levels twice a day. However, on 9/13/17 the physician discontinued the order to have blood glucose levels checked twice a day. On 9/14/17 a new order was written to begin blood glucose levels checks one time a day on Monday and Thursday. On 10/16/17 the physician discontinued the order to have blood glucose checked at all. On 12/14/17 in an interview with the unit manager s/he confirmed that blood glucose monitoring had been discontinued, but the care plan was never revised.",2020-09-01
67,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2017-12-14,677,D,0,1,0QUX11,"Based on observations, record review and interviews, the facility failed to assure that 1 of 23 residents in the sample, who are unable to carry out activities of daily living, receives the necessary services to maintain good nutrition, grooming, and personal and/or oral hygiene. (Resident #144) Findings include: 1).Per record review Resident #144 was identified but did not receive services as care planned for needing assistance with meals, set up, cueing and requiring nectar thick drinks. On 12/12/17 at 12:12 P.M. Resident #144 was observed in the dining area at a far table, slightly bent forward, out of reach of the table, with the soup bowl and drinks both having covered lids. An unidentified staff person asked the resident at 12:45 [NAME]M. {greater than half hour later} if help was needed and the resident replied well maybe. A small rolling, over the lap table was set up and the lids removed and a packet of thickener was added to the glass of milk. The LNA at 12:48 P.M. offered to help feed the resident. The LNA was not sure why the resident had not been fed yet, stating we all are supposed to help but I just found out (resident) had not been feed yet. At that time, the nurse surveyor intervened and pointed out that the soup bowl felt cool to the touch and perhaps the milk was not nectar thick. The unidentified staff confirmed one packet of 'thick-n-easy was added to the 8 oz (240 ml) cup of milk. {Per the packet direction, one packet is needed for every 4 oz (120 ml)}. The LNA then re-heated the soup and added another packet to the milk. Per interview at 1:00 P.M. the physical therapy assistant acknowledged that the resident was brought down to the dining area a little after 12:00 but did not stay to cue/assist. In addition, nursing staff working on this unit were observed assisting other residents with meals and answering call lights. During the greater than half hour wait, four facility employees {non nursing staff) who were present, including the food server, did not cue, assist with feeding nor provide the correct therapeutic amount of thickener for this resident. ALSO SEE F-725.",2020-09-01
68,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2017-12-14,684,D,0,1,0QUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 21 residents (Resident #24) regarding implementing physician orders. Findings include: Per record review a physician's orders [REDACTED].>400 ml (milliliters) two times a day for [MEDICAL CONDITION] (enlarged prostate). Per review of the Medication Administration Record [REDACTED]. Per interview on 12/13/17 at 3:13 PM with the Director of Nursing (DNS), s/he confirmed that the physician's orders [REDACTED]. Lippincott Manual of Nursing Practice (9th ed.). Wolters Kluwer Health/Lippincott[NAME] & Wilkins, pg 17.",2020-09-01
69,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2017-12-14,725,F,0,1,0QUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to assure sufficient nursing staff to provide consistent nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. Findings include: 1). During interview at the Resident Council meeting on 12/12/17 at 10:06 A M., the seven active residents that were present, strongly voiced there are issues around staffing and they all had to wait a period of time to receive help. They expressed that although they like the staff, there isn't enough of them and they're doing their best but sometimes it is just hard to wait. The Residents stated that there was no one specific shift or day of week, rather it depended on what unit needed help and then that shorts the other floors. One anonymous resident stated that, at one point, she wasn't turned for three hours and staff does not respond in a reasonable amount of time usually around meal times and in the middle of the night. 2). Based upon direct observation and confirmed through interviews staff did not provided the needed care and services for Resident #144 who needed dining assistance. On 12/12/17 at 12:12 P.M., Resident #144 was observed in the dining area at a far table, slightly bent forward, out of reach of the table, with the soup bowl and drinks both having covered lids. Although four facility (non-nursing) employees were in the dining area helping set up tables and serving the plates, none offered to cue and help feed this resident. The nursing staff (LNAs), who were helping other residents with meals and answering call lights, assisted this resident at 12:48 P.M. Resident #144 waited greater than half hour while other residents including the table mate, were served, ate and left the dining room. ALSO SEE F-677. 3). Per interviews with interviewable residents, who wish to be anonymous, on one unit, three of six residents stated that waits for assistance when the call lights are used are long. One resident stated that during meals and at change of shifts waits are 1/2 hour or more. Another resident stated that despite the fact that s/he should have assistance, there have been times when the wait was so long that s/he has gone to the bathroom without the required assistance. 4). In a requested interview with a family member of a resident, who wishes to be anonymous, staffing affects care. The family member, interviewed on 12/12/17, stated that the resident requires the assistance of two staff to safely ambulate. The resident should be ambulated 1-2 times a day and there have been days that this has not been done because staff was too busy or there weren't two people available. As a result the family member states that the resident's ability to ambulate has not improved and may have declined. Additionally when the resident was moved from a rehabilitation unit to a long term care unit the resident experienced new episodes of incontinence due to the lack of staff assistance. 5). In a review of the call light log response times are as follows: During the period of 12/7 10 am to 12/10/2017 9:34 pm there are 256 times when call light response times for units 3, 4 & 5 are longer than 10 minutes with some waits greater than 1 hour. During the period of 12/11 2:34 am to 12/14/2017 9:54 am the response times spread among units 3, 4, & 5 are as follows: 10-15 minutes- 184; 16-21 minutes- 53; 22-26 minutes- 34; 27-32 minutes- 14; 33 minutes and above- 15; The longest waits break down as follows: Unit 3: 34 minutes x2 35 min 38 min 40 min Unit 4: 43 min Unit 5: 33 min 35 min 38 min 46 min x2 47 min 48 min 49 min. 6). Per review of Resident #45's medical record, it identifies that the resident is at end stage Kidney Disease and has been receiving Hospice services. The resident is at risk for falls. In the month of (MONTH) (YEAR), falls have occurred on 12/1/17 and 12/11/17. The Interdisciplinary Care Plan identifies that Resident #45 is to be in a supervised area when out of bed. Per observation on 12/13/17 at 1:05 PM, Resident #45 was in the TV lounge, in a recliner and was sitting upright with both legs elevated. No staff presence identified. At 1:07 PM an Licensed Nurse Aide (LNA) enters the lounge and removes lunch trays. At 1:15 PM an LNA walks through the area. At 1:30 PM, the Registered Nurse (RN) staff educator enters the lounge and sits with Resident #45. Fluids that have been sitting on the table in front of the resident, are offered. The RN provides the resident with a blanket and leaves the area. At 1:33 PM, the resident is sound asleep in the TV lounge unattended. At 1:40 PM the RN directs staff to assist the resident to bed. Per interview with the RN at 1:40 PM, confirmation was made. that the Resident #45, has been left unattended in the TV Lounge. S/He also confirms that care plan does identify that the resident is to be attended when out of bed.",2020-09-01
