cms_VT
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid ▼ | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1025 | 1025 | GREENSBORO NURSING HOME | 475043 | 47 MAGGIE'S POND ROAD | GREENSBORO | VT | 5841 | 2016-12-06 | 280 | D | 1 | 0 | Deficiency Text Not Available | 2018-08-01 | |
| 1026 | 1026 | GREENSBORO NURSING HOME | 475043 | 47 MAGGIE'S POND ROAD | GREENSBORO | VT | 5841 | 2016-12-06 | 281 | D | 1 | 0 | Deficiency Text Not Available | 2018-08-01 | |
| 1027 | 1027 | GREENSBORO NURSING HOME | 475043 | 47 MAGGIE'S POND ROAD | GREENSBORO | VT | 5841 | 2017-05-31 | 155 | D | 1 | 0 | Deficiency Text Not Available | 2018-08-01 | |
| 1028 | 1028 | GREENSBORO NURSING HOME | 475043 | 47 MAGGIE'S POND ROAD | GREENSBORO | VT | 5841 | 2017-05-31 | 225 | D | 1 | 0 | Deficiency Text Not Available | 2018-08-01 | |
| 1029 | 1029 | GREENSBORO NURSING HOME | 475043 | 47 MAGGIE'S POND ROAD | GREENSBORO | VT | 5841 | 2017-05-31 | 282 | D | 1 | 0 | Deficiency Text Not Available | 2018-08-01 | |
| 1030 | 1030 | GREENSBORO NURSING HOME | 475043 | 47 MAGGIE'S POND ROAD | GREENSBORO | VT | 5841 | 2017-05-31 | 323 | D | 1 | 0 | Deficiency Text Not Available | 2018-08-01 | |
| 1806 | 1806 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2013-02-27 | 223 | E | 1 | 0 | 000Z11 | br>Based upon resident interview, staff interview, and record review, the facility failed to assure that 2 out of 3 residents (Residents #2 & #3) in the sample group remained free from verbal, physical and mental abuse. Findings include: 1) Per record review on 2/28/13 the Plan of Care for Resident #1 dated 12/27/12 includes 'alterations in behavior manifested by socially inappropriate behavior, verbally abusive, physically abusive to other residents'. Per record review of an Incident Note on Resident #1's medical record dated 1/28/13 at 3:40 P.M. (Resident #1) hit (Resident #2) with closed fist on side of face. The Plan of Care was revised on 1/29/13 to include the interventions 15 min. checks for behavior monitoring and behavior tracking to establish pattern, triggers, and effectiveness of interventions. Per record review, Resident #1 was maintained on 15 minute checks and Behavior Monitoring each 8 hour shift beginning on 1/28/13 and continuing through the day of the investigation on 2/28/13. Per Nursing Notes on 2/14/13 Resident #1 was witnessed hitting Resident #2 on the leg. On 2/15/13 interventions of separate resident from the people she feels are bothering her, encourage her to her room/sitting area and sitting area out of heavy traffic area were added to Resident #1's Plan of Care. Per interview on 2/28/13 at 3:03 P.M. a Licensed Practical Nurse on Resident #1's unit stated We started a strategy a few weeks ago. We asked (Resident #1) to try to stay at end of the hall - away from the central nurses' station activity .It has made a significant difference. Per record review Nursing Notes record on 2/20/13 patient continues to be on 15 min. checks .this patient (Resident #1) in (h/her wheelchair) pulling on both of the arms of the other resident (Resident #3) shaking (h/her). A staff member .stated that (h/she) saw this resident grabbing (Resident #3's) right hand and hitting left arm multiple times. Per interview on 2/28/13 at 11:20 A.M. Resident #1 stated Yes I've had trouble .you're not supposed to put … | 2016-02-01 |
| 1613 | 1613 | GREEN MOUNTAIN NURSING AND REHABILITATION | 475040 | 475 ETHAN ALLEN AVENUE | COLCHESTER | VT | 5446 | 2013-12-06 | 282 | D | 1 | 0 | 08F611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure that the services provided or arranged by the facility were provided by qualified persons in accordance with each resident's written plan of care for 1 of 2 residents sampled (Resident #1). Findings include: 1. Per record review on 12/2-12/3/13, Resident #1 had a [DIAGNOSES REDACTED]. The resident also took a diuretic blood pressure medication that increased the possibility of dehydration. The plan of care for nutrition included the intervention of monitoring intake and output daily. Upon review of the documentation since the resident's admission, the daily logs of meal and fluid intake were sporadically filled out since the admission date of [DATE]. In the month of July 2013, there was blank meal percentage spaces on 7/12- 7/16, as well as 7/20, 7/21, 7/25, 7/26, 7/27, and 7/30/13. In August and September, the meal percentage documentation was also sporadic, with many days left blank for one or more meals. With regard to the fluid intake sheets, there were many blank spaces also, starting in July 2013 and going until the resident's discharge from the facility on 9/21/13. The plan of care for this resident stated to monitor intake and record on ADL flow sheets. Per interview on 12/3/13 at 11:30 AM, the Director of Nursing confirmed that Resident #1 had a care plan in place that included monitoring food and fluid intake, that documentation of the resident's intake of food and fluids was very inconsistent, and that staff were expected to record an accurate amount on both documents. | 2016-12-01 |
| 1614 | 1614 | GREEN MOUNTAIN NURSING AND REHABILITATION | 475040 | 475 ETHAN ALLEN AVENUE | COLCHESTER | VT | 5446 | 2013-12-06 | 309 | D | 1 | 0 | 08F611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure that each resident received, and the facility provided, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 2 residents sampled (Resident #1). Findings include: Per record review on 12/3/13, Resident #1 was admitted to the facility on [DATE], after living at home with a family member. The resident has dementia. Upon admission, the resident was taking Quetiapine XR (sustained release) 150 mg. once daily, an anti-psychotic medication. A suggestion of dose reduction was made by the consultant Pharmacist during the July review, and the MD agreed to a dose reduction on 8/1/13, changing the order to Quetiapine XR 100 mg. once daily. The pharmacy received the order, however had a question regarding whether the order should be for the XR (extended release) or an instant release formula. Nursing staff started marking the Medication Administration Record [REDACTED]. The resident did not receive any of this prescribed medication for 11 days. According to manufacturers' warnings, stopping this anti-psychotic medication suddenly may cause side effects. One nurse was putting their initials down without circling them, although the medication was unavailable, and when the DNS followed up with that nurse, they stated that they indeed did not give the medication or circle their initials. The staff did not follow up with the pharmacy, nor did the pharmacy follow up with the facility until finally on 8/12/13, the medication was sent to the facility and it was administered to the resident as ordered by the Physician. Per interview on 12/3/13 at 11:45 AM, the DNS confirmed that there was a lack of follow up by staff with the pharmacy to inquire about the medication, and that the resident did not receive the scheduled prescribed medication for 11 days du… | 2016-12-01 |
| 1615 | 1615 | GREEN MOUNTAIN NURSING AND REHABILITATION | 475040 | 475 ETHAN ALLEN AVENUE | COLCHESTER | VT | 5446 | 2013-12-06 | 425 | D | 1 | 0 | 08F611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 residents sampled (Resident #1) Findings include: Per record review on 12/3/13, Resident #1 was admitted to the facility on [DATE], after living at home with a family member. The resident has dementia. Upon admission, the resident was taking Quetiapine XR (sustained release) 150 mg. once daily, an anti-psychotic medication. A suggestion of dose reduction was made by the consultant Pharmacist during the July review, and the MD agreed to a dose reduction on 8/1/13, changing the order to Quetiapine XR 100 mg. once daily. The pharmacy received the order, however had a question regarding whether the order should be for the XR (extended release) or an instant release formula. Nursing staff started marking the Medication Administration Record [REDACTED]. The resident did not receive any of this prescribed medication for 11 days. One nurse was putting their initials down without circling them, although the medication was unavailable, and when the DNS followed up with that nurse, they stated that they indeed did not give the med or circle their initials. The staff did not follow up with the pharmacy, nor did the pharmacy follow up with the facility until finally on 8/12/13, the medication was sent to the facility and it was administered to the resident as ordered by the Physician. Per interview on 12/3/13 at 11:45 AM, the DNS confirmed that there was a lack of follow up by staff with the pharmacy to inquire about the medication, and that Resident #1 did not receive the scheduled prescribed medication for 11 days due to the oversight. Refer also to F309. | 2016-12-01 |
| 1616 | 1616 | GREEN MOUNTAIN NURSING AND REHABILITATION | 475040 | 475 ETHAN ALLEN AVENUE | COLCHESTER | VT | 5446 | 2013-12-06 | 514 | D | 1 | 0 | 08F611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. Findings include: 1. Per record review on 12/2-12/3/13, Resident #1 had a [DIAGNOSES REDACTED]. The resident also took a diuretic blood pressure medication that increased the possibility of dehydration. The plan of care for nutrition included the intervention of monitoring intake and output daily. Upon review of the documentation since the resident's admission, the daily logs of meal and fluid intake were sporadically filled out since the admission date of [DATE]. In the month of July 2013, there was blank meal percentage spaces on 7/12- 7/16, as well as 7/20, 7/21, 7/25, 7/26, 7/27, and 7/30/13. In August and September, the meal percentage documentation was also sporadic, with many days left blank for one or more meals. With regard to the fluid intake sheets, there were many blank spaces also, starting in July 2013 and going until the resident's discharge from the facility on 9/21/13. The plan of care for this resident stated to monitor intake and record on ADL flow sheets. Per interview on 12/3/13 at 11:30 AM, the Director of Nursing confirmed that Resident #1 had a care plan in place that included monitoring food and fluid intake, that documentation of the resident's intake of food and fluids was very inconsistent, and that staff were expected to record an accurate amount on both documents. | 2016-12-01 |
| 1009 | 1009 | MAPLE LANE NURSING HOME | 475042 | 60 MAPLE LANE | BARTON | VT | 5822 | 2015-09-16 | 280 | D | 0 | 1 | 0BZX11 | Based on record review, staff and resident interview, the facility failed to ensure that a resident with the capability to participate in planning care was invited to the care plan meeting for 2 of 17 residents sampled (Resident #44, #52). Findings include: 1. Per interview on 9/14/15, Resident #44 answered the resident interview question No regarding involvement in their care and treatment. The resident stated that they were not invited to the care plan meeting and did not participate in the process. Per review of the Social Service notes and the care plan meeting sign-in sheet, there was no evidence that suggested s/he was asked to attend the care plan meeting. Per interview on 9/15/15 at 10:45 AM, the Director of Social Services (DSS) confirmed that the resident was not invited to attend the care plan meeting, however the family was involved. Per the DSS, the resident is cognitively intact enough to participate in the care planning process, however was not consulted about attending the meeting. 2. Per resident interview on 9/14/15, Resident #52 stated that they were not involved in decisions about their care, and did not attend the care plan meetings, nor were they invited to attend them. Per review of the social service notes and care plan attendance sign-in sheet, there was no evidence that suggested the resident was invited to attend the care plan meeting or participated in any way. Per interview on 9/15/15 at 10:45 AM, the DSS confirmed that although family members were notified regarding the care plan meeting, Resident #52 was not consulted to see if they would like to attend themselves to be a part of the care plan development process. | 2018-09-01 |
| 1010 | 1010 | MAPLE LANE NURSING HOME | 475042 | 60 MAPLE LANE | BARTON | VT | 5822 | 2015-09-16 | 431 | D | 0 | 1 | 0BZX11 | Based on observation and staff interview, the facility failed to ensure that all medications were labeled in accordance with accepted professional principles for expiration dates for 3 resident's medications (Resident #13, #24, and #66). Findings include: 1. Per observation on 9/14/15 at 7:25 AM, the medication cart on the upstairs west wing contained insulins that were in use for residents. Per observation, the opened vial of Levemir Insulin in use for Resident # 24 had no date written on the vial or box to indicate when it had been opened to indicate when it needed to be discarded per the pharmacy recommendation. Also at this time a Humalog insulin pen which was opened and in use for Resident #13 was found to have no date written on it to indicate when it was opened. Per interview on 9/14/15 at 7:35 AM, the nurse administering medications confirmed that these two insulins were not labeled with the date that they were opened. 2. Per observation on 9/15/15 at 2:35 PM, the downstairs unit medication cart was observed to have a Lantus insulin pen prescribed and in use for Resident #66 that did not have the date written on it to indicate when it had been opened. Per interview on 9/15/15 at 2:40 PM, the nurse administering medications confirmed that the Insulin pen was unlabeled with the date it was opened. Per a reference sheet published by the American Society of Consultant Pharmacists, the recommended discard dates for insulin vials and pens are as follows: Lantus Insulin- 28 days, Levemir- 42 days, and Humalog - 28 days, after opening. | 2018-09-01 |
| 1011 | 1011 | MAPLE LANE NURSING HOME | 475042 | 60 MAPLE LANE | BARTON | VT | 5822 | 2015-09-16 | 441 | D | 0 | 1 | 0BZX11 | Based on observation and staff interview, the facility failed to ensure that infection control practices were followed for the disposal of soiled linens for 1 of 17 residents sampled (Resident #44). Findings include: Per observation on 9/14/15 at 7:05 AM, by the bed of Resident #44, there was a soiled bedpad lying on the carpet, and next to it a visibly soiled and wet washcloth was seen lying directly on the carpet. Per interview on 9/14/15 at 7:10 AM, the LNA working on that wing confirmed that they had completed incontinence care on Resident #44 and had placed the wet pad and soiled washcloth directly on the carpeted floor. | 2018-09-01 |
| 1012 | 1012 | MAPLE LANE NURSING HOME | 475042 | 60 MAPLE LANE | BARTON | VT | 5822 | 2015-09-16 | 514 | D | 0 | 1 | 0BZX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the faciliy failed to maintain clinical records that were complete and accurate regarding documentation for 1 of 3 residents with an identified nutrition risk. Findings include: Per staff interview and record review, the facility failed to maintain complete and accurate documentation to establish that physician orders [REDACTED]. The lack of documentation made it difficult to determine whether or how frequently the resident was receiving or refusing the supplements and whether other nutritional strategies should be implemented for the weight loss. Per 9/15/15 medical record review, the Unit Coordinator (UC) documented on 6/3/15 that Resident #28 was steadily losing weight and had lost a total of 12 pounds since admission 5 weeks ago. The resident was reported to receive health shakes with each meal which s/he did not take consistently. The physician was notified and on 6/3/15 signed an order adding 'Banana Flip' drinks two times per day and to continue Health Shakes (both high calorie supplements) with every meal. Per review of the resident's weekly weights, the resident weighed 148.4 pounds on 4/22/15 and his/her weight dropped to 132.6 pounds on 9/11/15. Per interviews with nursing staff, the facility tracks supplement intake on a meal percentage sheet and staff LNA's (Licensed Nursing Assistants) enter the amounts of the supplement consumed. Per review, for the month of June, there was documentation that Resident #28 consumed a health shake supplement on 4 of 90 opportunities and refused the supplement one time; for July, documentation supported that the resident took the supplement on 5 of 93 opportunities and refused the supplement two times; in August, s/he took the supplement on 6 of 93 opportunities and in September, documentation supported that the resident took the supplement one time through (MONTH) 15th. On 9/15/15 at 10:07 AM, LNA #1 reported that LNAs are supposed to document t… | 2018-09-01 |
