cms_VT: 27

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
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