70,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2017-12-14,761,D,0,1,0QUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews the facility failed to assure that drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Findings include: 5). During observation of the Medication storage room (Unit 3) on [DATE] at 11:10 AM, a small plastic container and a small metal box, which were locked, were stored in the medication refrigerator. However, the nurse did not have the correct keys to open them. It could be determined that there were items inside the containers, as evidenced by the rattling sound inside when picked up. The nurse stated that the keys needed to be found and were most likely controlled drugs but was not sure. The nurse found that the plastic box contained a 30 ml bottle of [MEDICATION NAME] for a resident who died several months ago (beginning of (MONTH) (YEAR)) and the metal container had four 1 ml vials of [MEDICATION NAME], which had to be pried opened as no keys were found. Review of the facility's policy and procedures Management of Controlled Drugs states below: #5 -Ongoing Inventory of Controlled Drugs (shift count) all Schedule II to IV at change of shifts or any time in which keys are surrendered from one licensed nursing staff to another, counting of schedule V is optional , but recommended; #6.2 Destruction will occur when drugs are discontinued, daily or a minimum of weekly; # 6.1.2 quantities of controlled drugs (e.g. discontinued outdated) maybe destroyed immediately OR stored awaiting destruction. During Interview on [DATE] @ 12:01 P.M. the Unit Manager (UM), acknowledged that according to the Narcotic Log Book the expected daily/shift counts were not done for period of four(4) months for the bottle of [MEDICATION NAME] , as well as for the [MEDICATION NAME] vials, for several months, which were in the metal box. The UM stated that the medications were not accounted for and destroyed according to the facility's policy and procedures and acceptable practices. 2.) During observation of the 5th floor medication storage room, a bottle of Beefeater gin with a resident's name on the label was noted to be locked in the refrigerator with insulin and the emergency medication box. Per interview with the DNS on [DATE] at 8:05 AM, s/he confirmed that the bottle of gin should not be in the medication refrigerator and removed it immediately.",2020-09-01
71,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2017-12-14,804,E,0,1,0QUX11,"Based on observation the facility failed to assure that food, served from a steam table, was served at a safe and and appetizing temperature. Findings include: Per resident interviews on 12/11 and 12/12/17 several residents of 11 initial pool candidates stated that the food was cold when served and the best meal was at breakfast. In observation at the lunch meal on 12/12/17 a test tray, served from the steam table, and sampled by two surveyors had the following: Soup which was at 82 degrees when checked, Roast beef and gravy was at 84 degrees, and mashed potatoes were at 118 degrees. The food temperatures, checked by the server before service, were reported to be at or above 140 degrees.",2020-09-01
72,BURLINGTON HEALTH & REHAB,475014,300 PEARL STREET,BURLINGTON,VT,5401,2017-12-14,880,E,0,1,0QUX11,"Based on observation and staff interview the facility failed to assure a sanitary environment in the dining area for 2 of 4 units and to assure that staff consistently implement handwashing after removing gloves to help prevent the development and transmission of communicable diseases and infections. Findings include: 1). Per observations during two days of survey, (12/11/17 & 12/12/17) on Unit 3, there was potential cross-contamination of resident food items caused by splashing of water from the hand-washing sinks. The hand-washing sinks, behind the counter and hot services table, had several stacks of plastic lids which are used to covered residents' bowls and cups. These item were on a small shelf above the hand washing sink as well as to the side of the sink, in near proximity. There were also clean plastic cups and several opened, partly used bottles of soda, in very near proximity, (less than 12 inches) to the faucet and handles. During the days of survey observations, facility employees, including therapy, administrative and nursing staff used the sink, while those items remained. Per Interview on the morning of 12/13/17, prior to breakfast, the food server stated the lids and the other items are kept there because it is easy to reach when the I plate the bowls and cups. However, the food server acknowledged I did think about that (water splashing up on the lids and glasses) so I guess they should be moved. The items were moved away from hand-washing sink. In addition, in response to the Resident Council Meeting held on 12/12/17 at 10:00 [NAME]M. concerns were raised about the dining tables not always being thoroughly cleaned. During observation on 12/13/17 at 11:45 [NAME]M. (after breakfast but before lunch) several tables on Unit 3 dining area were noted to have a build up of sticky and/or dried food debris around edges and sides of the tables. This was brought to the attention of staff present who cleaned the tables at once. 2). Per observation, during the first two days of survey, the food guard on the steam table was spotted with splashes of food and other spots both on the inside and the outside and food debris was noted around the steam table pans. The server stated that the food guard was to be cleaned every evening after dinner and confirmed that the guard was not clean. 3.) Per observation on 12/11/17 at 2:19 PM of a dressing change for Resident #393, a Registered Nurse (RN) washed his/her hands, gathered supplies and entered the resident's room. The RN donned clean gloves and measured the wound on the Resident's left gluteal fold. The RN then removed his/her gloves and put the soiled gloves on the window sill in the resident's room. Without washing his/her hands, the RN donned clean gloves and proceeded to clean and dress the Resident's wound. The RN removed his/her soiled gloves, touched the Resident's tube feed pump, started the tube feed, and then proceeded to the bathroom to wash his/her hands. On 12/11/17 at 2:30 PM the RN confirmed that s/he left soiled gloves on the window sill during the Resident's dressing change. The RN further confirmed that the facility policy was to wash hands with an alcohol based sanitizer and/or soap water after removing gloves.",2020-09-01
73,HELEN PORTER HEALTHCARE & REHAB,475017,30 PORTER DRIVE,MIDDLEBURY,VT,5753,2018-02-28,567,B,0,1,TV7Z11,"Based on interview and record review the facility failed to assure that residents have reasonable access to their personal funds. Findings include: Per interview on 2/26/18 at 4:52 PM with Resident # 84, s/he stated that s/he was not able to get his/her money on weekends. Per interview on 2/28/18 at 10:47 AM with the social worker, s/he stated that the individual who handled the residents' personal funds was at the facility Monday through Friday until 4:30 PM. S/he stated that residents' were not able to get their money on evenings and/or weekends unless prior arrangements were made.",2020-09-01
74,HELEN PORTER HEALTHCARE & REHAB,475017,30 PORTER DRIVE,MIDDLEBURY,VT,5753,2018-02-28,585,C,0,1,TV7Z11,"Based on staff and resident interview and record review the facility failed to establish a grievance policy that ensures the prompt resolution of all grievances and protection of residents' rights. Findings include: Per interview on 2/27/18 at 3:11 PM with the Resident Council, it was discussed that not all residents were aware of the grievance procedure. Per review of the facility's current Grievance Procedure for Residents dated 2/11/16, it did not contain the contact information of the grievance official. Per interview at 1:25 PM with the Administrator, s/he confirmed that the facility grievance policy was not updated with the necessary regulatory requirements and was in the process of being updated. S/he further stated that information needed to be included about the Ombudsman and Grievance official. The facility provided additional information which contained a copy of the grievance procedure that was given to residents on admission. In reviewing this information, there was no information stating that the resident has the right to make an anonymous grievance. There was also no contact information for the grievance official; nothing documented about the right to obtain a written decision; the immediate reporting of all alleged violations involving neglect, abuse, including injuries of unknown origin, and/or misappropriation of resident property; and there was no information that stated the results of all grievances will be maintained for a period of no less than three years.",2020-09-01
75,HELEN PORTER HEALTHCARE & REHAB,475017,30 PORTER DRIVE,MIDDLEBURY,VT,5753,2018-02-28,655,D,0,1,TV7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to provide 2 of 23 sampled residents (Resident #58 and #194) and their representative, a summary of the baseline care plan that includes, but is not limited to: 1) the initial goals of the resident, 2) a summary of the resident's medications and dietary instructions, 3) any services and treatments to be administered by the facility and personnel acting on behalf of the facility and 4) any updated information as necessary. The findings include the following: 1. Per record review, Resident #194 was admitted on [DATE]. Review of the Electronic Medical Record (EMR) identifies that a baseline care plan was developed for this resident within the forty-eight (48) hour time frame. However, there is no evidence that the resident and or family representative was provided with the necessary information as outlined above. The Director of Nurses (DNS) confirms, during interview on 2/27/18 at approximately 2:45 PM, that the required information in the 48-hour care plan was not provided to the resident and /or representative. 2. Resident #58 was admitted to the facility on [DATE], and a baseline care plan had been developed. Per interview on 2/28/18 at 2:33 PM with the social worker, s/he stated that the written summary of the baseline care plan was not provided to the resident and/or resident's representative. S/he further stated that the facility had not been providing the resident and/or resident's representative a written summary per the new regulations.",2020-09-01