| 1065 | 1065 | MOUNTAIN VIEW CENTER GENESIS HEALTHCARE | 475012 | 9 HAYWOOD AVENUE | RUTLAND | VT | 5701 | 2014-11-05 | 241 | E | 0 | 1 | 0D3E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review, the facility failed to promote care for 5 of 22 residents (#45, 118, 28, 22, & 160) in the sample group in a manner and in an environment that maintains or enhances each resident's dignity, self-esteem and self-worth. Findings include: 1). Per record review Resident #45, Minimum Data Sheet (MDS), dated [DATE], assesses the resident as needing extensive assist with toileting with two or more persons physically assisting, and 'only able to stabilize with human assistance' when moving on and off the toilet. Resident #45 has [DIAGNOSES REDACTED]. Per record review Resident #45 has Care Plan documents that indicate the resident demonstrates a deficit in toileting related to functional deterioration with the intervention to provide patient with needed assistance. The Care Plan also records that the resident is incontinent of urine with potential for improved control and to monitor for and assist toileting needs and provide access to the bathroom. Per interview with Resident #45 on 11/5/14 at 9:36 A.M., the resident stated, they don't have staff enough to take care of us. I have waited a half hour to go to the bathroom. I take [MEDICATION NAME] (a diuretic medication) and I have to go quite often. I've had to wait so long I couldn't wait any longer. I'll be wet. It makes me feel awful; like I've gone back to babyhood. 2). Per record review, Resident #118's Minimum Data Sheet ((MDS) dated [DATE], assesses the resident as occasionally incontinent and needing extensive assist with toileting, 'only able to stabilize with human assistance' when moving on and off the toilet. Resident #118's [DIAGNOSES REDACTED]. Per interview with Resident #118 on 11/3/14 and 11/5/14, the resident replied 'no' when asked if h/she was treated with respect and dignity. The resident stated h/she needs assistance going to the bathroom and uses the call bell to ask for help, and sometimes I have to wait so long I wet myself… | 2018-05-01 |
| 1066 | 1066 | MOUNTAIN VIEW CENTER GENESIS HEALTHCARE | 475012 | 9 HAYWOOD AVENUE | RUTLAND | VT | 5701 | 2014-11-05 | 280 | D | 0 | 1 | 0D3E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, record review and staff interview the facility failed to update the interdisciplinary care plan for 1 of 3 applicable residents in the stage 2 sample of 22, Resident #64. Findings include the following: Per medical Record review on 11/5/14 at approximately 10 AM, Resident #64 was initially admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) assessment dated [DATE] evidences that Resident #64 is always continent. MDS assessment dated [DATE], evidences that Resident #64 is occasionally incontinent, which is defined as less than 7 episodes of incontinence during the 7 day look back period. MDS assessment dated [DATE], evidences that Resident #64 is frequently incontinent, which is defined as 7 or more episodes of urinary incontinence, but at least one episode of continent voiding, over the 7 day look back period. Assessment also identifies that the Basic Interview for Metal Status (BIMS) score determines the resident to have a score of 9, signifying mild cognitive loss. The MDS assessment was confirmed by the MDS RN Coordinator on 11/5/14 at approximately 12 noon. Per Interdisciplinary Care Plan initiated on 6/25/12 and reviewed on 10/7/14, identifies a focus/problem for Resident #64, as being occasionally incontinent of urine. Goal documents that Resident #64 will demonstrate improved urinary elimination control as evidenced by experiencing decreased urinary incontinence. Interventions are to encourage resident to use toilet upon awakening, after meals, nightly and as needed. Per Activities of Daily Living (ADL) Record during the look back period, Resident #64 required extensive assistance of 1 or 2 staff members for toileting/transfer. Therefor, resident was dependent on staff to complete the toileting task and maintain continence. Per interview on 11/5/14 at 12:10 PM with the Director of Nurses (DNS) and the Unit Manager (UM), both confirm that Resident #64 's voiding pattern has no… | 2018-05-01 |
| 1067 | 1067 | MOUNTAIN VIEW CENTER GENESIS HEALTHCARE | 475012 | 9 HAYWOOD AVENUE | RUTLAND | VT | 5701 | 2014-11-05 | 315 | D | 0 | 1 | 0D3E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure that a resident who is incontinent of bladder received the appropriate treatment to restore as much normal bladder function as possible for 1 of 3 applicable residents in the stage 2 sample of 22, Resident #64. Findings include the following: Per medical Record review on 11/5/14 at approximately 10 AM, Resident #64 was initially admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) assessment dated [DATE] evidences that Resident #64 is always continent. MDS assessment dated [DATE], evidences that Resident #64 is occasionally incontinent, which is defined as less than 7 episodes of incontinence during the 7 day look back period. MDS assessment dated [DATE], evidences that Resident #64 is frequently incontinent, which is defined as 7 or more episodes of urinary incontinence, but at least one episode of continent voiding, over the 7 day look back period. Assessment also identifies that the Basic Interview for Metal Status (BIMS) score determines the resident to have a score of 9, signifying mild cognitive loss. The MDS assessment was confirmed by the MDS RN Coordinator on 11/5/14 at approximately 12 noon. Per Interdisciplinary Care Plan initiated on 6/25/12 and reviewed on 10/7/14, identifies a focus/problem for Resident #64, as being occasionally incontinent of urine. Goal documents that Resident #64 will demonstrate improved urinary elimination control as evidenced by experiencing decreased urinary incontinence. Interventions are to encourage resident to use toilet upon awakening, after meals, nightly and as needed. Per Activities of Daily Living (ADL) Record during the look back period, Resident #64 required extensive assistance of 1 or 2 staff members for toileting/transfer. Therefore, resident was dependent on staff to complete the toileting task and maintain continence. Per interview on 11/5/14 at 12:10 PM with the… | 2018-05-01 |
| 1068 | 1068 | MOUNTAIN VIEW CENTER GENESIS HEALTHCARE | 475012 | 9 HAYWOOD AVENUE | RUTLAND | VT | 5701 | 2014-11-05 | 356 | C | 0 | 1 | 0D3E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to post the daily accurate nursing staff information in a prominent place readily accessible to all residents and visitors. Findings include: During the initial tour upon entrance into the facility on [DATE] at 5:55 AM, the posting of the Daily Nurse Staffing Form was found to be in a hallway that consists of offices for facility staff. The posting was in a clear hard plastic holder that was at eye level for someone standing and it was posted outside the office door of the Nurse Practice Educator (NPE). The date on the posting was for 10/29/14. Per confirmation from the NPE at 6:45 AM, h/she confirmed, upon his/her arrival to the facility that the posting for staffing was dated for 10/29/14 and there was no evidence that there were any other postings with current dates. H/she also confirmed that the corridor where the posting is housed is in the Administrative Hallway which is not a main corridor used by all visitors or residents, that it is used by staff and sometimes visitors that go to Cherry Tree and Dogwood Drive. It is also utilized by Physical Therapy for ambulating residents. Per interview with the Human Resource Manager at 7:15 AM, h/she stated that it is their responsibility to post the Daily Nurse Staffing Form from Monday through Friday and the weekend supervisor posts the all staffing on Saturday and Sunday that h/she provides for them. There was no evidence of the postings other than the one dated 10/29/14 and confirmed by the NPE. | 2018-05-01 |
| 2019 | 2019 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2012-04-12 | 157 | D | 1 | 0 | 0DC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, the facility failed to ensure the physician and responsible party were notified of the development of an additional pressure ulcer until three days after it was first documented. This affected one (Resident #4) of four sampled resident records reviewed. Findings include: Per clinical record review on 03/21/12, Resident #4 was admitted on [DATE] with one open area noted to the right buttocks measuring 0.5 centimeters in diameter. The Nursing Admission assessment dated [DATE] also indicated the left buttock was reddened and intact. The Nurse's Notes dated 03/05/12, and timed 7:00 A.M. to 7:00 P.M., indicated the dressing was changed to the right buttocks open area. The note did not include a description of the area at that time. The Nurse's Notes dated 03/06/12 at 2:00 P.M., indicated Resident #4 had two open areas on buttocks. The coccyx measured 0.4 centimeters in diameter and the left gluteal fold measured 0.3 centimeters in diameter. The Weekly Pressure Ulcer Flow Sheet indicated that the initial assessment of the pressure ulcers by the Wound Nurse was completed on 03/06/12 and two pressure ulcers were present in close proximity on the right buttock at that time. A Nurse's Note dated 03/09/12, 7:00 A.M. to 7:00 P.M., indicated that the dressing was changed secondary to loose stools and the open areas were not described. On 03/09/12 at 1:30 P.M., an entry indicated the responsible party was notified of a new pressure ulcer noted by the wound care nurse on 03/09/12 and at 1:45 P.M. the Nurse's Note indicated the physician was notified of the development of a new stage II (partial thickness) ulcer located in close proximity to the stage II ulcer noted on admission. Orders for treatment were noted at that time. The Nurse's Notes revealed no indication that the physician or responsible party was notified of the development of additional skin breakdown between 03/06/12 and 03/09/12. Interview of the … | 2015-08-01 |
| 2020 | 2020 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2012-04-12 | 278 | D | 1 | 0 | 0DC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, the facility failed to ensure that an accurate assessment of pressure ulcer risk was conducted for one Resident (Resident #4) admitted with a pressure ulcer. This affected one of four applicable resident records reviewed. Findings include: Per clinical record review on 03/21/12, Resident #4 was admitted on [DATE] with an open area to the right buttock measuring 0.5 centimeters in diameter. The Braden (pressure risk assessment) score was noted to be 17 (low risk for those over [AGE] years old). The assessment indicated no impairment of sensory perception, occasional moisture to skin, walks occasionally for activity, slightly limited mobility with frequent position changes, adequate nutrition, and potential friction and shear problem. No individualized interventions were noted to be implemented based on a risk for pressure ulcers. The Braden assessment was completed again on 03/09/12, and indicated a score of 15 (indicating mild risk). The sensory perception box had the date of 03/09/12 in it and indicated no score. The assessment indicated the skin was rarely moist, activity walks occasionally, mobility slightly limited with frequent position changes, nutrition adequate, and potential sheer and friction problem. Review of the nurse's notes from 03/02/12 through 03/09/12 indicated that Resident #4 was noted on admission to be incontinent at times. The notes indicated that Resident #4 developed loose, watery stools on 03/03/12 and was incontinent of urine and stool daily. Review of the Nurse Aid flow sheet revealed that Resident #4 was incontinent of urine from one to six times daily and incontinent of stool one to four times daily with the exception of 03/08/12 and 03/10/12. Review of intake and output records for the period indicated that Resident #4 was not meeting hydration goals due to the frequent loose stools and daily hydration monitoring continued. Dietary notes dated 03/07/12 indicated Res… | 2015-08-01 |
| 2021 | 2021 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2012-04-12 | 281 | D | 1 | 0 | 0DC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, the facility failed to implement a physician's order to insert a Foley catheter to promote wound healing until the following day and failed to provide documentation of collaboration with the wound care clinic that was ordered on two occasions to promote wound healing and prevent the development of additional skin breakdown. This affected one (#3) of four applicable Resident records reviewed. Findings include: Per clinical record review on 03/21/12, Resident #3 was admitted to the facility for a three week respite stay with [DIAGNOSES REDACTED]. The Admission Nursing Assessment indicated that Resident #3 had a Stage II (partial thickness) open area on the coccyx, had a Foley catheter, required the assistance of two staff to reposition in bed and the assistance of two staff and a standing lift to transfer. The Admission physical exam completed on 02/09/12 by the Nurse Practitioner acknowledged the three week respite stay. The note indicated a wound was present on the gluteal fold and indicates it was not observed because the Resident was dressed. It went on to state: get the wound care plan from the wound center. The notes acknowledged the use of the Foley catheter for wound healing and indicated to begin bladder retraining to remove the Foley catheter. These orders were written on the physician's order sheet. After a three day clamping schedule was completed, the Foley catheter was removed at 6:00 A.M. on 02/13/12 and incontinence was noted twice on that night shift. Review of the Nurse Aid Activities of Daily Living Flow Sheet for February 2012, revealed that Resident #3 was incontinent of urine from four to seven times daily after the catheter was removed and no continent episodes were documented. On 02/17/12 an untimed order was noted to place a Foley catheter due to the sacral wound and to refer Resident #3 to the wound care clinic. No evidence of collaboration with the wound care clinic was l… | 2015-08-01 |
| 2022 | 2022 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2012-04-12 | 314 | G | 1 | 0 | 0DC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, the facility failed to provide services to prevent two residents admitted with pressure ulcers from developing additional pressure ulcers while in the facility. This affected two (#4, #3) of four applicable resident records reviewed. Findings include: 1. Per clinical record review on 03/21/12, Resident #4 was admitted on [DATE] with one open area noted to the right buttocks measuring 0.5 centimeters (cm). The Nursing Admission assessment dated [DATE] also indicated the left buttock was reddened and intact. The admission Braden (pressure risk) assessment indicated a score of 17 indicating low risk. The Nurse's Notes dated 03/05/12, and timed 7:00 A.M. to 7:00 P.M., indicated the dressing was changed to the right buttocks open area. The note did not include a description of the area at that time. The Nurse's Notes dated 03/06/12 at 2:00 P.M., indicated Resident #4 had two open areas on the buttocks and coccyx measuring 0.4 cm in diameter and to the left gluteal fold measuring 0.3 cm in diameter. The note indicated the areas were present on admission and no new intervention was implemented. The dietary notes dated 03/07/12 indicated poor intake and recommended diet liberalization and the addition of supplements twice daily. This was implemented on 03/08/12. The Weekly Pressure Ulcer Flow Sheet indicated that the initial assessment of the pressure ulcers by the wound nurse was completed on 03/06/12, and two ulcers were present in close proximity on the right buttock at that time. This was the only assessment documented by the wound nurse and indicated area #1, located to the superior right buttock, measured 0.4 cm by 0.8 cm and was superficial in depth, and area #2 measured 0.3 cm by 0.5 cm and was superficial in depth. Both flow sheets indicated the ulcers were present on admission and were acquired outside of the facility. The Braden (pressure risk) assessment dated [DATE] indicated a score of 15 (… | 2015-08-01 |
| 2023 | 2023 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2012-04-12 | 514 | D | 1 | 0 | 0DC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, the facility failed to ensure that one clinical record contained documentation of collaboration with a wound specialist. This affected one (#3) of four applicable Resident records reviewed. Findings include: Per clinical record review on 03/21/12, Resident #3 was admitted to the facility for a three week respite stay with [DIAGNOSES REDACTED]. The Admission Nursing Assessment indicated that Resident #3 had a Stage II (partial thickness) open area on the coccyx. The Admission physical exam completed on 02/09/12, by the Nurse Practitioner acknowledged the three week respite stay. The note indicated a wound was present on the gluteal fold and indicated it was not observed because the Resident was dressed. It went on to state: get the wound care plan from the wound center. This order was written on the physician's orders [REDACTED].#3 to the wound care clinic. No evidence of collaboration with the wound care clinic was located in the record. Interview of the Director of Nursing Services (DNS) on 03/21/12 at 3:00 P.M. confirmed that there were orders to get the wound plan of care from the wound center on 02/09/12 and to refer Resident #3 to the wound center on 02/17/12. S/he confirmed that no documentation of collaboration with the wound clinic was located in the clinical record despite orders on 02/09/12 and 02/17/12 to get the wound plan of care from the wound center and to refer Resident #3 for wound care. S/he stated that someone spoke with the wound specialist and the Foley catheter was reinserted because of their recommendation. S/he stated that an appointment was made for follow up at the clinic on 02/29/12 (the day of discharge). S/he was unable to state who spoke with the clinic or when, and could locate no documentation in the record. | 2015-08-01 |
| 317 | 317 | VERMONT VETERANS' HOME | 475032 | 325 NORTH STREET | BENNINGTON | VT | 5201 | 2017-06-21 | 242 | D | 0 | 1 | 0EBD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and observations, 3 of 22 residents did not have their preferences about aspects of their life in the facility that are significant to them, honored. (Residents #122, #8 and #13) Findings include: 1. Based upon interview, observations and record review for Resident #122, the facility failed to honor the resident's preferences for showering frequency. During interview on 06/20/17 at 09:19 AM when asked about bathing preferences, the resident stated that's the big problem, I am told I can only have one a week, when I was younger I would take sometimes two a day. Review of the bathing schedule demonstrates that the resident receives his/her shower weekly and in the evening. During a follow up conversation, the resident made his/her preference known but stated it is not worth it (to tell staff again) .they don't listen anyway, but gosh it could be twice a week which would be ok (with me). The most recent Care Plan is for one person assist, stand by guard for ADLs (activities of daily living). Observation during the three days of survey shows the resident ambulates with a walker but can be unsteady at times. During interview on 06/20/17 at 5:00 PM, the DNS (director of nursing services) identified that the residents' preferences are made known during the admission process conducted by the Activity Department. During interview on 06/21/17 at 9:21 AM, the Activity Director (AD) acknowledged that upon admission, the resident (or the responsible person) will fill out an 'Activities Hello' sheet. The AD explained that this is a set of questions pertaining to the resident's likes, favorite situations and preferences and stated It is like their personal history so that we get to know them better and what is important to them. Resident #122 filled out this form with a preference under #3- 'my usual daily routine' .get up, shower, dress, breakfast, read the newspaper. The nurse surveyor asked if this preference sheet is … | 2020-09-01 |
| 376 | 376 | BARRE GARDENS NURSING AND REHAB LLC | 475037 | 378 PROSPECT STREET | BARRE | VT | 5641 | 2018-02-07 | 550 | E | 0 | 1 | 0GXJ11 | Based on observation and confirmed by staff interview, the facility failed to ensure that 1 of 21 sampled residents was treated with respect and dignity in a manner and in an environment that promotes and enhances quality of life. The facility also failed to ensure that all residents are served meals/desserts on dishes that are not disposable. The findings include the following: 1. Per observation during the three days of survey (2/5, 2/6, and 2/7/18), Resident #45 was found to have a fabric recliner next to the bed, smeared with dried fecal material visible on the seat. The soiled chair was brought to the attention of the Director of Nurses on 2/7/18 at 7 AM, who confirmed that the chair needed cleaning. 2. Per observation of the noon meal on 2/5/18, residents were served cookies for dessert on disposable Styrofoam plates. Per observation of the evening meal on 2/6/18 residents were served a slice of pie for dessert on disposable Styrofoam plates. Licensed Nurse Aide staff confirm that desserts are always served on disposable Styrofoam plates unless ice-cream or pudding is being offered. The Director of the Dietary Department confirms on 2/6/18 at approximately 5:15 PM, that the facility does not have enough dessert plates. When asked if they are being ordered, h/she responded that there had been a discussion with the supervisor about month ago, but there has not been and further discussion or a conclusion determined. | 2020-09-01 |
| 377 | 377 | BARRE GARDENS NURSING AND REHAB LLC | 475037 | 378 PROSPECT STREET | BARRE | VT | 5641 | 2018-02-07 | 600 | D | 1 | 1 | 0GXJ11 | > Based on record review and confirmed by staff interview, the facility failed to protect 1 of 21 applicable residents from willful mistreatment and abuse (Resident #35). The findings include the following: Facility reported information and the facility internal investigation identifies that on 1/21/18 at approximately 11:30 AM, two (2) facility Licensed Nurse Aides (LNA) identified that Resident #35 had a call light in his/her hand that was not connected to the wall unit. The call cord was resting on the floor and was not functioning as intended. The LNA staff replaced the disconnected call light and reported the situation to the Registered Nurse (RN), who immediately reported to the Administrator. The LNA staff confirmed that the Licensed Practical Nurse (LPN) assigned to that unit was overheard complaining that Resident #35 rings the bell too much and questioned if there were any broken call cords on the unit. Per the internal investigation conducted by the Administrator, the LPN was candid about knowingly placing the inoperable call bell in Resident #35's hand, (s/he) was on the bell too much. The internal investigation also identifies that the LPN was surprised at the Administrator's questioning and unapologetic for the action taken. The LPN was as contracted employee who was terminated. | 2020-09-01 |
| 378 | 378 | BARRE GARDENS NURSING AND REHAB LLC | 475037 | 378 PROSPECT STREET | BARRE | VT | 5641 | 2018-02-07 | 689 | D | 0 | 1 | 0GXJ11 | Based on observations, interviews and record review, the facility failed to supervise 1 of 21 residents (Resident #38) sufficiently to prevent wandering and intrusion. Findings include: During observations on wing 2 on 2/6/18, Resident #38 was returned from breakfast to the area of the nurses' station by a Licensed Nurse Assistant (LNA). Both nurses and all three LNAs assigned to the wing were then engaging in medication administration or direct care while Resident #38 and Resident #50 were near the nurses' station. Resident #38, per the care plan, has behaviors of wandering, intrusion, and inappropriateness toward females. At 9:13 AM Resident #38 tried to bump the wheelchair of Resident #50 and was intercepted by the nurse who was on the way to the medication cart. Once left on his/her own, Resident #38 then proceeded to and intruded into the room of Resident #19 (who was still in bed). The nurse came away from the medication cart and redirected Resident #38 back to the nurses' station, and returned to duties. At 9:20 AM Resident #38 again went to and intruded into the room of Resident #19; the nurse again came away from medication duties to redirect. At 9:48 AM Resident #38 tried to bump the wheelchair of Resident #50 again, and was redirected by the social worker who had just come to the nurses' station for a survey related task. Activity staff then removed Resident #38 to a 10:00 AM activity. It was confirmed with the clinical supervisor that there had not been an activity from 9-10 AM in the sunroom, that there were 3 nurse aids on duty instead of 4 for the 2 halls of the wing, and that the clinical supervisor was covering as the medication nurse. | 2020-09-01 |
| 379 | 379 | BARRE GARDENS NURSING AND REHAB LLC | 475037 | 378 PROSPECT STREET | BARRE | VT | 5641 | 2018-02-07 | 725 | E | 0 | 1 | 0GXJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility assessment, and confirmed by family and staff interviews, the facility failed to have sufficient nursing staff to provide nursing and related services assuring resident safety and maintaining the highest practicable physical, mental and psychosocial well-being for 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 repeated citation from November, (YEAR). The findings include the following: 1. Per review of the facility assessment dated [DATE], the Nursing staffing plan is as follows: Full time Director of Nurses-Registered Nurse (RN); Full time Assistant Director of Nurses-RN; 2 RN/LPN on each unit (8 hours each)-RN's and LPN's are used interchangeably for both day and evening shifts and 1 nurse on each unit on the over night shift; Direct Care Staff: 4 Licensed Nurse Aides (LNA'S) on each unit for both day and evening shifts (8 hours each) and 2 LNA's on the over night shift (8 hours each). During the three days of survey (2/5, 2/6 and 2/7/18), the facility had numerous direct care staff calling out of work for various reasons. The staffing pattern identified was not met as follows: Review of the LNA assignments for the entire building, average 9 residents each on the day and evening shifts, with the census being 74, if the staffing pattern is met. Of those 74 residents, 20 require the assistance of 2 to transfer the resident from one location to another using a mechanical lift, 8 residents require 2 assistants for transfer from one location to another, and 19 require the assistance of 1. 52 of the 74 residents require incontinent care and/or assistance with toileting. 17 of the 74 residents require 2 assistants for bathing and dressing. 2. Per interview with family members during the 3 day survey, concerns were voiced related to untimely call light answering, lack of facility … | 2020-09-01 |
| 747 | 747 | SAINT ALBANS HEALTHCARE AND REHABILITATION CENTER | 475021 | 596 SHELDON ROAD | SAINT ALBANS | VT | 5478 | 2016-09-13 | 157 | D | 1 | 0 | 0MLI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to inform the resident's legal guardian and representative of a significant change in [MEDICAL CONDITION] medications for 1 of 3 residents (Resident #1) prior to implementing the medication changes. Findings include: Per record review, Resident #1 was seen for a tele-psychiatric consult on 6/23/16 for evaluation of dementia with physical and verbal aggression. The psychiatrist recommended that the resident's Quetiapine (an antipsychotic medication) be stopped and the resident be started on [MEDICATION NAME] 0.5 mg twice daily (another antipsychotic medication) to increase by 0.5 mg increments every 5 days to a maximum dose of 2 mg. The psychiatrist also recommended that the resident's order for [MEDICATION NAME] (an anti-anxiety medication) be discontinued; that [MEDICATION NAME] 50 mg (an antidepressant/antianxiety medication) be offered three times daily as needed for moderate emergent agitation; that [MEDICATION NAME] 0.25 mg be offered twice daily as needed for severe emergent agitation; and that [MEDICATION NAME] (an anti-depressant medication) be started after 1 week on the scheduled [MEDICATION NAME]. On 6/23/16 at 12:38 PM, a staff nurse documented in the progress notes that, new orders obtained, message left for (responsible party) to call facility for update. On 6/23/16 the facility Nurse Practitioner (NP) documented that new orders were written based on the psychiatrist's recommendations. Per review of the MAR (Medication Administration Record) for (MONTH) (YEAR), the orders for the new [MEDICAL CONDITION] medications were implemented on 6/24/16. On 9/13/16 at 1:20 PM, the Nurse UM (Unit Manager) reported that prior to starting a new medication or [MEDICAL CONDITION] medication, a resident's family/responsible party is to be notified and a verbal consent given; a signed consent is to be obtained as soon as able. The UM confirmed that there was no evidence that Reside… | 2019-09-01 |
| 748 | 748 | SAINT ALBANS HEALTHCARE AND REHABILITATION CENTER | 475021 | 596 SHELDON ROAD | SAINT ALBANS | VT | 5478 | 2016-09-13 | 281 | G | 1 | 0 | 0MLI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to ensure that nurses met professional standards of nursing practice regarding failure to follow physician orders [REDACTED].#2) Findings include: 1. Per record review, due to a transcription error, Resident #2 was not administered physician ordered [MEDICATION NAME] for 5 days and experienced physical symptoms of increased [MEDICAL CONDITION], weight gain, shortness of breath and lethargy that impacted his/her health and safety ([MEDICATION NAME] is a diuretic medication that helps the body get rid of excess fluid). Resident #2 had [DIAGNOSES REDACTED]. On 8/18/16 the Resident's physician ordered an increase in [MEDICATION NAME] from 40 mg daily to 40 mg twice daily for 5 days and then was to resume [MEDICATION NAME] 40 mg daily. Per review of the MAR (Medication Administration Record), the resident received the increased dose of [MEDICATION NAME] from 8/18/16 -8/22/16. On 8/23/16 the resident received 1 dose of [MEDICATION NAME] 40 mg and then did not receive the medication from 8/24-8/28/16 (5 days) until the error was discovered on 8/29/16. Per interview on 9/13/16 beginning at approximately 9:00 AM, the nursing UM (Unit Manager) stated that there was a transcription error made in the MAR indicated [REDACTED]. S/he confirmed during the interview that the physician orders [REDACTED]. 2. Per record review, Resident #2 did not receive his/her physician ordered IV (intravenous) infusions of [MEDICATION NAME]/Sulbactam (antibiotic) to treat osteo[DIAGNOSES REDACTED] (infection into the bone of the left foot) as ordered. Per record review, Resident #2 was admitted to the facility for IV antibiotic treatment of [REDACTED]. The orders stated to give [MEDICATION NAME]/Sulbactam 3 gm every 8 hours IV through a PICC line (peripherally inserted central catheter). Per review of the infusion Medication Administration Record [REDACTED]. Per interview with the UM (Unit Manager) on 9/13/16 … | 2019-09-01 |