76,HELEN PORTER HEALTHCARE & REHAB,475017,30 PORTER DRIVE,MIDDLEBURY,VT,5753,2018-02-28,880,D,0,1,TV7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections for 1 resident in the applicable sample (Resident# 148). Findings include: Per observation on 2/27/18 at 9:47 AM of a disconnection of an intravenous (IV) tubing from a peripherally inserted central catheter (PICC-a line to help access the blood stream), a Registered Nurse (RN) donned gloves; touched his/her pocket, and then with the same gloved hands disconnected the IV tubing from the connector of the PICC line. With the same gloved hands, s/he proceeded to scrub the connector with alcohol for approximately 2-3 seconds; and then attached a saline (salt water) syringe to flush the line. Per interview with the RN at that time s/he confirmed that s/he touched multiple surfaces prior to disconnecting the IV tubing from the PICC line and stated that s/he should have removed his/her gloves, sanitized his/her hands and donned new gloves prior to disconnecting and flushing the PICC line. When asked how long s/he was to scrub the connector end of the IV extension of the PICC line, s/he stated approximately 10 seconds. Per review of the policy titled Flushing Peripheral Catheter and Midline it read, 5) Cleanse needleless connector end of IV extension set with alcohol or [MEDICATION NAME] pad x 20-30 seconds. Allow to air dry. Per observation on 2/27/18 at 10:10 AM of a PICC line dressing change, a RN donned gloves, touched the resident's pillow, touched the resident's arm, removed the old dressing, disposed of the old dressing, and then removed his/her gloves. Without sanitizing his/her hands, the RN opened up the package that contained the sterile dressing, donned sterile gloves, proceeded to clean the exit site of the PICC line, and then applied a new dressing to the site. Per interview with the RN at that time s/he stated that s/he had washed his/her hands prior to the procedure and did not need to wash/sanitize after removing the gloves as long as s/he did not touch anything that was contaminated. Per interview on 2/28/18 at 8:59 AM with the Infection Prevention RN, s/he stated that when gloves were removed for any reason staff needed to wash and/or sanitize their hands prior to donning a new pair. Per review of the policy titled Central Line Dressing Change Procedure it read, 1) Perform hand hygiene; 2) Gather supplies; 3) Explain procedure to patient; 4) Place patient in comfortable position; 5) Perform hand hygiene; 6) Set up sterile field with supplies; 7) Put mask on patient and operator; 8) Perform hand hygiene; 9) Put on non-sterile gloves; .13) Remove gloves and discard; 14) Perform hand hygiene; 15) Put on sterile gloves.",2020-09-01
77,HELEN PORTER HEALTHCARE & REHAB,475017,30 PORTER DRIVE,MIDDLEBURY,VT,5753,2017-03-16,280,D,0,1,LMI011,"Based on observation, interview and record review the facility failed to revise a comprehensive care plan for 1 of 19 sampled residents in the Stage 2 survey for Resident #33 as it relates to anxiety after a resident to resident altercation. Findings include the following: Per review of the Nurse Notes and facility Internal Investigation dated 12/17/16, Resident #33 and Resident # 35 had an altercation in the Community Room. As a result of the altercation, Resident #33 developed anxiety related to getting bumped, especially his/her feet. Per review of Interdisciplinary Care plan dated 1/24/17 a problem was initiated identifying anxiety about getting bumped, especially his/her feet. This was 38 days after the incident, when Resident #33's left great toe had been rolled over with a wheelchair by Resident #35. Per interview with the Charge Nurse on 3/16/17 at approximately 12:56 PM, confirmation was made that the care plan was not updated until 1/24/17.",2020-09-01
78,HELEN PORTER HEALTHCARE & REHAB,475017,30 PORTER DRIVE,MIDDLEBURY,VT,5753,2017-03-16,281,E,0,1,LMI011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to provide evidence that wounds were assessed and documented according to accepted professional standards for 2 residents with pressure ulcers in a sample of 3 reviewed, Resident #130 and #202. Findings include: 1). Per record review Resident#130 has a Deep Tissue Injury (DTI) to his/her Left (L) heel. The resident was admitted to the facility on [DATE] with a documented DTI on his/her Left Heel. In the Electronic Medical Record (EMR) there are Skin notes in the Nursing documentation that on 10/25/2016 Resident #130 is noted to have scab(s) dark scab intact to left heel. Approx (approximately) the size of a nickel. Receives turning/repositioning program. float heels-pillow scab(s) intact on left heel otherwise skin intact. Skin intact to the left heel pressure ulcer. A note dated 11/2/16 states scab(s) DTI continues to L Heel. scab(s) knee Rt.(right)( heel, 2 cm (centimeter) diameter. A note dated 11/10/16 states scab(s) intact to L heel (DTI). float heels-pillow. Skin intact, 3-4 cm dark circular spot, dry. Elevated heels.scab(s) (DTI) intact to left heel; heels elevated; skin prep applied; continue to monitor. Throughout the record, notes constantly have inconsistent content and wound descriptions. In an interview on 3/14/17 at 3:05 PM the Director of Nursing Services (DNS) stated that it is expected that when a wound is present it is evaluated/assessed daily and the documentation of that assessment will contain stage and wound measurements. In a review of the facility policy for Pressure Ulcer Management a clear description of wound evaluation includes wound measurement and staging of a wound and includes an attachment with illustration of various Pressure Ulcer stages. The DNS confirmed that each unit has the policy on the unit. In an interview on 3/15/17 at 2:25 PM a Registered Nurse (RN) stated that the measurement of wounds is done by either an Licensed Practical Nurse (LPN) or an RN and that staging of wounds, done only by an RN, is done about every two months on a chronic wound. (See also F314) 2). Per record review Resident #202 was admitted on [DATE] following a right [MEDICAL CONDITION] repair. The skin assessment from 3/1/17 at 23:26 (11:26 PM) noted that the Resident had an intact surgical incision on right hip, swelling to the right lower extremity just above the knee, and a small reddened area inside right buttocks that was not open and to which moisture barrier was applied. Upon further review of skin assessments for Resident #202, on 3/11/17 Resident #202 developed a blister on his/her right heel, with light serous (clear fluid) drainage; on 3/12/17 the blister on the right heel had light serous drainage; on 3/13/17 the blister on right the heel had light serosanguinous (fluid that is blood tinged) drainage, and at 21:59 PM the blister was open on the right heel with no drainage present. Per observation on 3/14/17 at 11:44 AM, the Resident's right heel had a beefy, red opened area, measuring 3 centimeters x 2.5 centimeters. Prior to the surveyor's observation on 3/14/17, there was no evidence of any measurements and/or staging of the wound in the medical record. Per interview on 3/15/17 at 1:35 PM with the DNS, s/he stated that s/he would classify a blister as a Stage 2 pressure ulcer and would expect a blister to be staged, measured and documented by the Registered Nurse who performed the skin assessment. Per interview on 3/15/17 at 2:44 PM with the Unit Manager s/he also confirmed that a blister would be a Stage 2 pressure ulcer and would expect the Registered Nurse performing the skin assessment to stage and measure the wound appropriately. Per review of the facility Skin Care Guidelines it states, Refer to the following protocols for alteration in tissue integrity related: prevention/treatment guidelines, pressure ulcers, friction and shear, incontinence/moisture, yeast/candidiasis, skin tears, non pressure skin injury (bruising). Prevention/Treatment Guidelines-Step 1: Recognition-Examine the patient's skin thoroughly to identify existing pressure ulcers. Step 2: Determine if the patient is at risk for pressure ulcers and manage pressure. Step 3: Characterize the pressure ulcer (staging) and assess the patient's overall physical and psychological health. (See also F309) *In a position statement article by the W[NAME]N Society (Wound, Ostomy, and Continence Nurses) it clearly states: Accurate and thorough documentation is essential for effective prevention and management of pressure ulcers. Good documentation must be comprehensive, consistent, concise, chronological, continuing and reasonably complete. (Ayello et al., 2009). According to Dahlstrom et al. (2011), initiation of appropriate treatment of [REDACTED].e., location, stage, and size), and ongoing measurements and descriptions of the wound are necessary to monitor the progression of the wound and the effectiveness of interventions. However, based on a retrospective chart review, Dahlstrom et al. found documentation of the characteristics of pressure ulcers was frequently missing key descriptors, such as the stage, location and size; and therefore, was not meeting quality guidelines. *Source: Wound, Ostomy, and Continence Nurses Society. (2017) W[NAME]N position paper: Avoidable vs. unavoidable pressure ulcers (injuries). Mt[NAME]NJ: Author. Copyright (YEAR) by the Wound, Ostomy, and Continence Nurses Society (TM) (W[NAME]N). Date of Publication: (MONTH) 22,2017.",2020-09-01