| 749 | 749 | SAINT ALBANS HEALTHCARE AND REHABILITATION CENTER | 475021 | 596 SHELDON ROAD | SAINT ALBANS | VT | 5478 | 2016-09-13 | 282 | D | 1 | 0 | 0MLI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to provide services in accordance with the plan of care for 1 of 3 residents (Resident # 2) related to wound care. Findings include: Per record review, the facility failed to follow Resident # 2's care plan related to the evaluation and monitoring of a left foot ulcer. Resident # 2's care plan for actual skin breakdown related to vascular disease and diabetes, left foot ulcer states that the staff are to: Provide wound treatment as ordered. Provide weekly wound assessment to include measurements and description of wound status. Per review of Resident # 2's medical record, nursing staff failed to obtain new orders for wound care after the 8/23/16 order for wound cleansing and wet to dry dressings ended on 8/29/16. A nurse signed on the TAR (Treatment Administration Record) that wound care was provided on 8/31/16; on 9/2/16 a nurse documented in the progress notes that dressing changed on foot; however, there was no current physician order [REDACTED]. On 9/13/16 at an interview beginning at approximately 9:00 AM, the Unit Manager (UM) confirmed that the last skin integrity report that included a description of the resident's left foot wound and measurements was completed on 8/22/16. The resident was discharged from the facility on 9/6/16; per care plan, weekly wound assessment and measurements were due on 8/29/16 and 9/5/16. On 9/13/16 at approximately 1:00 PM, the UM confirmed that the resident's care plan for the treatment of [REDACTED]. (Refer to 281, 514) | 2019-09-01 |
| 750 | 750 | SAINT ALBANS HEALTHCARE AND REHABILITATION CENTER | 475021 | 596 SHELDON ROAD | SAINT ALBANS | VT | 5478 | 2016-09-13 | 333 | G | 1 | 0 | 0MLI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews the facility failed to assure that residents are free of any significant medication errors for 1 of 3 residents (Resident #2). Findings include: Per record review, due to a medication error of omission, Resident #2 experienced physical symptoms of increased [MEDICAL CONDITION], weight gain, shortness of breath and lethargy that impacted his/her health and safety. Resident #2 had [DIAGNOSES REDACTED]. On 8/18/16 the Resident's physician ordered an increase in [MEDICATION NAME] from 40 mg daily to 40 mg twice daily for 5 days and then to resume [MEDICATION NAME] 40 mg daily ([MEDICATION NAME] is a diuretic medication that helps the body get rid of excess fluid). Per review of the MAR (Medication Administration Record), the resident received the increased dose of [MEDICATION NAME] from 8/18/16 -8/22/16. On 8/23/16 the resident received 1 dose of [MEDICATION NAME] 40 mg and then did not receive the medication from 8/24-8/28/16 (5 days) until the error was discovered on 8/29/16. Per review of Nurse Practitioner (NP) notes, on 8/29/16 Resident #2 was seen in follow up for [MEDICAL CONDITION] and shortness of breath. The resident states (s/he) is feeling very fatigued and having a hard time catching (his/her) breath. The NP reported meeting with nursing and according to (the resident's) MAR, (s/he) had not received (his/her) [MEDICATION NAME] since 8/23/16. In that time frame (the resident) has had an 18 pound weight gain. (His/her) baseline weight is about 226 to 231. Today (his/her) weight is 249. Per the exam, the resident was noted to have +2 to +3 [MEDICAL CONDITION] to bilateral lower extremities. (The resident) was restarted on (his/her) [MEDICATION NAME] today. .In early afternoon, I reassessed (the resident) and (s/he) had not voided much and still feels symptomatic. I ordered an additional 40 mg of [MEDICATION NAME]. Nursing is aware that (s/he) bears close monitoring. Per nurses progress notes… | 2019-09-01 |
| 751 | 751 | SAINT ALBANS HEALTHCARE AND REHABILITATION CENTER | 475021 | 596 SHELDON ROAD | SAINT ALBANS | VT | 5478 | 2016-09-13 | 514 | D | 1 | 0 | 0MLI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to maintain complete and accurately documented medical records for the administration of medication and treatments for 1 of 3 residents (Resident #2) Per record review, the MAR (medication administration record) and TAR (treatment administration record) for Resident #2 had incomplete documentation that medications were administered and dressing treatments were performed per orders. Per review, Resident #2 had [DIAGNOSES REDACTED]. Per record review, there is no documentation on the infusion Medication Administration Record [REDACTED]. Per record review, physician orders [REDACTED]. Per review of the infusion Medication Administration Record [REDACTED]. Per interview with the UM (Unit Manager) on 9/13/16 at approximately 9:00 AM, s/he reported that on some of the days, the resident had medical appointments and left the facility at about 5- 5:30 AM and returned at about 6:00 PM; the UM also reported that on some of the other days, s/he thought there could be a documentation error and thinks the resident could have been administered the antibiotic. On 8/18/16 the Resident #2's physician ordered an increase in [MEDICATION NAME] from 40 mg daily to 40 mg twice daily for 5 days and then was to resume [MEDICATION NAME] 40 mg daily. Per review of the MAR (Medication Administration Record), the resident received the increased dose of [MEDICATION NAME] from 8/18/16 -8/22/16. On 8/23/16 the resident received 1 dose of [MEDICATION NAME] 40 mg and then did not receive the medication from 8/24-8/28/16 (5 days) until the error was discovered on 8/29/16. Per interview on 9/13/16 beginning at approximately 9:00 AM, the nursing UM (Unit Manager) stated that there was a transcription error made in the MAR indicated [REDACTED]. Per record review, there is no documentation in the TAR that orders for a wet to dry dressing of Resident #2's left foot wound was performed on 8/26 and 8/27/16 per orders.… | 2019-09-01 |
| 107 | 107 | ST JOHNSBURY HEALTH & REHAB | 475019 | 1248 HOSPITAL DRIVE | SAINT JOHNSBURY | VT | 5819 | 2019-03-11 | 689 | D | 1 | 0 | 0MYX11 | > Based on observations, record review, and staff interviews, the facility failed to ensure that one of five residents in the applicable sample received adequate supervision to prevent physical altercations. Findings include: 1. Resident #1 suffers from dementia and has an established pattern of potential for hitting out at both staff and other residents. The written plan of care directs staff that these behaviors can come without warning. Per record review, Resident #1 is capable of self propelling the wheelchair and is known to intrude into resident rooms. On 1/12/19, Resident #1 entered the room of Resident #2 and touched the food and drink on the tray. When asked by Resident #2 to stop, Resident #1 hit Resident #2 with fists on both hands, causing bruising. This was confirmed by interview with Resident #2 at about 9:30 AM, and per staff written notes and statements. Measures of medication, supervision and activity engagement employed by staff were insufficient to prevent the intrusion and altercation. 2. On 1/29/19 while in the main dining room, per staff witness statements, Resident #1 wheeled over to Resident #3 and struck him/her 3-4 times. Resident #3 has significant dementia, but did yell Stop, get away from me. Despite the written care plan which addresses this potential, nearby staff failed to anticipate and prevent another physical altercation by Resident #1. During interview at 3:30 PM on 3/11/19, the Director of Nursing confirmed a failure to prevent physical altercations by Resident #1 on 1/12 and 1/29/19. | 2020-09-01 |
| 108 | 108 | ST JOHNSBURY HEALTH & REHAB | 475019 | 1248 HOSPITAL DRIVE | SAINT JOHNSBURY | VT | 5819 | 2019-03-11 | 755 | E | 1 | 0 | 0MYX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure that controlled drugs were reconciled and disposed of to prevent diversion for 4 residents reviewed (Residents #4, 5, 6, and 7). Findings include: Per record review, the Medical Director asked a nurse to review residents with narcotic orders to determine who would need a new prescription written on 2/18/19. The nurse discovered that Resident #4 had an order for [REDACTED]., give every 24 hours as needed (PRN) for pain. The medication was signed out by the same LPN twice on 2/10/19 at 0800 and again at 1900 (not following the MD order of once daily), on 2/11/19 at 0600, twice on 2/13/19 at 0600 and 1900, on 2/14/19 at 0500, 2/17/19 at 0500, and 2/18/19 at 0600. When the nurse asked Resident #4 if they had asked for and been administered a [MEDICATION NAME] pill that morning, or on any of those days, they stated that they had not asked or been given one. The resident also stated that they had not needed any of the [MEDICATION NAME] for pain in quite awhile. Administration record and narcotic count sheet showed that the last time the resident had received the [MEDICATION NAME] was on 1/26/19. Also, the medication was signed out on the narcotic sheet, but not recorded as being given on the Medication Administration Record [REDACTED]. This discovery initiated an investigation into other residents who take narcotic pain medications and the following residents also had discrepancies in the record. Per review of the record of Resident #5, there was an MD order for [MEDICATION NAME] that started out on 1/29/19 as every day in the AM for 5 days, then once daily PRN for pain for 7 days, discontinued on 2/10/19. The MD then wrote the order for the 2 mg. [MEDICATION NAME] to only be given 30-40 minutes before dressing changes, and was then completely discontinued on 2/18/19. Per review of the narcotic sign-out sheet, the same LPN had signed out the [MEDICATION NAME] on 2/10/19 at … | 2020-09-01 |
| 619 | 619 | THE MANOR, INC | 475057 | 577 WASHINGTON HIGHWAY | MORRISVILLE | VT | 5661 | 2018-06-06 | 584 | B | 0 | 1 | 0OOP11 | 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 1 of 2 resident units. The findings include the following: Per tour of the Spruce Unit, in the presence of the Housekeeping and Maintenance Supervisors on 6/5/18 at approximately 12:58 PM, multiple exhaust vents located in shared resident bathrooms were visually coated with dust and grime. Confirmation was made by both supervisors during the tour, that the vents needed cleaning. | 2020-09-01 |
| 620 | 620 | THE MANOR, INC | 475057 | 577 WASHINGTON HIGHWAY | MORRISVILLE | VT | 5661 | 2018-06-06 | 756 | D | 0 | 1 | 0OOP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with the Registered Pharmacist, s/he failed to report a medication irregularity to the appropriate professional staff as required, for 1 of 6 sampled residents, (Resident #12). The physician also failed to document in 1 of 6 sampled resident's medical record (Resident # 28), that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. The findings include the following: 1. Per medical record review, Resident #12 had a physician order [REDACTED]. On 5/21/18 the physician changed the scheduled dose to as needed (PRN) without including administration parameters (such as indications for use or how often to give it). The pharmacy consultation report conducted on 6/5/18, shows no recommendations for further administration parameters. Confirmation was made by the pharmacist on 6/6/18 at approximately 12:30 PM, that s/he was aware that there were no indications for PRN use of the [MEDICATION NAME], but that the nurse was in the process of contacting the physician to clarify the order. Confirmation was also made by the pharmacist, that no notation was made on the consultation report of his/her knowledge of the lack of indication for use. 2. Per record review, Resident #28's physician did not address a Gradual Dose Reduction (GDR) recommendation by the consulting pharmacist. The consulting pharmacist recommended a GDR for 3 [MEDICAL CONDITION] medications on 2/6/18. There is no evidence in the clinical record that the physician acted on this recommendation as of 6/6/18. The Unit Clinical Coordinator confirmed the above on 6/6/18 at 9:22 AM. | 2020-09-01 |
| 621 | 621 | THE MANOR, INC | 475057 | 577 WASHINGTON HIGHWAY | MORRISVILLE | VT | 5661 | 2018-06-06 | 758 | D | 0 | 1 | 0OOP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the physician failed to document in 1 of 6 applicable resident's medical record (Resident # 28) that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. Findings include: Per record review, Resident #28's physician did not address a Gradual Dose Reduction (GDR) recommendation by the consulting pharmacist. The consulting pharmacist recommended a GDR for 3 [MEDICAL CONDITION] medications on 2/6/18. There is no evidence in the clinical record that the physician acted on this recommendation as of 6/6/18. Additionally, there is no evidence that the facility took actions to ensure follow-up by the physician. The Unit Clinical Coordinator confirmed the above on 6/6/18 at 9:22 AM. | 2020-09-01 |
| 63 | 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 | 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 | 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) th… | 2020-09-01 |
| 66 | 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 stock… | 2020-09-01 |
| 67 | 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 … | 2020-09-01 |
| 68 | 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 | 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. A… | 2020-09-01 |
| 70 | 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 U… | 2020-09-01 |
| 71 | 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 | 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… | 2020-09-01 |
| 1466 | 1466 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2014-01-08 | 333 | D | 0 | 1 | 0TWW11 | Deficiency Text Not Available | 2017-05-01 |
| 1572 | 1572 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2014-01-08 | 250 | D | 1 | 0 | 0TWW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to provide medically related social services for 1 resident identified (Resident #83) to attain or maintain the highest practicable physical, mental and psychosocial well-being. The findings include; 1. Per review of a facility self reported incident on 1/8/14, Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the investigation on 10/29/13, Resident #83 reported to staff that during care a facility employee had tossed me around and hurt me. Resident #83 indicated it was not an accident that the employee doesn't like me and beat me about, the employee got discouraged and beat me up and shoved me. Per review of the nurse notes for Resident #83, after the incident on 10/29/13, Resident #83's behavior declined. Resident #83 became more weepy than prior to 10/29/13, and was unable to articulate reason for the weepiness. After 10/29/13, Resident #83 did voice concern on 11/3/13 that he/she feared being dropped on the floor by an aide when being turned. The notes indicate that Resident #83 was needing more physical assistance, and on 11/5/13, Resident #83 was refusing care from numerous caregivers. On 11/6/13 the nurse notes indicate that Resident #83 had a very flat affect. The notes also reflect on 11/8/13 Resident #83 was weepy at comfort care orders and when staff asked resident why he/she was crying Resident #83 responded I don't know. Per review of the Social Service notes, the Social Service Worker (SSW) interviewed Resident #83 on 10/29/13 regarding the interaction between the facility staff member and Resident #83. Per review of the SS notes, there was no evidence that the SSW assessed the change in status with Resident #83 and the increase in weepiness, refusal of care, voiced fears of staff and the resident's inability to articulate what was wrong when questioned by staff. Per review of the medical record there was evidence that Resid… | 2017-01-01 |
| 1573 | 1573 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2014-01-08 | 280 | D | 1 | 0 | 0TWW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to review and revise the comprehensive care plan for 1 resident identified (Resident #83) after a noted decline in resident's physical and mental status. The findings include: 1. Per review of the facility self report on 1/8/14, Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the investigation on 10/29/13, Resident #83 reported to staff that during care a facility employee had tossed me around and hurt me. Resident #83 indicated it was not an accident that the employee doesn't like me and beat me about, the employee got discouraged and beat me up and shoved me. Per review of the nurse notes for Resident #83, after the incident on 10/29/13, Resident #83 behavior declined. Resident #83 became more weepy than prior to 10/29/13, was unable to articulate reason for the weepiness. After 10/29/13, Resident #83 did voice concern on 11/3/13 that he/she feared being dropped on the floor by an aide when being turned. The notes indicate that Resident #83 was needing more physical assistance, on 11/5/13, Resident #83 was refusing care from numerous caregivers. On 11/6/13 the nurse notes indicate that Resident #83 had a very flat affect. The notes also reflect on 11/8/13 Resident #83 was weepy at comfort care orders and when staff asked resident why he/she was crying Resident #83 responded I don't know. Per review of the medical record there was evidence that Resident #83 was also experiencing a decline in physical condition and that this was causing weepiness and potential distress to Resident #83 when comfort care changes were placed for Resident #83. Per interview with the Director of Nursing Services (DNS) on 1/8/14, he/she reviewed the medical record and confirmed that after the 10/29/13 incident with Resident #83 and a facility staff member, there was a decline in the resident's behavior after the 10/29/13 incident and that further behavior cha… | 2017-01-01 |
| 2149 | 2149 | THOMPSON HOUSE NURSING HOME | 475050 | 80 MAPLE STREET | BRATTLEBORO | VT | 5302 | 2012-01-25 | 151 | D | 1 | 0 | 0U7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that one resident reviewed in the sample (Resident #1) was free to exercise his/her rights as a resident of the facility and as a citizen of the United States. The findings include: Based on interview and record review, Resident #1 was isolated for an extended period of time and was limited in the amount of time that the resident could interact with the facility population. 1. Per medical record review on 1/23/12, Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Per review of Resident #1's medical record, Resident #1 is alert and oriented and per review of the Psychiatric evaluation dated 11/08/11, indicated that Resident #1 "is violent to other residents at times." The evaluation also stated that for Resident #1 there is a "question of mental [MEDICAL CONDITION], though (he/she) is quite highly functioning." Review of the admission paperwork, indicates that Resident #1 does not have a legal guardian and per interview with the facility Administrator on 1/25/12, Resident #1 is able to make his/her own decisions. Per the medical record, Resident #1 had physical altercations with other residents on 11/19/11, 12/30/11 and 1/13/12. Per review of the nurse's notes, Resident #1 scratched the face of another resident and the facility's immediate intervention was to confine Resident #1 to his/her room and only allow Resident #1 out of the room for supervised phone calls with staff and supervised activities during the timeframe of 11/19 until 11/28/11 (total of 9 days). Per nurse's notes on 12/30/11, Resident #1 "slapped" the hand of a resident that utilized Resident #1's walker to stabilize his/her self to stand. The facility's immediate intervention was to confine Resident #1 to his/her room for a time period of 12/30/11 to 1/1/11. Resident #1 was allowed out of room only with supervision to utilize the phone. Per review of the nurse's notes dated 1/13/12, Resident #1 "kicked" another resident who was in hi… | 2015-05-01 |
| 2150 | 2150 | THOMPSON HOUSE NURSING HOME | 475050 | 80 MAPLE STREET | BRATTLEBORO | VT | 5302 | 2012-01-25 | 223 | E | 1 | 0 | 0U7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that one resident identified in the sample (Resident #1) was free from extended involuntary seclusion as a result of behavior issues and failed to protect 3 of 4 residents reviewed in the sample (Resident #2, #3 and #4) from abuse by another resident. The findings include: Based on interview and record review, the facility involuntarily secluded Resident #1 from the general facility population on three separate occasions for longer than an emergent short-term period of time as a way to control Resident #1's behavior issues. The facility also failed to protect 3 of 4 Residents from physical abuse by another resident. 1. Per medical record review on 1/23/12, Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Per the medical record, Resident #1 has had a noted documented history since admission of being physically aggressive toward other residents. Per review of the nurse's notes and the facility's internal investigation, on 11/19/11 Resident #1 admitted to staff to physically "assaulting" Resident #2. Resident #2 had wandered into Resident #1's room and lay down on Resident #1's bed. Resident #1 admitted to scratching Resident #2's face in an attempt to get him/her to leave. Per review of Resident #1's medical record, Resident #1 is alert and oriented and per review of the Psychiatric evaluation dated 11/08/11, indicated that Resident #1 "is violent to other residents at times." The evaluation also stated that for Resident #1 there is a "question of mental [MEDICAL CONDITION], though (he/she) is quite highly functioning." Review of the admission paperwork indicates that Resident #1 does not have a legal guardian and per interview with the facility Administrator on 1/25/12, Resident #1 is able to make his/her own decisions. Per interview with Resident #1 on 1/23/12 at 3:00 PM, Resident #1 verbalized that after she/he scratched Resident #2 in the face because he/she would not get off Resident #1's bed and… | 2015-05-01 |
| 2151 | 2151 | THOMPSON HOUSE NURSING HOME | 475050 | 80 MAPLE STREET | BRATTLEBORO | VT | 5302 | 2012-01-25 | 250 | E | 1 | 0 | 0U7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to provide medically- related social services to attain the highest practicable physical, mental and psychosocial well-being, for 4 of 4 residents (Resident #1, #2, #3 and #4) who were involved in physical altercations. The findings include: Based on interview and medical record review the facility failed to ensure the mental and psychosocial well-being for four residents who were participants in physical altercations with another resident. 1. Per medical record review on [DATE], Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Per the medical record, Resident #1 had physical altercations with other residents on [DATE], [DATE] and [DATE]. Per review of the nurse's notes, Resident #1 scratched the face of another resident and the facility's immediate intervention was to confine Resident #1 to his/her room and only allow Resident #1 out for supervised phone calls with staff and supervised activities during the timeframe of ,[DATE] until [DATE] (total 9 days). Per nurse's notes on [DATE], Resident #1 "slapped" the hand of a resident that utilized Resident #1's walker to stabilize his/her self to stand. The facility's immediate intervention was to confine Resident #1 to his/her room for a time period of [DATE] to [DATE]. Resident #1 was allowed out of room only with supervision to utilize the phone. Per review of the nurse's notes dated [DATE], Resident #1 "kicked" another resident who was in his/her way and the facility's immediate intervention was to confine Resident #1 to his/her room and allowed to come out to use the phone with supervision from staff and had to have all his/her meals in his/her room over the course of a weekend. Per review of the Social Services (SS) notes for Resident #1, there was no evidence that Resident #1 was assessed and evaluated by SS after the incident on [DATE] or [DATE]. Per interview with the SS Director on [DATE], he/she confirmed that he/she was made aware of the resident to r… | 2015-05-01 |
| 2152 | 2152 | THOMPSON HOUSE NURSING HOME | 475050 | 80 MAPLE STREET | BRATTLEBORO | VT | 5302 | 2012-01-25 | 280 | D | 1 | 0 | 0U7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to revise the comprehensive care plan that includes measurable objectives and timetables to meet the each resident's medical, nursing, mental and psychosocial needs for 1 of 4 residents reviewed in the sample (Resident #1). The findings include: The facility failed to revise the comprehensive care plan after two separate incidents of resident to resident physical aggression, and the confinement of Resident #1 on 12/30/11 and 1/13/12. Per medical record review on 1/23/12, Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Per the medical record, Resident #1 had physical altercations with other residents on 11/19/11, 12/30/11 and 1/13/12. Per review of the nurse's notes, Resident #1 scratched the face of another resident and the facility's immediate intervention was to confine Resident #1 to his/her room and only allow Resident #1 out for supervised phone calls with staff and supervised activities during the timeframe of 11/19 until 11/28/11 (total of 9 days). Per nurse's notes on 12/30/11, Resident #1 "slapped" the hand of a resident that utilized Resident #1's walker to stabilize his/her self to stand. Resident #1 was confined to his/her room for a time period of 12/30/11 to 1/1/11. Resident #1 was allowed out of room only with supervision to utilize the phone. Per review of the nurse's notes dated 1/13/12, Resident #1 "kicked" another resident who was in his/her way and the facility's immediate intervention was to confine Resident #1 to his/her room and allowed to come out to use the phone with supervision from staff and had to have all his/her meals in his/her room over the course of a weekend. Review of the comprehensive care plan titled Potential for adjustment, difficult interaction with others, with a goal date of 2/17/12, it indicated that on 11/19/11 resident was to receive checks every 15 minutes for suicidal verbalization, 1:1 if out of room (aggression) and these … | 2015-05-01 |
| 2153 | 2153 | THOMPSON HOUSE NURSING HOME | 475050 | 80 MAPLE STREET | BRATTLEBORO | VT | 5302 | 2012-01-25 | 282 | D | 1 | 0 | 0U7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to implement the comprehensive care plan for 1 of 4 residents reviewed in the sample (Resident #2). The findings include: Based on interview and record review the facility failed to provide services by qualified persons in accordance with 1 of 4 residents reviewed in the resident sample (Resident #2). The findings include: The facility failed to implement the plan of care for Resident #2 regarding the utilization of "as needed" Trazadone for resident symptoms of restlessness, wandering and [MEDICAL CONDITION] on 4 occasions during the time period of 12/9/11 to 1/8/12. Per review of the comprehensive care plan dated 12/9/11, titled, Anxiety related to cognitive deficits, the care plan indicates that Trazadone (medication to help with symptoms of [MEDICAL CONDITION]) is to be given per MD order and utilizing of the PRN (as needed) dose when unable to settle the resident with non pharmacological methods. Per review of the Medication Administration Record [REDACTED]. Review of the nurse's notes showed there was no documented evidence of any non pharmacological interventions used prior to the administration of the Trazadone. Review of the Medication Administration Record [REDACTED]. Review of the nurse's notes showed there was no documented evidence of any non pharmacological interventions used prior to the administration of the Trazadone. Per interview with the Director of Nursing on 1/23/12 at 11:28 AM, he/she reviewed the nurses notes for 12/13/11, 12/20/11, 12/23/11 and 1/8/12 and confirmed that no documentation was in the medical record regarding any non pharmacological interventions prior to the administration of PRN Trazadone. | 2015-05-01 |
| 608 | 608 | MAYO HEALTHCARE INC. | 475053 | 71 RICHARDSON AVE | NORTHFIELD | VT | 5663 | 2019-12-24 | 580 | E | 1 | 0 | 0VG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, the facility failed to notify the residents representative (POA) immediately at the time of treatment change, medication order changes, and at the time of transfer to the hospital resulting in an admission for 1 applicable resident, (Resident #1). The finding are as follows; Per record review Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the progress notes by the surveyor, the following physician order [REDACTED]. They are as follows: -02/06/19 Advanced Practice Registered Nurse (APRN) visit with new orders for chest x-ray, and the administration of [MEDICATION NAME] and antibiotics; -03/25/19 Resident #1 had an elevated temperature and physician order [REDACTED]. POA and Social Worker conversation on 03/26/19; -04/05, 04/06, 04/07 and 04/08/19 [MEDICAL CONDITION] eye drops not administered (possible refusal), and/or not available; -06/13/19 Resident #1 was started on an antibiotic for a [DIAGNOSES REDACTED]. Per review of the progress notes, confirmation is made that in some instances another relative was notified, but not the family member responsible for health care decisions. | 2020-09-01 |
| 609 | 609 | MAYO HEALTHCARE INC. | 475053 | 71 RICHARDSON AVE | NORTHFIELD | VT | 5663 | 2019-12-24 | 757 | E | 1 | 0 | 0VG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to ensure that a resident's drug regimen is free of unnecessary medications, including medications administrated for excessive duration and without adequate indications for use, for 1 applicable resident sampled (Resident #1). The findings include the following: Per record review Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the Medication Administration Record [REDACTED]. On 06/26/19, the physician's orders [REDACTED].) by mouth 2 times a day at 8 AM and 7 PM for cough. Antibiotic treatment was completed on 06/15/19, but the [MEDICATION NAME] cough syrup continued twice a day until 10/03/19. For the months of July, (MONTH) and (MONTH) 2019 there is no documentation by the nursing staff identifying a cough. The resident continued receiving the cough syrup twice a day. | 2020-09-01 |