79,HELEN PORTER HEALTHCARE & REHAB,475017,30 PORTER DRIVE,MIDDLEBURY,VT,5753,2017-03-16,309,D,0,1,LMI011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents receive the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being and receive care and treatments in accordance with professional standards of practice for 1 applicable resident. (Resident #202) Per record review Resident #202 was admitted on [DATE] following a right [MEDICAL CONDITION] repair. The skin assessment from 3/1/17 at 23:26 (11:26 PM) noted that the Resident had an intact surgical incision on right hip, swelling to the right lower extremity just above the knee, and a small reddened area inside right buttocks that was not open and to which moisture barrier was applied. Upon further review of skin assessments for Resident #202, on 3/11/17 Resident #202 developed a blister on his/her right heel, with light serous (clear fluid) drainage; on 3/12/17 the blister on the right heel had light serous drainage; on 3/13/17 the blister on right the heel had light serosanguinous (fluid that is blood tinged) drainage, and at 21:59 PM the blister was open on the right heel with no drainage present. Per observation on 3/14/17 at 11:44 AM, the Resident's right heel had a beefy, red opened area, measuring 3 centimeters x 2.5 centimeters. Prior to the surveyor's observation on 3/14/17, there was no evidence of any measurements and/or staging of the wound in the medical record. Per interview on 3/15/17 at 1:35 PM with the DNS, s/he stated that s/he would classify a blister as a Stage 2 pressure ulcer and would expect a blister to be staged, measured and documented by the Registered Nurse who performed the skin assessment. Per interview on 3/15/17 at 2:44 PM with the Unit Manager s/he also confirmed that a blister would be a Stage 2 pressure ulcer and would expect the Registered Nurse performing the skin assessment to stage and measure the wound appropriately. Per review of the facility Skin Care Guidelines it states, Refer to the following protocols for alteration in tissue integrity related: prevention/treatment guidelines, pressure ulcers, friction and shear, incontinence/moisture, yeast/candidiasis, skin tears, non pressure skin injury (bruising). Prevention/Treatment Guidelines-Step 1: Recognition-Examine the patient's skin thoroughly to identify existing pressure ulcers. Step 2: Determine if the patient is at risk for pressure ulcers and manage pressure. Step 3: Characterize the pressure ulcer (staging) and assess the patient's overall physical and psychological health.",2020-09-01
80,HELEN PORTER HEALTHCARE & REHAB,475017,30 PORTER DRIVE,MIDDLEBURY,VT,5753,2017-03-16,314,E,0,1,LMI011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to provide evidence that wounds were assessed and documented according to accepted professional standards for 1 resident with pressure ulcers in a sample of 3 reviewed, Resident #130. Findings include: 1). Per record review Resident#130 has a Deep Tissue Injury (DTI) to his/her Left (L) heel. The resident was admitted to the facility on [DATE] with a documented DTI on his/her Left Heel. In the Electronic Medical Record (EMR) there are Skin notes in the Nursing documentation that on 10/25/2016 Resident #130 is noted to have scab(s) dark scab intact to left heel. Approx (approximately) the size of a nickel. Receives turning/repositioning program. float heels-pillow scab(s) intact on left heel otherwise skin intact. Skin intact to the left heel pressure ulcer. A note dated 11/2/16 states scab(s) DTI continues to L Heel. scab(s) knee Rt.(right)( heel, 2 cm (centimeter) diameter. A note dated 11/10/16 states scab(s) intact to L heel (DTI). float heels-pillow. Skin intact, 3-4 cm dark circular spot, dry. Elevated heels.scab(s) (DTI) intact to left heel; heels elevated; skin prep applied; continue to monitor. Throughout the record, notes constantly have inconsistent content and wound descriptions. In an interview on 3/14/17 at 3:05 PM the Director of Nursing Services (DNS) stated that it is expected that when a wound is present it is evaluated/assessed daily and the documentation of that assessment will contain stage and wound measurements. In a review of the facility policy for Pressure Ulcer Management a clear description of wound evaluation includes wound measurement and staging of a wound and includes an attachment with illustration of various Pressure Ulcer stages. The DNS confirmed that each unit has the policy on the unit. In an interview on 3/15/17 at 2:25 PM a Registered Nurse (RN) stated that the measurement of wounds is done by either an Licensed Practical Nurse (LPN) or an RN and that staging of wounds, done only by an RN, is done about every two months on a chronic wound.",2020-09-01
81,HELEN PORTER HEALTHCARE & REHAB,475017,30 PORTER DRIVE,MIDDLEBURY,VT,5753,2017-03-16,371,D,0,1,LMI011,"Based on observation and confirmed by staff interview the facility failed to store food in 1 of 2 resident units according to professional standards for food service safety. The findings include the following: 1. Per observation and inspection of the Otter Creek kitchenette on 3/13/17 at approximately 11 AM, the refrigerator contained a small jar in a plastic bag labeled Salmon and identified the resident's name. The date on the plastic bag was 2/10/17 which was crossed out. There is no date identifying when the Salmon was placed in the refrigerator. Per interview with the Food Service Manger at approximately 11:30 AM confirmation was made that the plastic bag had been reused and there is no date identifying when the Salmon was placed in the refrigerator. 2. Per observation and inspection of the Otter Creek kitchenette on 3/13/17 at approximately 11 AM, the freezer contained a bag of approximately 5 frozen burritos. The bag was labeled with the resident's name and identified the contents, but the bag was stamped with an expiration date of 5/7/15. Confirmation was made by the Food Service Manger at approximately 11:33 AM that the bag was reused and the staff did not notice the date of expiration. Per interview with the Food Service Manager, refrigerated foods are kept for 3-5 days and frozen foods are kept for approximately 2 months then discarded. Facility policy Food Storage identifies that all foods that are opened or prepared will be stored in an approved container with an appropriate cover. Also will include a label that lists food item and date prepared or opened.",2020-09-01
82,HELEN PORTER HEALTHCARE & REHAB,475017,30 PORTER DRIVE,MIDDLEBURY,VT,5753,2017-07-17,323,D,1,0,BGUQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews and record review, the facility failed to provide adequate supervision to prevent an altercation for 1 of 4 residents, Resident #1. Findings include: Per record review on 7/17/17, Resident #1 has a [DIAGNOSES REDACTED]. Per record review, or per nursing notes, On 6/26/17 s/he was in the outer dining area waiting for lunch and was yelling out and banging on the table wanting his/her food. Per interview with the unit clerk at 11:58 AM on 7/17/17, s/he said that the behavior was not usual. The unit clerk further stated that s/he was in the process of getting the tickets ready for lunch when another resident, Resident #2, who was in an inner dining area got up from his/her table and came toward Resident #1 and called him/her a derogatory name. When staff heard this they intervened and stepped between the two residents. Resident #2 was directed back to his/her seat and within a few minutes, Resident #1 started to bang on the table and calling out again. When the unit clerk turned from the tray line with Resident #1's lunch tray, s/he saw Resident #2 hit Resident #1 with the flat palm of their hand. The unit clerk stated that these two residents have had a history of [REDACTED].#2 required a room change. Interview with the Licensed Nursing Assistant (LNA) at 12:21 PM , that prior to this incident the two residents had been bumping heads. S/he further stated that Resident #1 was sitting at the table and calling out, and Resident #2 tried to confront him/her and was calling him/her names, the unit clerk directed Resident #2 back to their own table, but did not ask anyone to keep an eye on him/her and confirmed that no one was watching either resident when Resident #2 got up and went after Resident #1 and hit him/her. Interview with the unit manager at 1:15 PM, s/he confirmed that there had been an altercation between the two residents prior to the incident that occurred on 6/26/17 and after the staff intervened to prevent an altercation, there was no follow supervision of either residents. S/he also stated that staff was aware that there was a history between the two residents and should have because of the yelling out behavior that Resident #1 exhibits, and the other incidents that have occurred with Resident #1, staff should have been alert and supervised resident #1.",2020-09-01