| 551 | 551 | BEL AIRE CENTER | 475049 | 35 BEL-AIRE DRIVE | NEWPORT | VT | 5855 | 2017-08-30 | 157 | G | 1 | 1 | 0XXR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to immediately notify the physician when one resident in the applicable sample of 17 (Resident #93) had a significant change of condition. Findings include: Per review of documentation provided by the facility, Resident #93 was admitted to the facility on [DATE] for rehabilitation following hip replacement surgery. At approximately 7:30 PM on 8/15/17, Resident #93 transferred from the commode to the bed with the assistance of one Licensed Nurse Assistant (LNA). The Licensed Practical Nurse (LPN) on duty was administering medications to the roommate and reported hearing through the privacy curtain, Oh, my leg, stated by Resident #93. The LNA reported to the LPN that Resident #93 sat abruptly on the bed during the transfer. The medical record showed that the LPN examined Resident #93 and found no apparent injury. Resident #93 rated pain at that time as 4 on a scale of 0-10, with 10 being the worst possible pain. Pain medication (50 milligrams [MEDICATION NAME] orally every 6 hours as needed for pain) was administered at 7:45 PM and was documented on the Medication Administration Record (MAR) as having a positive effect. The MAR further indicated that the night nurse (an LPN) administered doses of pain medication at 1:35 AM and 6:30 AM. Significantly, the LPN documented medication effects for each of these doses bad hip pain. The LPN also documented in a night shift note (8/16/17 at 4:59 AM) that Resident #93 was in bad pain all night, did not sleep well, did not tolerate being transferred to the bedside commode, and was yelling out. The incident report and a nurse note (written at 9:09 AM) indicated that a Registered Nurse (RN) examined Resident #93 at the beginning of the day shift (7:00 AM) on 8/16/17. The RN found that Resident #93 was in pain, per non-verbal symptoms exhibited, and that the right leg had swelling and deformity. Per the incident report, the physician was notif… | 2020-09-01 |
| 552 | 552 | BEL AIRE CENTER | 475049 | 35 BEL-AIRE DRIVE | NEWPORT | VT | 5855 | 2017-08-30 | 309 | G | 1 | 1 | 0XXR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to respond appropriately to the presence or progression of pain for one of 17 residents in the applicable sample (Resident #93). Findings include: Per review of documentation provided by the facility, Resident #93 was admitted to the facility on [DATE] for rehabilitation following hip replacement surgery. At approximately 7:30 PM on 8/15/17, Resident #93 transferred from the commode to the bed with the assistance of one Licensed Nurse Assistant (LNA). The Licensed Practical Nurse (LPN) on duty was administering medications to the roommate and reported hearing through the privacy curtain, Oh, my leg, stated by Resident #93. The LNA reported to the LPN that Resident #93 sat abruptly on the bed during the transfer. The medical record showed that the LPN examined Resident #93 and found no apparent injury. Resident #93 rated pain at that time as 4 on a scale of 0-10, with 10 being the worst possible pain. Pain medication (50 milligrams [MEDICATION NAME] orally every 6 hours as needed for pain) was administered at 7:45 PM and was documented on the Medication Administration Record (MAR) as having a positive effect. However, the MAR further indicated that the night nurse (an LPN) administered doses of pain medication at 1:35 AM and 6:30 AM. Significantly, the LPN documented medication effects for each of these doses bad hip pain. The LPN also documented in a night shift note (8/16/17 at 4:59 AM) that Resident #93 was in bad pain all night, did not sleep well, did not tolerate being transferred to the bedside commode, and was yelling out. The incident report and a nurse note (written at 9:09 AM) indicated that a Registered Nurse (RN) examined Resident #93 at the beginning of the day shift (7:00 AM, 8/16/17). The RN found that Resident #93 was in pain, per non-verbal symptoms exhibited, and that the right leg had swelling and deformity. Per the incident report, the physician was notified… | 2020-09-01 |
| 553 | 553 | BEL AIRE CENTER | 475049 | 35 BEL-AIRE DRIVE | NEWPORT | VT | 5855 | 2017-08-30 | 514 | D | 1 | 1 | 0XXR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation/examination of medical records and staff interview the Licensed Practical Nurse (LPN) failed to ensure that 1 of 17 sampled residents, had complete and accurate documentation to include the resident's evaluation pre-and post-procedure and the actual insertion of an Indwelling Foley Catheter (Resident #65). The findings include the following: Per record review for Resident #65, a progress note written by the LPN states: 5/6/17 1:20 PM. Resident alert and oriented. C/O (Complaining of) bladder discomfort with PRN (as needed) Tylenol and PRN [MEDICATION NAME] given .Bladder scanned for 723, straight cath prior to inserting cath as ordered. Took 2 attempts for cath insertion, used a 16 FR. Min amount of blood noted. Urine dip obtained at this time. Resident was shaking this morning with relief after straight cath. Temp 102 with PRN Tylenol given with some effect. 100.1 at this time. Urine is dark, and has a foul smell. Fluids encouraged. Resident was up walking and transferring self prior to breakfast, took 2 assist at lunch time for bed mobility. Medications administration as per order. Resident is resting at this time. Will continue to monitor. The LPN documentation does not identify that after the straight catheterization that an indwelling catheter was left in place, documentation does not identify the amount of urine obtained at the time of catheterization, and documentation does not identify the location or source of the visual blood and documentation does not identify catheter patency. Per interview with the LPN on 8/29/7 at approximately 3:55 PM, confirmation is made that the documentation is not complete. Output flow sheet dated 5/4, 5/9, 5/10, 5/11, 5/12, 5/13 and 5/14/17 identify urine outputs for all three shifts. However, there is no documentation of output for the date of 5/6/17 which is the day Resident #65 was catheterized. This identifies incomplete documentation. This information was reviewed with the Nurs… | 2020-09-01 |
| 978 | 978 | RUTLAND HEALTHCARE AND REHABILITATION CENTER | 475039 | 46 NICHOLS STREET | RUTLAND | VT | 5701 | 2016-01-13 | 253 | B | 0 | 1 | 12300000000000.0 | Based on observation and confirmed by staff interview the facility failed to ensure that ventilation ducts located in resident care areas, are adequately maintained in a sanitary and orderly manner. The findings include the following: Per room to room tour on all three units with the Nursing Home Administrator (NHA), Maintenance Director, and Housekeeping Supervisor on 1/13/15, confirmation was made that vents in multiple resident shared bathrooms on all three units on the south side have accumulated dust and debris. The Maintenance Director confirms that there is no schedule or preventative maintenance program for cleaning of the bathroom vents. | 2018-11-01 |
| 979 | 979 | RUTLAND HEALTHCARE AND REHABILITATION CENTER | 475039 | 46 NICHOLS STREET | RUTLAND | VT | 5701 | 2016-01-13 | 280 | D | 0 | 1 | 12300000000000.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise/update and/or evaluate/review in a timely manner, the plan of care for 2 of 15 residents in the sample (Residents #69 & #123) Findings include: 1. Resident #69''s care plan was not revised or evaluated in a timely manner for independent smoking. A care plan (related to smoking on admission 05/19/15) states: educate (Resident #69) on the facility's smoking policy, reassess patient's ability to smoke independently with any change in condition, and to monitor patient's compliance to smoking policy. The facility's policy for smoking OPS137 states patients will be assessed on admission, quarterly and with change in condition for the ability to smoke safely and if necessary will be supervised. The resident had an order for [REDACTED]. A Social Service note dated 12/05/15 noted a discussion regarding certain recent behaviors talking in rude ways to fell ow residents particularly on the smoking porch. On 12/17/15 at approximately 11:00 AM the resident had a fall while on the smoking porch. The facility's Accident/Incident tool states that staff found the resident laying on the concrete floor flat on (his/her) back with wheelchair behind . The resident stated felt something snap. The resident reported pain as '8 out of 10' per the nursing note of 12/17/15 at 7:00 PM. Additionally, a nursing note of 01/05/2016 states ''Resident fell on [DATE] at which time began to have pain with lower back. Since the fall, resident has begun to decline''. There was not a smoking evaluation after the 12/05/15 incident or after the fall on 12/17/15 nor a timely revision to the care plan . An unsigned evaluation was dated 01/04/16 and a revision dated 01/05/15, nearly a month later. Per interview on 01/13/16 at 1:02 PM the Unit Manager confirmed there were not timely evaluations or revisions regarding the smoking care plan. 2. Resident #123's care plan (admitted on [DATE]) was not revised to reflec… | 2018-11-01 |
| 980 | 980 | RUTLAND HEALTHCARE AND REHABILITATION CENTER | 475039 | 46 NICHOLS STREET | RUTLAND | VT | 5701 | 2016-01-13 | 323 | E | 0 | 1 | 12300000000000.0 | Based observation and confirmed by staff interview the facility failed to ensure that the residents' environment remains free of accident hazards and each resident receives adequate supervision to prevent accidents. The findings include the following: Per observation during the initial tour and through out the three day survey, all five surveyors identified that the stairwell door (that is centrally located on the first floor), leading down to the basement and up to the second and third floors is not secure. The second and third floor doors do have a security system enabling staff, visitors and the public to access by utilizing a security code. The security is intended to keep residents safe from injury by not having access to the stairwell. Per interview with the Nursing Home Administrator (NHA) on 1/13/15, the unsecured first floor door was brought to his attention. NHA confirmed that he has made a capital expense requests to his Corporate Office on 2/6/15 and 5/18/15, of which they have both been denied due to budget constraints. The NHA has no documentation evidencing the denial, but confirms that the Regional Property Manager informed him via telephone, after both requests were denied. Per observation there are 3 doors that are unsecured on the first floor: The employee exit is locked from the outside, not allowing individuals in, the stairwell door is open unsecured at all times and lastly the doorway that exits to the outside at the north end of the building next to a conference room. Per interview with the Unit Manager (UM) and the Registered Nurse (RN) who oversee the first floor unit, confirmation is made that the resident population on the unit currently houses both long term and short stay rehabilitation residents. Eight (8) of the seventeen (17) residents residing on the unit have cognitive deficits. Two (2) have severe cognitive losses and six (6) have moderate cognitive losses. Of the eight residents, one (1) resident wanders, one (1) resident is able to wheel themselves in a wheelchair and one (1)… | 2018-11-01 |
| 981 | 981 | RUTLAND HEALTHCARE AND REHABILITATION CENTER | 475039 | 46 NICHOLS STREET | RUTLAND | VT | 5701 | 2016-01-13 | 371 | D | 0 | 1 | 12300000000000.0 | Based on observation the facility failed to assure that food was served under sanitary conditions. Findings include: Per dining observation at the lunch meal on 1/11/2016, the Licensed Nurses Assistant (LNA) at 12:25 PM, failed to wash or sanitize hands after assisting another LNA with repositioning a resident in a room across the hall (Room 218). At 12:45 PM, for the second lunch seating, the same LNA removed an overbed table from room 218 to use for a resident (R#128) who was not in that room without cleaning or sanitizing it, and set the food tray on the table. In an interview on 1/11/2016 the LNA confirmed that s/he should have sanitized her hands and sanitized the table before using it for another resident. Based on observation, staff confirmation and policy review the facility failed to store food safely to prevent foodborne illness, for residents who have personal refrigerators in their rooms on second floor north. The findings include the following: Per observation during Stage 1 and Stage 2 of the survey, on the second floor north unit multiple personal refrigerators located in resident rooms were identified with incomplete temperature logs. One of the refrigerators had outdated cottage cheese and yogurt. Per facility log titled Refrigerator/Freezer and Temperature Log (dated as revised 2/06), located on the side of each refrigerator, #3 identifies Temperature Checks will be checked and recorded daily. Per interview on 1/12/15 at approximately 8:30 AM, with the Unit Manger and the Licensed Practical Nurse, confirmation is made that the temperature logs have not been consistently completed as per policy. | 2018-11-01 |
| 982 | 982 | RUTLAND HEALTHCARE AND REHABILITATION CENTER | 475039 | 46 NICHOLS STREET | RUTLAND | VT | 5701 | 2016-01-13 | 516 | B | 0 | 1 | 12300000000000.0 | Based on observation and confirmed through staff interview the facility failed to safeguard resident clinical information against unauthorized use. The findings include the following: Per observation during the initial tour on 1/11/16 and again on the second day of the survey, resident personal health information (PHI) was located on the second floor north, in the day/dining room that is frequently left unattended by staff. Multiple notebooks containing resident PHI related to care needs, specific directions to staff on the managing and monitoring of falls, flow sheets evidencing food and fluid intake, evacuation logs, resident pictures and staff assignments were left on the table and/or sitting next to the toaster. Per interview with a Licensed Nurse Aide (LNA) on 1/12/16 confirmation was made that the log books are kept in the dining/day room for easy access for staff use. Confirmation was also made on 1/12/16 by the Director of Nurses, Nursing Home Administrator and Unit Manger that residents' PHI has been stored in the day/dining room which has public access and does not always have staff presence. Therefore making the log books available to anyone who had interest, but no authority. | 2018-11-01 |
| 1871 | 1871 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2013-01-03 | 157 | D | 1 | 0 | 12H711 | br>Based upon interview and record review, the facility failed to document that the resident or legal representative was notified when there was a room change for 1 of 8 residents in the applicable sample. (Resident #1). Finding includes: 1. Per record review and confirmed during an interview with the Director of Nursing (DNS) on 1/3/13 at 10:50 AM, Resident #1 was moved from the first floor to the second floor on 12/18/12 and there is no documentation that the family was notified of the room change in either the electronic or hard copy medical record. | 2016-01-01 |
| 1872 | 1872 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2013-01-03 | 223 | E | 1 | 0 | 12H711 | br>Based upon interview, observation, and record review the facility failed to assure that 8 of 8 residents living on the 2nd floor were not involuntary secluded (separated from other residents or confined to his or her room with or without room mates) and allowed free movement throughout the facility after the stair chair lift was out of working order from 12/11/12 to 1/2/13. (Residents # 1, 2, 3, 4, 5, 6, 7, 8) Findings include: 1. Per joint resident interview with resident room mates #7 and #8 on 1/2/13 at 2:00 PM, both residents were aware that the chair stair lift was out of working order. Both residents stated I have not been downstairs since the stair glide has been broken. I used to use the glide to go downstairs. Resident #7 stated that It would be very hard to go down the stairs without the stair glide. I have a bad shoulder and use a quad cane and walker. Resident #8 stated she/he Does not use a cane and only uses a walker and I would have difficulty getting down the stairs if I had to use them. In addition, Resident #7 stated We are very clean people, but have not had a bath or shower since the glide has been broken. It's hard being clean only taking a sponge bath. Both Residents stated they are only doing sponge baths in the bathroom in their room and would like a bath or shower. 2. Per resident interview with Resident #7 on 1/2/13 at 2:00 PM, resident stated I haven't played Bingo downstairs since the chair lift went out. I like playing downstairs. In addition, per review of the activities log for Resident room mates #7 and #8 and interview on 1/2/13 at 2:19 PM, the Activities Director stated, Prior to the stair glide being out, (Residents #7 and #8) enjoyed going downstairs for Bingo, meals and Sing Along. Since the stair glide has been out, the Activities Director has been doing Bingo in their room with just the two of them. 3. Per resident interview on 1/3/13 at 8:53 AM, Resident #4 stated I don't have anybody to talk to except myself. Per staff interview and review of the activities log on 1/2/1… | 2016-01-01 |