83,HELEN PORTER HEALTHCARE & REHAB,475017,30 PORTER DRIVE,MIDDLEBURY,VT,5753,2017-11-15,157,B,1,0,TBWB11,"> Based on staff interview and record review, the facility failed to provide notification of room change for 2 of 2 residents in the applicable sample, Resident #2 and 3. Findings include: During interview with Resident #2, on 11/15/17, the resident stated that s/he liked his/her new roommate. The resident further stated that s/he had been moved to his/her current room a while ago and there had been a couple of different roommates. There was no evidence, during record review, that notification had been provided to Resident #2 prior to placement in current room. Further record review presents that Resident #2 was also transferred from her current room to another room on a temporary basis and then returned to the current room and there is no evidence that notification was given regarding the room change. Confirmation made by Social Service at 3:00 PM that it appears that no notification was provided to the current room. Review of the medical record for Resident #3 had a room change between 9/6 and 9/29/17 and there is no evidence that s/he had been given a notification of room change. Confirmed at 3:00 PM by the social service that notification was not given prior to the the room change.",2020-09-01
84,HELEN PORTER HEALTHCARE & REHAB,475017,30 PORTER DRIVE,MIDDLEBURY,VT,5753,2017-11-15,225,D,1,0,TBWB11,"> Based on staff interview and record review, the facility failed to report an allegation of verbal abuse for 1 resident, Resident #2. Findings include: During record review, a social service note for Resident #2, dated 8/22/17 presented that the Registered Nurse (RN) Unit Manager and the Social Worker met with the resident in the morning as s/he had reported to the medication nurse that a Licensed Nursing Assistant (LNA) yells at him/her. The resident said that the LNA doesn't let him/her do what s/he wants and takes things from him/her. S/he further stated that the LNA acts like they are the boss. Per interview with the RN at 3:00 PM, the allegation had not been reported to the Director of Nursing or to Adult Protective Services or the Division of Licensing and Protection. The RN further stated that the s/he and the social worker did not think it was reportable, but did confirm that it was an allegation of verbal abuse against the LN[NAME]",2020-09-01
85,HELEN PORTER HEALTHCARE & REHAB,475017,30 PORTER DRIVE,MIDDLEBURY,VT,5753,2017-11-15,281,D,1,0,TBWB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to adhere to professional standards of quality regarding implementation of physician orders [REDACTED].#1. Findings include: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The resident received the [MEDICATION NAME] twice a day, once in the morning and the second dose at 12 noon. On 8/20/17 nurse progress note states that '[MEDICATION NAME] held at 12 noon per daughter (POA) asked that due to weight loss, s/he and MD (Medical Doctor) agreed to holding afternoon dose unless pt (patient) is experiencing [MEDICAL CONDITION] sx. (symptoms).' There is no evidence that the physician was notified to confirm that the 12 noon [MEDICATION NAME] was to be held and no evidence that the physician was notified that it was held. The Registered Nurse, on 11/14/17 at 10:30 AM, confirmed that the medication was held and that the physician order [REDACTED]. Reference: Lippincott Manual of Nursing Practice (9th edition). Wolters Kluwer Health/Lippincott[NAME] & Wilkins, page 17.",2020-09-01
86,THE PINES AT RUTLAND CENTER FOR NURSING AND REHABI,475018,99 ALLEN STREET,RUTLAND,VT,5701,2018-06-28,580,D,0,1,WX2411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family and staff interviews and record review, the facility failed to notify the resident's representative immediately at the time of a significant change in condition; and of a room change, for 2 residents in the applicable sample (Resident #92 and Resident #372). Findings include: 1. Per record review for Resident #92, progress notes identify the following: -6/12/18 at approximately 23:15 (11:15 PM), the resident complained of not being able to swallow and the resident's tongue was slightly swollen. Supervisor notified; -6/13/18 at approximately 02:20 (2:20 AM), the resident still complaining of not being able to swallow well and tongue more swollen. Hospice Nurse notified and will come into the facility to assess the resident; -6/13/18 at approximately 03:00 AM, Hospice Nurse assessed the resident and concluded the resident was having a reaction to the antibiotic, that began on 6/12/18. Nurse Practitioner (NP), contacted and orders received for treatment; -6/13/18 at approximately 03:45 AM, medications administered; -6/13/18 at approximately 04:30 AM, Hospice Nurse left the facility, but provided nursing staff with instructions if condition changes; -6/13/18 at approximately 07:00 AM, resident still complaining of trouble swallowing and tongue remains swollen; -6/13/18 at approximately 07:34 AM medication administered for [MEDICATION NAME] ( a severe, potentially life-threatening allergic reaction); -6/13/18 at approximately 08:00 AM NP on site, assessed resident and injectable medications administered; -6/13/18 at approximately 11:34 AM progress notes identify family communication. Per family interview on 6/25/18 at 12:00 PM, on 6/27/18, and on 6/28/18 at approximately 12:30 PM, the notification of Resident # 92's allergic reaction/[MEDICATION NAME] did not occur until 6/13/18 at approximately 7:20 AM. Per interview on 6/27/18 with an Administrator from Hospice, s/he confirmed that the hospice nurse was on site on 6/13/18; and did not notify the family of the resident's condition at the time of his/her assessment/visit. 2. Per record review Resident #372 was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] on 6/26/18. There was no evidence in the medical record that the resident and/or resident's representative was notified of the room change prior to the room change taking place. Per interview on 6/27/18 at 8:24 AM with the social worker, s/he confirmed that the resident and/or resident's representative was not notified of the room change.",2020-09-01
87,THE PINES AT RUTLAND CENTER FOR NURSING AND REHABI,475018,99 ALLEN STREET,RUTLAND,VT,5701,2018-06-28,584,E,0,1,WX2411,"Based on observation and interview, the facility failed to ensure a safe and homelike environment for residents on the third and fourth floor. Findings include: 1. Per observation during the initial tour on 6/25/18 at approximately 9:24 AM the fire exit on the third floor, at the renovation site, was found to be partially obstructed. The door at the end of the hall marked Danger Authorized Personnel Only, was found to be partially obstructed by a mechanical lift stored to the left of the exit. The handle of the lift, was directly obscuring the door handle. Also identified at this time, in the same location, wheelchairs and a laundry cart was also stored. The equipment was observed being used during the three days but after use was returned to this location for storage. On 6/26/18 an inspector from the Division of Life Safety, confirmed the deficient practice to the surveyor at approximately 11 AM. The inspector immediately brought this to the attention of the facility administrator. On 6/27/18 at approximately 8:18 AM, the equipment was once again found to be stored obstructing the fire exit. The administrator was immediately notified by the surveyor. The administrator confirmed the equipment was blocking the fire exit. Per review of documentation provided by the Administrator, Memorandum dated 5/3/18 identified education provided to staff:, (Mitigation Plan: As a result of the diminished corridor width and blocked stairwell egress there will be a daily inspection of the area outside of the construction area to ensure no equipment is left blocking the corridor.). The administrator confirmed on 6/26/18 at approximately 3 PM, that staff observed the fire exit and corridor throughout the day/evening/night shifts. However, there were no no logs or documentation that identified the inspections were conducted. Education forms identify, sixty-three (63) employees were aware of the plan. 2. While doing observations on the fourth floor at 10:30 AM on 6/25/18, it was noted that the hallway contained linen carts, medication carts, mechanical lifts, meal delivery carts and empty wheelchairs on both sides of the hallway and in the middle of the hallway. There were mechanical lifts in front of the doorways of 2 resident rooms (421, 426). The Unit Manager stated that there was not enough space to store equipment while not in use. S/he confirmed that the lifts should not be in front of the doors to resident rooms. During further observation at this time, another room (423) which housed 3 residents had 6 wheelchairs that were stored in an empty corner of the room. Per the nursing staff, one of the residents used 2 different types of the chairs that were stored in the room, one of the other residents used a wheelchair, and the third resident occasionally used a wheelchair; however, was not using it currently. Per observation on 6/26/18 at 8:53 AM, the doorway to another resident's room (426) was partially blocked with a mechanical lift. There were also meal carts, linen carts, wheelchairs, mechanical lifts, and medication carts on both sides of the hall and in the middle of the hall making it difficult to pass by without having to move them. These observations were confirmed with a Registered Nurse at 9:15 AM, after the Vermont State Fire Marshall voiced concerns about the hall clutter and his/her observation of the resident's room (426) being blocked.",2020-09-01
88,THE PINES AT RUTLAND CENTER FOR NURSING AND REHABI,475018,99 ALLEN STREET,RUTLAND,VT,5701,2018-06-28,656,D,0,1,WX2411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a comprehensive care plan regarding nutrition for one resident in the applicable sample (Resident #2). Findings include: Per record review Resident #2 has a [DIAGNOSES REDACTED]. There was no evidence in the medical record that a care plan was developed to address acceptable parameters of nutrition for a resident on [MEDICAL TREATMENT]. Per interview on 6/28/18 at 11:29 AM with the Registered Dietitian (RD), s/he confirmed that a care plan was not developed.",2020-09-01
89,THE PINES AT RUTLAND CENTER FOR NURSING AND REHABI,475018,99 ALLEN STREET,RUTLAND,VT,5701,2018-06-28,658,E,0,1,WX2411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review the facility failed to assure that services provided met professional standards regarding following physician's orders [REDACTED].#20 and Resident #27). Findings include: 1. Per record review for Resident #20, there were two physicians' orders dated 1/7/18 that state to, document occurrence, intervention, and outcome. Target behavior: sad, weepy, isolates self, withdrawn every shift for monitoring of behavior interventions; and document occurrence, intervention, and outcome. Target behavior: restlessness, increased concern, agitation every shift for monitoring of behavioral interventions. Per review of Resident #20's progress notes and care plan, the resident had a potential to yell out and demand care and services related to [MEDICAL CONDITION] (decline in thinking skills caused by a reduced blood flow to the brain). Per review of the nursing progress notes, on 5/8/18, the resident was combative, refusing medications, yelling out, and swinging fists as staff. On 6/22/18, the resident was yelling out, cussing at staff and swinging fist at staff. On 6/28/18, the resident was yelling at another resident and staff requiring one to one staff interventions. There was no evidence of behavior monitoring in the medical record. Per observation on 6/25/2018, Resident #20 was isolated, withdrawn, and restless with increased concern and agitation. Per interview on 6/27/18 at approximately 10:00 AM, with the Unit Manager, s/he stated that any behavior monitoring was documented in the medical record and further confirmed that there was no behavior monitoring done for Resident #20. Per interview 6/27/2018 at approximately 10:15 AM with the Assistant Director of Nursing, s/he also confirmed that there was no behavior monitoring done for Resident #20. 2. Per observation on 6/26/18 at 8:30 am of a medication administration for Resident #27, the Licensed Practical Nurse (LPN), did not check placement of Resident #27's gastro-intestinal tube (tube in the stomach used to feed and/or give medications) prior to administering Resident #27's 9 AM medications. Per record review, Resident #27 had a physician's orders [REDACTED]. Per interview on 6/26/2018 at 9:30 AM with the LPN, s/he confirmed that s/he did not check placement of the gastro-intestinal tube prior to administering the medications. S/he stated that the gastro-intestinal tube was checked earlier in the shift as this was usual practice. Per interview on 6/26/2018 with the Unit Manager and the DNS, they stated that the usual practice was to check the gastro-intestinal tube once a day per the recommendation of the Wound Ostomy and Continence Nurse (W[NAME]N). References: American Nurses Association (2015). Nursing: Scope and Standards of Practice (3rd ed.). Silver Spring, MD: ANA (pg. 61). Lippincott Manual of Nursing Practice (9th ed.). Wolters Kluwer Health/Lippincott[NAME] & Wilkins, (pg 17).",2020-09-01
90,THE PINES AT RUTLAND CENTER FOR NURSING AND REHABI,475018,99 ALLEN STREET,RUTLAND,VT,5701,2018-06-28,921,E,0,1,WX2411,"Based on observation and confirmed by staff interview, the facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly and comfortable interior for 3 of the 3 units. The findings include the following: Per facility tour on all three units, in the presence of the Maintenance Director and the Housekeeping/Laundry Supervisor on 6/27/18 at 8:14 AM the following was discovered: -Numerous resident bathrooms were found with dusty bathroom exhaust vents; -Two resident commodes located in resident bathrooms were identified to be soiled with dry brown matter; -One resident who spends much of her/his time in bed, was found with a wall fan heavily caked with dust and grime and the ceiling tiles above the bed were spotted with brown matter; -One resident bathroom was found to have a ceiling tile peeling and discolored; -One resident bathroom had an exhaust fan/vent missing, the casing was caked with dust and had visible cobwebs. The vent area was not covered, and the space was vacant; -Numerous resident wheel chairs, bed side tables and equipment were found with accumulated dust and dried food splatters. A resident recliner was found with multiple tears and missing portions of the vinyl covering; -Two resident bathroom lights had bulbs that were not functioning; -In one resident room, the heating/air conditioning wall unit had a portion of the cover covered with cardboard that was taped in place with white surgical tape. The cardboard and tape were discolored. During the tour, both professionals confirmed that all of the above discovered conditions were in need of repairs and cleaning.",2020-09-01
91,THE PINES AT RUTLAND CENTER FOR NURSING AND REHABI,475018,99 ALLEN STREET,RUTLAND,VT,5701,2018-07-18,600,D,1,0,YLEU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff/resident interviews, the facility failed to ensure that 1 applicable resident was free from non-consensual sexual contact, (Resident #2),. The findings include the following: Per medical record review, Resident #1 was admitted in 2013, with [DIAGNOSES REDACTED]. Progress notes identify that the resident has had times when sexual comments have been directed toward care givers, but none towards other residents prior to the 7/9/18 incident. Interviews conducted by the State Surveyor on 7/18/18, identified that the resident rarely left his/her room, has an unsteady gait and is usually spends the day partially dressed. In the month of (MONTH) (YEAR) documentation identifies (8) eight occurrences of sexual comments towards staff and on one occasion hit a nurse aide during personal care. The resident was found on 3 occasions in the hall with the lower half of his/her body naked. Staff redirected the resident to his/her room without incident. Medication adjustment was made at the end of the month. In (MONTH) there were (3) three documented instances when Resident #1 made inappropriate sexual comments to the nursing staff. In (MONTH) (1) one incident of non-consensual sexual contact towards Resident #2. Per review of intake form, facility internal investigation, Med Options Assessment and Advanced Practice Registered Nurse (APRN) assessment all dated 7/9/18, identify that at approximately 7 AM, Resident #1 entered Resident #2's room, partially dressed and proceeded to fondle his/her breast(s). The perpetrator pulled the victim's sheet and blanket down to his/her feet/ankles, uncovering the resident and proceeded to attempt to remove the attached brief. During this deliberate action, Resident #1 voiced various suggestive sexual comments. The victim was unable to utilize the call bell for it was attached to the blankets/sheets that had been removed by Resident #1. Therefore, Resident #2, began to yell for help. The victim attempted to protect her/himself by demanding the perpetrator to leave the room. The victim pulled at Resident #1's, eyeglasses and beard. Resident #1 left the room and the victim was able to use the call light to request assistance. Per internal investigation and interviews conducted by the State Surveyor on 7/18/18 with Resident #2, RN, LNA, Social Services (SS) and Administration all confirm the occurrence as documented.",2020-09-01