| 1873 | 1873 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2013-01-03 | 241 | E | 1 | 0 | 12H711 | br>Based upon interview, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity for 2 of 8 residents in the applicable sample from 12/11/12 to 1/2/13. (Residents #7 and 8) Finding includes: 1. Per joint resident interview with resident room mates #7 and #8 on 1/2/13 at 2:00 PM, both residents were aware that the chair stair lift was out of working order. Both residents stated I have not been downstairs since the stair glide has been broken. I used to use the glide to go downstairs. Resident #7 stated We are very clean people, but have not had a bath or shower since the glide has been broken. It's hard being clean only taking a sponge bath. Both Resident #7 and #8 stated they are only doing sponge baths in the bathroom in their room and would like a bath or shower. In addition, Resident #7 stated that It would be very hard to go down the stairs without the stair glide. I have a bad shoulder and use a quad cane and walker. Resident #8 stated she/he Does not use a cane and only uses a walker and I would have difficulty getting down the stairs if I had to use them. | 2016-01-01 |
| 1874 | 1874 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2013-01-03 | 242 | E | 1 | 0 | 12H711 | br>Based upon interview and record review, the facility failed to allow residents to choose activities consistent with his or her interests, assessments, and plans of care; interact with members of the community both inside and outside the facility for 5 of 8 Residents in the applicable sample from 12/11/12 to 1/2/13. (Residents # 1, 4 ,7, 8) 1. Per joint resident interview with resident room mates #7 and #8 on 1/2/13 at 2:00 PM, both residents were aware that the chair stair lift was out of working order. Both residents stated I have not been downstairs since the stair glide has been broken. I used to use the glide to go downstairs. Resident #7 stated, I haven't played Bingo downstairs since the chair lift went out. I like playing downstairs. Per review of the activities log for Resident room mates #7 and #8 and staff interview on 1/2/13 at 2:19 PM, the Activities Director stated, Prior to the stair glide being out, (Residents #7 and #8) enjoyed going downstairs for Bingo, meals and Sing Along. Since the stair glide has been out, the Activities director has been doing Bingo in their room with just the two of them. 2. Per resident interview on 1/3/13 at 8:53 AM, Resident #4 stated I don't have anybody to talk to except myself. Per staff interview and review of the activities log on 1/2/13 at 2:19 PM, the Activities Director stated that , (Resident #4) has been alone in (his/her) room for approximately a week and has had no interactions with other residents since the room mate left and the stair glide broke. 3. Per interview with Director of Nursing (DNS) on 1/3/13 at 10:50 AM, the DNS stated Before the chair lift went out, (Resident #1) went downstairs for meals and for the day. S/he stated the resident has not been downstairs since coming back up to the second floor from 12/18/12 to 1/2/13. Per resident observation on 1/2/13 at 3:06 PM, Resident #1 was sitting in a chair watching television in his/her room on the second floor. Per resident observation on 1/3/13 at 8:53 AM, Resident #1 was eating breakfast in his… | 2016-01-01 |
| 1875 | 1875 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2013-01-03 | 246 | E | 1 | 0 | 12H711 | br>Based upon interview and record review, the facility failed to ensure that residents had reasonable accommodations of individual needs and preferences for 4 of 8 residents in the applicable sample from 12/11/12 to 1/2/13. (Residents #1, 7, and 8). Findings include: 1. Per joint resident interview with resident room mates #7 and #8 on 1/2/13 at 2:00 PM, both residents were aware that the chair stair lift was out of working order. Both residents stated I have not been downstairs since the stair glide has been broken. I used to use the glide to go downstairs. Resident #7 stated, I haven't played Bingo downstairs since the chair lift went out. I like playing downstairs. Per review of the activities log for Residents #7 and #8 and staff interview on 1/2/13 at 2:19 PM, the Activities Director stated, Prior to the stair glide being out, (Residents #7 and #8) enjoyed going downstairs for Bingo, meals and Sing Along. Since the stair glide has been out, he/she has been doing Bingo in their room with just the two of them. 2. Per interview with Director of Nursing (DNS) on 1/3/13 at 10:50 AM, the Director of Nursing (DNS) stated Before the chair lift went out, (Resident #1) went downstairs for meals and for the day. S/he stated the resident has not been downstairs since coming back up to the second floor from 12/18/12 to 1/2/13. Per resident observation on 1/2/13 at 3:06 PM, Resident #1 was sitting in a chair watching television in his/her room on the second floor. Per resident observation on 1/3/13 at 8:53 AM, Resident # 1 was eating breakfast in his/her room on the second floor. In addition, per record review of the Care Plan for Resident #1 interventions include provide activities that promote exercise and strength building , invite the resident to activities that promote additional (nutritional) intake, and encourage and provide opportunities for exercise, physical activity. Additionally, Resident #1's Activities Care Plan lists get downstairs; bingo, special events, etc. Per record review Resident #1's Daily Particip… | 2016-01-01 |
| 1876 | 1876 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2013-01-03 | 248 | E | 1 | 0 | 12H711 | br>Based on record review and interview, the facility failed to provide a program of activities to meet the assessed needs of 8 of 8 residents (Residents #1, 2, 3, 4, 5, 6, 7, and 8) while the stair chair lift was not in working order, preventing the residents from being able to go downstairs. Findings include: 1. Per record review and confirmed during an interview with the Director of Social Services and Director of Nursing (DNS) on 1/3/13 at 2:14 P.M., Care Plans for Residents #1, #2, #3, #4, #5, #6, #7 and #8 were not implemented due to the stair chair lift not working. Per record review, Care Plan interventions for Resident #1 include provide activities that promote exercise and strength building, invite the resident to activities that promote additional (nutritional) intake, and encourage and provide opportunities for exercise, physical activity. Additionally, Resident #1's Activities Care Plan lists get downstairs; bingo, special events, etc. Per record review Resident #1's Daily Participation Record for December 2012 documents the resident attended 1 social hour/special event, a Christmas party on 12/12/12, and no social hours or special events after that date. Resident #1 was moved from the first floor to the second floor on 12/18/12. Per record review, Care Plan interventions for Resident #2 include take to recreational activities/programs. Per record review Resident #2's Daily Participation Record for December 2012 documents the resident attended 1 social hour/special event, a Christmas party on 12/12/12, and no social hours or special events after that date. Per record review, Care Plan interventions for Resident #3 include take to recreational activities/programs, encourage resident to attend group activities, encourage resident to take active social role within facility, offer activities of which the resident has shown interest: small group discussion. Per record review Resident #3's Daily Participation Record for December 2012 documents the resident attended 1 social hour/special event, a Christmas … | 2016-01-01 |
| 1877 | 1877 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2013-01-03 | 280 | E | 1 | 0 | 12H711 | br>Based upon observation, interview, and record review, the facility failed to revise the care plan for 8 of 8 residents to reflect that residents were not able to leave the second floor from 12/11/12 to 1/3/13 while the stair chair lift was out of working order. (#1, 2, 3, 4, 5, 6, 7, and 8) Findings include: 1. Per record review and confirmed during an interview with the Director of Social Services and Director of Nursing (DNS) on 1/3/13 at 2:14 P.M., Care Plans for Residents #1, #2, #3, #4, #5, #6, #7 and #8 were not revised to reflect that the stair chair lift was not working and how this impacted the resident's activities and mobility. Per record review, Care Plan interventions for Resident #1 include provide activities that promote exercise and strength building, invite the resident to activities that promote additional (nutritional) intake, and encourage and provide opportunities for exercise, physical activity. Additionally, Resident #1's Activities Care Plan lists get downstairs; bingo, special events, etc. Per record review Resident #1's Daily Participation Record for December 2012 documents the resident attended 1 social hour/special event, a Christmas party on 12/12/12, and no social hours or special events after that date. Resident #1 was moved from the first floor to the second floor on 12/18/12. Per record review, Care Plan interventions for Resident #2 include take to recreational activities/programs. Per record review Resident #2's Daily Participation Record for December 2012 documents the resident attended 1 social hour/special event, a Christmas party on 12/12/12, and no social hours or special events after that date. Per record review, Care Plan interventions for Resident #3 include take to recreational activities/programs, encourage resident to attend group activities, encourage resident to take active social role within facility, offer activities of which the resident has shown interest: small group discussion. Per record review Resident #3's Daily Participation Record for December 2012 doc… | 2016-01-01 |
| 1878 | 1878 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2013-01-03 | 282 | E | 1 | 0 | 12H711 | br>Based upon observation, interview, and record review, the facility failed to provide or arrange services in accordance with each resident's written plan of care for 8 of 8 residents from 12/11/12 to 1/3/13 while the stair chair lift was out of working order. (#1, 2, 3, 4, 5, 6, 7, and 8) Findings include: 1. Per record review and confirmed during an interview with the Director of Social Services and Director of Nursing (DNS) on 1/3/13 at 2:14 P.M., Care Plans for Residents #1, #2, #3, #4, #5, #6, #7 and #8 were not implemented due to the stair chair lift not working. Per record review, Care Plan interventions for Resident #1 include provide activities that promote exercise and strength building, invite the resident to activities that promote additional (nutritional) intake, and encourage and provide opportunities for exercise, physical activity. Additionally, Resident #1's Activities Care Plan lists get downstairs; bingo, special events, etc. Per record review Resident #1's Daily Participation Record for December 2012 documents the resident attended 1 social hour/special event, a Christmas party on 12/12/12, and no social hours or special events after that date. Resident #1 was moved from the first floor to the second floor on 12/18/12. Per record review, Care Plan interventions for Resident #2 include take to recreational activities/programs. Per record review Resident #2's Daily Participation Record for December 2012 documents the resident attended 1 social hour/special event, a Christmas party on 12/12/12, and no social hours or special events after that date. Per record review, Care Plan interventions for Resident #3 include take to recreational activities/programs, encourage resident to attend group activities, encourage resident to take active social role within facility, offer activities of which the resident has shown interest: small group discussion. Per record review Resident #3's Daily Participation Record for December 2012 documents the resident attended 1 social hour/special event, a Christmas par… | 2016-01-01 |
| 1879 | 1879 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2013-01-03 | 456 | E | 1 | 0 | 12H711 | br>Based upon interview, the facility failed to maintain all essential mechanical equipment and patient care equipment in safe operating condition, which affected 8 of 8 residents on the 2nd floor. (Residents #1, 2, 3, 4, 5, 6, 7, and 8) Findings include: 1. Per interview with the Administrator on 1/2/13 at 1:08 PM, the stair chair lift which moves residents between the 1st and 2nd floors of the facility was out of working order from 12/11/12 to 1/2/13. There is no other equipment that allowed for the movement of residents between the 1st and 2nd floors. 2. Per observation on 1/2/13 at 3:00 P.M. and confirmed by a staff RN at 3:11 P.M. the bathroom serving residents in Room 12 & 13 contained a commode with a loose toilet seat that could be swung several inches side to side, and attached support rails that were unstable and easily twisted . | 2016-01-01 |
| 1880 | 1880 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2013-01-03 | 495 | E | 1 | 0 | 12H711 | br>Based upon observation, interview, policy review, and record review, the facility failed to train and determine that Licensed Nurse Assistant (LNA) staff were proficient in opening the Emergency Exit Door during non-fire related disasters for 2 of 3 LNAs observed, potentially affecting 8 of 8 residents on the 2nd floor (Residents #1, #2, #3, #4, #5, #6, #7 and #8). Findings include: 1. Per observation and interview on 1/2/13 at 3:17 PM, an LNA was unable to open the second floor Emergency Exit Door and was stopped by the Surveyor after 6 attempts. The LNA stated I've never played with the back door. In addition, per Surveyor request on 1/2/13, the Administrator stated all staff would be trained how to open the Emergency Exit Door prior to the start of their shift. 2. Per observation and interview on 1/3/13 (Day 2 of the Survey) at 10:30 AM, an LNA was unable to open the second floor Emergency Exit Door and was stopped by the Surveyor after 3 attempts. The LNA stated she was not trained on the second floor Emergency Exit Alarm System prior to working on 1/3/13. I was off yesterday and wasn't trained. I don't know how to open the door. I've never done it. 3. Per review of facility Disaster Policy and confirmed during interview on 1/3/13 at 11:20 AM, the Director of Nursing (DNS) stated that staff need to be able to open the Emergency Exit Door in non-fire related disasters which require resident evacuation, such as bomb threats and chemical spills. In addition, per telephone interview on 1/3/13 at 10:35 AM, the Fire Chief stated When the fire alarm is pulled, the Emergency Exit Door demagnetizes (unlocks). If there is a non-fire disaster, the fire alarm is not pulled by staff. The Emergency Exit Door stays magnetized (locked) and must be manually released by the staff. | 2016-01-01 |