92,THE PINES AT RUTLAND CENTER FOR NURSING AND REHABI,475018,99 ALLEN STREET,RUTLAND,VT,5701,2018-07-18,657,D,1,0,YLEU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews the facility failed to revise the Interdisciplinary Comprehensive Care Plan for 1 applicable resident reviewed, (Resident #1). The findings include the following: Per medical record review, Resident #1 was admitted in 2013 with [DIAGNOSES REDACTED]. Per Medication Management Assessment (Med Options) dated 5/20/18 and 5/29/18, completed by the Nurse Practitioner (NP), identifies target behaviors of changes in mood, Paranoia/Delusions and changes in appetite. The NP recommends a behavior health plan for [MEDICAL CONDITION] as follows: 1) Give him/her something to do with hands such as holding a blanket or stuffed animal, this will decrease the need for inappropriate touching; 2) Use diversion techniques such as turning on the TV/music (this will disrupt thinking); 3) If possibly create physical space; 4) Maintain eye contact and tell the resident the behavior will not be tolerated. Interdisciplinary Comprehensive Care Plan identifies that the resident has little or no activity involvement. Initiatives include that the resident prefers following television, hunting, baseball and fishing. The plan also identifies inappropriate sexual behavior with an initiative to identify inappropriate unacceptable behavior to the resident and to monitor behaviors to determine cause. The plan as identified by Med Options, is not specifically documented in the plan of care as recommended. The facility Administrator confirmed on 7/18/18, that the plan did address the resident's interests. The administrator also confirmed that the plan was not written exactly as the NP recommended, nor did the care plan identify the alarmed Stop sign or the barrier that was across the doorway. Per observation and interview on 7/18/18, with the nursing staff, Resident #1, has a barrier on the entrance of his/her private room that identifies Stop and is alarmed to alert staff of unwanted visitors that could have entered the room or that Resident #1 could have exited the room. Staff confirm that the resident spends most of his/her day in his/her room, is usually not fully dressed and on three (3) occasions in (MONTH) the resident was found in the hall with no pants on. S/He was redirected by the staff. None of this information is included on the Interdisciplinary Care Plan.",2020-09-01
93,THE PINES AT RUTLAND CENTER FOR NURSING AND REHABI,475018,99 ALLEN STREET,RUTLAND,VT,5701,2018-07-18,658,E,1,0,YLEU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and confirmed by staff interview, the facility failed to ensure that services provided meet professional standards regarding documentation of behaviors identified on the Medication Administration Record [REDACTED]. The findings include the following: Per medical record review, Resident #1 was admitted in 2013, with [DIAGNOSES REDACTED]. Per review of the Medication Administration Records (MAR) for the months of May/June/July (YEAR), it directs the nurse to document behaviors, interventions utilized and outcomes every shift. The following behavior interventions; 1). 1:1. 2) Redirect behavior; 3) toilet; 4) provide snack and outcomes are to be documented as improved, worsened or no change. The MAR indicated [REDACTED]. Per review of the progress notes dated May/June/July (YEAR), documentation evidences the following: -May - (8) eight occurrences when the resident made sexual inappropriate comments to the nursing staff and on (1) one occasion hit the nurse aide during personal care; -June - (3) three occurrences when the resident made sexual inappropriate comments to the nursing staff; -July - (1) one incident of non-consensual sexual contact of a resident. Confirmation was made by the Registered Nurse on 7/18/18 at approximately 11 AM that the nurses document on the MAR indicated [REDACTED]. If behaviors are identified, the nurse will further document in the progress notes. However, the documentation in the progress notes does not follow the direction identified on the MAR indicated [REDACTED]. (Lippincott Manual of Nursing Practice (9th ed.) Wolters Kluwer Health/Lippincott[NAME] & Wilkins.)",2020-09-01
94,THE PINES AT RUTLAND CENTER FOR NURSING AND REHABI,475018,99 ALLEN STREET,RUTLAND,VT,5701,2017-10-10,152,D,1,0,7SD111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interviews and record review the facility failed to adequately consider a choice made by the resident's representative on the formal side rail assessment for the use side rails on a bed for safety for one applicable resident (Resident #1). Findings include: Per record review, Record #1 has a [DIAGNOSES REDACTED]. S/he relies on his/her representative to make decisions regarding his/her care. S/he has had two documented falls at the facility on 4/30/17 and 5/7/17; and per a facility incident report dated 9/23/17, on 9/15/17, during the overnight shift, Resident #1 was found with his/her body askew and head resting on bedside mat. Per observation during the survey on 10/9/17 & 10/10/17, the resident had a bariatric bed with an air mattress and the bed did not have side rails. Per telephone interview on 10/5/17 at 9:48 AM with the resident's representative, s/he stated that s/he wanted Resident #1 to have padded side rails on his/her bed for safety. S/he stated that Resident #1 has already had two or three falls in the facility; and that when Resident #1 was in another facility, s/he had a bed with padded side rails and had no falls. During interviews on 10/9/17 and 10/10/17 with the Administrator and Director of Nursing, they confirmed that the resident's representative did want side rails used for Resident #1's safety. They stated that Resident #1 was not a candidate for side rails as the side rails posed more of a risk for Resident #1's safety. They stated that the facility has implemented multiple interventions to ensure that the Resident #1 is safe without the use of side rails. On 5/1/17, the facility evaluated Resident #1 for the use of side rails. The side rail evaluation inaccurately identified that the resident (in this case the legal representative) did not express a desire for siderails, stating, 1. Has the resident expressed a desire to have Side rails while in bed for their own safety and comfort? 'N' Interdisciplinary Team Recommendation: Side rails will not be used at this time. Per the previously stated interview, the resident's representative had repeatedly expressed a desire for the resident to have side rails while in bed for his/her own safety. There was also no evidence in the medical record that Resident #1 had been re-evaluated for the use of side rails since 5/1/17, which was prior to the second and third incidents. Per interview with the Unit Manager on 10/10/17 at approximately 12:59 PM, s/he confirmed that the resident had not been re-evaluated for the use of side rails since 5/1/17 and that the resident's representative had desired that side rails be used for Resident #1's safety.",2020-09-01
95,THE PINES AT RUTLAND CENTER FOR NURSING AND REHABI,475018,99 ALLEN STREET,RUTLAND,VT,5701,2017-10-10,280,D,1,0,7SD111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview and record review the facility failed to revise the care plan regarding use and monitoring of a chair harness for one applicable resident (Resident #1). Findings include: Per record review, Record #1 has a [DIAGNOSES REDACTED]. During observation on 10/9/17 and 10/10/17, Resident #1 was up in a wheelchair with a harness that covered his/her chest. The harness had two straps; the straps went over the resident's shoulders and then clipped in the back of the wheelchair, securing the resident in an upright position. The medical record did not have a physician's orders [REDACTED]. The Unit Manager and the Administrator confirmed this on 10/9/17 at 11:57 PM. Resident #1's care plan for falls read, (MONTH) use chair harness with staff and/or family supervision. There was no indication for use of the chair harness and what monitoring was to be done while the harness was on Resident # 1. The Unit Manager confirmed this on 10/10/17 at approximately 3:45 PM.",2020-09-01
96,THE PINES AT RUTLAND CENTER FOR NURSING AND REHABI,475018,99 ALLEN STREET,RUTLAND,VT,5701,2017-10-10,323,G,1,0,7SD111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews and record review the facility failed to provide adequate supervision or assistance devices to prevent accidents for one applicable resident (Resident #2). Findings include: Per record review Resident #2 has multiple [DIAGNOSES REDACTED]. Per review of Resident #2's activities of daily living care plan, s/he was non-ambulatory and required one assist with personal hygiene, dressing, and bathing. Per review of the nurse's notes dated [DATE], the nurse heard a sound, went to Resident #2's room and found the resident lying on his/her back between the beds on the floor. The Licensed Nursing Assistant (LNA) had been performing a bed bath at this time. Resident #2 was assessed and had a large hematoma (blood filled bump) and abrasion on his/her head. Resident #2 was sent to the Emergency Department via ambulance for an evaluation. Per physician progress notes [REDACTED].#2 was on comfort measures, had a fall during a bed bath at the nursing home, and had a consequent head injury. Per review of the facility incident report from [DATE], Resident #2 had expired on the evening of [DATE]. Per interview with a Licensed Nursing Assistant (LNA) on [DATE] at 10:00 AM, s/he stated that on [DATE] at approximately 4:00 PM, s/he walked into Resident #2's room to perform afternoon care. S/he gathered all supplies needed for care and set them on the bedside table. S/he had finished performing care on all of Resident #2's body except for his/her bottom area. S/he washed Resident #2's front and then positioned Resident #2 to cleanse his/her back. The LNA positioned Resident #2 on his/her right side with his/her left leg over the right leg. S/he stated that s/he turned his/her head away from Resident #2 for approximately 3 seconds to get some ointment; and as s/he turned his/her head back; Resident #2 had rolled off the bed and hit the floor. The LNA stated s/he was on the left side of the bed; the bed was at waist level, Resident #2 did not use side rails, and that Resident #2 was positioned in the middle of the bed, closer to the edge of the right side of the bed away from the LN[NAME] Per interview with a Licensed Practical Nurse on [DATE] at 2:05 PM, s/he stated that s/he was passing medications and was just in Resident #2's room and had seen the LNA performing care for Resident #2. S/he stated that s/he had left the room and seconds later s/he had heard a loud thud. S/he went into the room and found Resident #2 lying on the floor on his/her back in a pool of blood. S/he stated that the bed was in a high position and that the resident did not have side rails.",2020-09-01
97,THE PINES AT RUTLAND CENTER FOR NURSING AND REHABI,475018,99 ALLEN STREET,RUTLAND,VT,5701,2019-11-13,880,D,1,0,JRWS11,"> Based on observation and interview the facility failed to help prevent the development and transmission of communicable diseases and infections as evidenced by staff failing to follow hand hygiene procedures while providing care to 1 of 2 resident's in the applicable sample (Resident #1). Findings include: Per observation of morning care for Resident #1 on 11-13-19 at 9:10 AM, a Licensed Nursing Assistant (LNA) donned clean gloves, cleansed Resident #1's genital area, removed his/her gloves, proceeded to dress the resident, touch multiple items in the resident's room, then exited the room without sanitizing and/or washing his/her hands. Per interview on 11-13-19 at 9:40 AM with the LNA, s/he confirmed that s/he didn't wash his/her hands after removing gloves and should have. Per interview on 11-13-19 at 11:25 AM with the Unit Manager, s/he stated that the expectation of hand hygiene for incontinence (loss of control over bladder and bowels) care and/or any care is to wash prior to providing care, sanitize hands in between glove use. Per review of the policy Infection Control Handwashing it read, [NAME] Handwashing should take place: 8. After touching blood, all body fluids, secretions and excretions, non-intact skin, mucous membranes, and contaminated items-whether or not gloves were worn. 9. Immediately after gloves are removed and between resident contacts.",2020-09-01
98,ST JOHNSBURY HEALTH & REHAB,475019,1248 HOSPITAL DRIVE,SAINT JOHNSBURY,VT,5819,2018-01-03,757,G,1,0,1SPM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to ensure 1 applicable resident (Resident #1) was free from unnecessary drugs. Findings include: Per record review, Resident # 1 was administered the wrong drug on 11/2/17. A fax notice from facility nursing staff to the physician dated 11/4/17 stated that flu vaccine was drawn up in error instead of [MEDICATION NAME] solution and administered. (H/she) does have a flu vaccine allergy listed. Review of the Medication Administration Record [REDACTED]. A second fax to the physician on 11/4/17 indicated that Resident # 1 had developed a rash to abdomen and bilateral thighs, bilateral arms and back, hive-like and itching. At 1:10 PM on 1/3/18, the Center Nurse Executive (CEN) confirmed that on 11/2/17, Resident # 1 was administered Influenza vaccine on 11/2/17 instead of [MEDICATION NAME] solution despite having a documented allergy to flu vaccine.",2020-09-01
99,ST JOHNSBURY HEALTH & REHAB,475019,1248 HOSPITAL DRIVE,SAINT JOHNSBURY,VT,5819,2018-01-03,760,G,1,0,1SPM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to ensure that 1 applicable resident (Resident #1) was free from any significant medication errors. Findings include: Per record review, Resident # 1 was administered the wrong drug on 11/2/17 which caused the resident discomfort and/or jeopardized his/her health and safety. A fax notice from facility nursing staff to the physician dated 11/4/17 stated that flu vaccine was drawn up in error instead of [MEDICATION NAME] solution and administered. (H/she) does have a flu vaccine allergy listed. Review of the Medication Administration Record [REDACTED]. A second fax to the physician on 11/4/17 indicated that Resident # 1 had developed a rash to abdomen and bilateral thighs, bilateral arms and back, hive-like and itching. At 1:10 PM on 1/3/18, the Center Nurse Executive (CEN) confirmed that on 11/2/17, Resident # 1 was administered Influenza vaccine on 11/2/17 instead of [MEDICATION NAME] solution despite having a documented allergy to flu vaccine.",2020-09-01
100,ST JOHNSBURY HEALTH & REHAB,475019,1248 HOSPITAL DRIVE,SAINT JOHNSBURY,VT,5819,2019-01-03,600,E,1,0,Z54211,"> Based on observation, record review and staff interview, the facility failed to ensure that residents were free from abuse for 2 of 5 residents ( Residents #3, #5). Findings include: Per record review, Resident #3 was admitted at the same time as their spouse (Resident #4) in (MONTH) (YEAR), and were sharing a room. Toward the end of October, there arose a concern about safety of the couple rooming together. Resident #3 has progressing dementia and began to not recognize their spouse and expressed fear and anxiety that there was a stranger in the room. Resident # 3 was moved to another room on the unit shared with Resident #5. 1. On 11/1/18, the facility reported an incident where Resident #4 went to the spouse's new room, and was yelling to try and wake them kicking their feet. Resident #4 was physically banging the walker into and running over their feet to rouse them. Staff intervened and Resident # 4 left the room. This was reported to the state agency as required. 2. On 12/4/18, the facility reported an incident that the married residents were in the hallway, and Resident #3 stated that they wanted to go back to their room. Resident #4 grabbed the spouse's arm and kicked the walker, pulling Resident #3 toward him/her. Staff intervened and brought Resident #3 to their room. Resident #4 followed them to the room and sat on the bed, but then was attempting to move the recliner that Resident #3 was sitting in and shook their walker and yelled at the spouse. Staff directed Resident #4 out of the room. 3. On 12/19/18, per review of documentation as well as a telephone interview with now discharged Resident #5 (the roommate of Resident #3), they had reported to staff that between 2:00 PM and 8:00 PM that day that Resident #4 had repeatedly entered the room and yelled at their spouse to wake up. After supper, Resident #4 entered the room, was yelling profanities and rummaging through the belongings of both residents. Resident #4 was attempting to change the spouse's clothing, took away a drink from them, and continued to yell. Resident #5 activated the call bell and told Resident #4 to stop. Resident #4 then slammed the room door and continued to yell and act angry toward their spouse. Resident #5 stated that they yelled for help as well, but that it was at least 15- 20 minutes before staff came to the room to intervene. Resident #5 stated that they were afraid for themselves, but even more for Resident #3 who was the focus of the aggression. Resident #5 was moved to another room after this incident, however they stated that they did not really want to leave as they wanted to protect Resident #3 from their spouse. Resident #5 said that they were very upset and afraid of Resident #4, but needed to move out as they were trying to get well and go home. Per review of the incident report, this was not reported to administration until the following day. (refer to citation at F609). 4. During this onsite investigation on 1/3/19, a 4th incident was reported that occurred on 12/29/18. Per the facility report, Resident #4 was in Resident #3's room, and staff heard yelling coming from the room. Per staff witnesses, Resident #4 was yelling, That's it, I never want to see you again, I'm leaving. The staff witnessed Resident #4 shaking a fist at Resident #3. When the staff told the resident that it wasn't nice to speak to their spouse that way, Resident #4 stated that they could treat their spouse any way they wanted to. Staff positioned themselves between the two residents, and Resident #4 was pushing them to try to get to Resident #3. Staff were able to get Resident #4 out of the room, and Resident #3 then said to the staff I hope s/he did not hurt you, and was crying and appeared to be afraid. After they directed Resident#4 out of the spouse's room, they were going into other resident's rooms, yelling and saying to another resident that I am leaving, this is goodbye. The nurse ended up calling the police, and Resident #4 was escorted by them and EMS to the local emergency room , and returned later that day. Per interview on 1/3/19 at 11:05 AM, the Director of Nursing confirmed that these four incidents had occurred, and that Resident #4 had not been supervised closely enough to prevent them.",2020-09-01