| 1881 | 1881 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2013-01-03 | 518 | E | 1 | 0 | 12H711 | br>Per observation, interview and record review, the facility failed to train employees in emergency procedures when they begin to work in the facility, periodically review procedures with existing staff and carry out unannounced staff drills using those procedures for 3 of 4 staff observed. Findings include: 1. Per observation and interview on 1/2/13 at 3:17 PM, an LNA was unable to open the second floor Emergency Exit Door and was stopped by the Surveyor after 6 attempts. The LNA stated I've never played with the back door. Per observation on 1/2/13, one RN was unable to open the second floor Emergency Exit Door and was stopped by the Surveyor after 3 attempts. Per Surveyor request on 1/2/13, the Administrator stated all staff would be trained how to open the Emergency Exit Door prior to the start of their shift. 2. Per observation and interview on 1/3/13 (Day 2 of the Survey) at 10:30 AM, an LNA was unable to open the second floor Emergency Exit Door and was stopped by the Surveyor after 3 attempts. The LNA stated she was not trained on the second floor Emergency Exit Alarm System prior to working on 1/3/13. I was off yesterday and wasn't trained. I don't know how to open the door. I've never done it. 3. Per review of facility Disaster Policy and confirmed during interview on 1/3/13 at 11:20 AM, the Director of Nursing (DNS) stated that staff need to be able to open the Emergency Exit Door in non-fire related disasters which require resident evacuation, such as bomb threats and chemical spills. In addition, per telephone interview on 1/3/13 at 10:35 AM, the Fire Chief stated When the fire alarm is pulled, the Emergency Exit Door demagnetizes (unlocks). If there is a non-fire disaster, the fire alarm is not pulled by staff. The Emergency Exit Door stays magnetized (locked) and must be manually released by the staff. 4. Per interview and record review on 1/3/13 at 1:35 PM the Staff Educator stated Everyone is trained in fire safety, emergency procedures at least annually. All staff are trained upon hiring, then … | 2016-01-01 |
| 480 | 480 | PINES REHAB & HEALTH CTR | 475044 | 601 RED VILLAGE ROAD | LYNDONVILLE | VT | 5851 | 2020-01-13 | 550 | G | 1 | 0 | 14YG11 | > Based on staff interviews and record review, the facility failed to protect and promote the rights of 1 of 4 residents in the applicable sample (Resident #4). The facility failed to treat Resident #4 with respect and dignity and in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing the resident's individuality. Findings include: Per review of written witness and alleged perpetrator statements, on (MONTH) 24, 2019, Resident #4 was observed having behaviors and being disruptive. The resident has a written care plan in place addressing these behaviors. However, the Licensed Practical Nurse (LPN) became visibly upset and stated to a Licensed Nurse Aide (LNA) stop babying the resident and came around behind Resident #4 and picked the resident up off the floor and carried them to their room. A subsequent exam showed Resident #4 had bruises under both arms and both sides of their rib cage, consistent with where the LPN's hands would have carried the resident. The LPN in question was subsequently suspended and eventually their agency contract was terminated citing unprofessional behavior. The regulation interpretive guidelines clearly indicate that all staff need to take into account that all interactions should be to assist the resident in maintaining and enhancing resident self-esteem and self-worth. That residents should be treated with dignity and respect. That staff must respect each resident's individuality. See also F600. | 2020-09-01 |
| 481 | 481 | PINES REHAB & HEALTH CTR | 475044 | 601 RED VILLAGE ROAD | LYNDONVILLE | VT | 5851 | 2020-01-13 | 600 | G | 1 | 0 | 14YG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to assure that 1 of 4 residents in the applicable sample (Resident #4) remained free from physical abuse. Findings include: Per record review, Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Per record review the resident is known to have multiple behaviors that include but are not limited to putting herself onto the floor at will. Per review of the facility's internal investigation along with written witness, alleged perpetrator statements, and employee interviews, Resident #4 was the victim of a physically abusive event on (MONTH) 24, 2019. The Licensed Practical Nurse (LPN) who was contracted by the facility from a Travel Nurse Agency, was observed being visibly upset when dealing with the resident who was being disruptive and the LPN told staff to not baby the resident. The resident had been lowered to the floor by staff and was sitting on the floor in the hallway of the dementia unit. The LPN was then observed going behind the resident and lifting Resident #4 up from the floor and carrying them to their room. Upon exam, Resident #4 was observed to have bruises under both arms and both sides of their rib cage, consistent with where the LPN's hands would have carried the resident. The regulation interpretive guidelines clearly indicate that the facility assumes the responsibility of ensuring the safety and well-being of the resident. It is the facility's responsibility to ensure that all staff are trained and knowledgeable in how to react and respond appropriately to resident behavior. All staff are expected to be in control of their own behavior, are to behave professionally, and should understand how to work with the nursing home population. | 2020-09-01 |
| 554 | 554 | THOMPSON HOUSE NURSING HOME | 475050 | 80 MAPLE STREET | BRATTLEBORO | VT | 5301 | 2020-01-14 | 689 | G | 1 | 0 | 15F111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review the facility failed to ensure that appropriate assistive devices were used to prevent a fall that resulted in a major injury for one (1) of three (3) sampled residents, (Resident #1). Findings include: Per record review, on [DATE] at 11:50 AM Resident #1 was Lowered to the floor by a Licensed Nursing Assistant (LNA) on the way to the bathroom. Per Resident #1's care plan at the time of the fall s/he required an extensive assist from 1 staff with ambulation, toileting, and transferring. The care plan did not reflect the use of a gait-belt. A Post Fall Investigation & Review form completed by a Registered Nurse (RN) dated [DATE], indicated that assistive devices assigned to the resident were a walker and gait-belt. Per Nurses Note dated [DATE] 22:48 the nurse was Called into res bathroom by LNA, the resident was complaining of left leg pain and only doing partial weight bearing. Pain to left femur on palpation. On [DATE] the nurse obtained an order for [REDACTED]. S/he was transported to the hospital for X-ray and returned with the [DIAGNOSES REDACTED]. S/he was placed on pallitaive (comfort) care and expired at the facility on [DATE]. On [DATE] at approximately 2:30 PM, during interview with the LNA, s/he stated that staff ambulated Resident #1 with a walker almost every day, but some days (Resident #1) required a wheelchair because s/he was too unsteady. The LNA also stated that s/he usually would use a gait-belt, but s/he has seen one both used and not used. According to the LNA s/he was ambulating the resident to her/his room with a walker. While entering the room the resident lost her/his balance and fell to the left, landing on her/his left side. The LNA confirmed that s/he had not used a gait-belt and that the resident fell , rather than being lowered to the floor as s/he had originally reported. On [DATE] at 3:08 PM, during an interview with the RN, s/he stated that the LNA had told him/her t… | 2020-09-01 |
| 2271 | 2271 | CENTERS FOR LIVING AND REHAB | 475029 | 160 HOSPITAL DRIVE | BENNINGTON | VT | 5201 | 2011-06-01 | 157 | D | 1 | 0 | 16J411 | Based on interviews and record reviews, the facility failed to inform family members of a discontinuation of treatment for 2 of 11 Residents in the sample (Residents #1 and #2). Findings include: 1. Per record review on 6/1/11, the facility failed to immediately inform Resident #1's family when the resident's restorative care plan to treat contractures was suspended for an indefinite period of time on 1/27/11. The family was not apprised of the changes until they inquired about care issues on 3/2/11. The lack of notice to the family was confirmed during interviews with the Administrator at 10:15 AM and the Unit Manager at 12:55 PM on 6/1/11. 2. Per record review on 6/1/11, the facility did not notify Resident #2's family when his/her restorative nursing program was discontinued on 2/1/11. This was confirmed by the Unit Manager (UM) during a 1:58 PM interview on 6/1/11. | 2014-10-01 |
| 2272 | 2272 | CENTERS FOR LIVING AND REHAB | 475029 | 160 HOSPITAL DRIVE | BENNINGTON | VT | 5201 | 2011-06-01 | 363 | D | 1 | 0 | 16J411 | Based on observation, interview and record review, for 1 applicable resident in the sample, the facility failed to assure that all menu types offered to residents were approved by the Registered Dietician (RD) to assure that the nutritional needs of residents were met and followed in accordance with the recommended allowances of the Food and Nutrition Board of the National Research Council. (Resident #1) Findings include: Per record review and confirmed by observation of the noon meal on 6/1/11, Resident #1 receives 1/2 portions per review of the meal ticket on the tray and the servings of chicken casserole, broccoli and glass of apple juice served to the resident. When asked for a copy of the policy/procedure for the 1/2 portion meals served at the facility, the Food Service Manager stated at that there was no policy/procedure. She verified that there were no written instructions, approved by and/or reviewed by the RD for staff to utilize regarding actual minimum portion sizes for the various food groups served each day (i.e. protein, carbohydrates and fats). | 2014-10-01 |
| 2273 | 2273 | CENTERS FOR LIVING AND REHAB | 475029 | 160 HOSPITAL DRIVE | BENNINGTON | VT | 5201 | 2011-06-01 | 282 | D | 1 | 0 | 16J411 | Based on interviews and record review, the facility failed to assure that care was provided in accordance with the plan of care for 1 applicable resident in the survey. (Resident #1) Findings include: Per review of the medical record and LNA documentation on 6/1/11, Resident #1's care plan dated 5/3/11 stated to provide Restorative Passive Range of Motion (PROM) to upper and lower extremities AM & PM. Based on written communication with the responsible family member on 5/31/11, the Director of Nurses had stated that, after a lapse in providing 15 minutes of the PROM exercises twice daily for the resident, that the exercises would resume for the specified time of 15 minutes twice each day starting in March, 2011. Per review of the Licensed Nursing Assistant (LNA) documentation of PROM exercises during May, 2011, they were not being provided for the full 15 minutes twice daily as stated by the DNS. There were several days when the 15 minutes was provided and there were several days when the time was documented as 5 minutes or 10 minutes. Based on interview on 6/1/11 at 12:00 PM, the LNA providing care stated that she usually spends about 5 minutes providing the PROM exercises during the AM shift. During interview at 11 AM on 6/1/11, the Registered Nurse (RN) who oversees the Restorative Program verified that the resident was currently on a PROM program, but only with daily care, not necessarily for 15 minutes twice daily as requested by the family. | 2014-10-01 |
| 2204 | 2204 | STARR FARM NURSING CENTER | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2011-10-12 | 225 | E | 1 | 0 | 1B1X11 | Based on record review and staff interviews, the facility failed to assure required checks of the State abuse, neglect, and exploitation registry (Vermont Adult Protective Services (APS) registry) were completed for all persons that work at the facility, including those employed by a sub-contractor. Findings include: Per record review of five individuals most recently employed by the sub-contractor Health Care Services (HCS), who provide housekeeping and laundry services in the facility, APS registry checks are not present in the files. In an interview at 3:30 PM on 10/12/11, the Manager of Housekeeping at Starr Farm (an employee of HCS), stated that in a phone call, the regional director of HCS stated to him/her that s/he had decided to stop the abuse (APS) registry checks in the belief that the national background checks conducted by HCS would meet the standard. The Manager stated that s/he was aware that the abuse (APS) checks were required and that s/he assumed that the checks were done when s/he was told by the corporate office that the employee had been cleared and were ready to work. | 2015-02-01 |
| 781 | 781 | MENIG NURSING HOME | 475058 | 215 TOM WICKER LANE | RANDOLPH CENTER | VT | 5061 | 2016-03-09 | 280 | D | 0 | 1 | 1B9E11 | Based on observation, record review, and staff interview, the facility failed to ensure that a care plan was revised to reflect current status and possible interventions for 1 of 14 residents sampled (Resident #9). Findings include: Per observation on 3/7/16, Resident #9 was sitting in the dining room with a short sleeved shirt on, and was noted to have a lot of small bruises and multiple skin tears on both arms. The skin tears were covered with a clear dressing to protect them. Review of the nurse's notes showed documentation of treating the wounds and their status. In review of the plan of care, there was no update to the current status of the open wounds, as well as no goals or interventions in place that addressed any possible strategies to prevent further skin tear wounds for this resident. Per interview on 3/8/16, the Director of Nursing confirmed that the plan of care had not been updated to include the actual skin integrity status and possible interventions to prevent further incidents. | 2019-08-01 |
| 782 | 782 | MENIG NURSING HOME | 475058 | 215 TOM WICKER LANE | RANDOLPH CENTER | VT | 5061 | 2016-03-09 | 325 | D | 0 | 1 | 1B9E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to monitor body weight for a resident with nutritional concerns for 1 of 14 residents (Resident #9). Findings include: Per record review, Resident #9 had an episode of losing weight in (MONTH) (YEAR), when s/he lost over 5 lbs. in a month. The interventions implemented at that time such as supplementation to the diet were successful in regaining weight lost and extra gain. The resident had a [DIAGNOSES REDACTED]. The resident's last weight recorded on 12/10/15 was 137 lbs. The resident had a fall at the facility, fracturing a hip and was hospitalized in (MONTH) (YEAR) for surgical repair and recovery. until a readmission to the nursing home on 12/28/15. Per review of the Dietician note at readmission, they stated that they followed the resident's progress at the hospital, that the resident had lost weight there, and wrote that no admission weight was available. Per further review of the record, there was no evidence that the resident was weighed upon readmission, and the first weight documented was 119.4 lbs. on 1/21/16. The following weights were also recorded: 1/30/16 - 119.4 lbs. On 2/11/16, the resident weighed 115 lbs. On 2/18/16, 116 lbs. The last two weights recorded were 2/25/16 : 113 lbs. and on 3/3/16 the resident weighed 111.4 lbs. There was documentation that the resident was not accepting meals, refusing supplements at times, and was refusing medications also. Per interview with Social Services, the resident had expressed to them many times that they have no appetite, and even with the addition of favorite foods and supplements would choose not to eat. The Social Services director stated that this resident was clear that they did not want to live any more, and was making this choice consciously. There was psychosocial support given to this resident from professionals, depression treatment with medication, and nutritional supplementation, however very little was accep… | 2019-08-01 |
| 1 | 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… | 2020-09-01 |
| 2 | 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 |
| 303 | 303 | ELDERWOOD AT BURLINGTON | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2017-12-20 | 609 | D | 0 | 1 | 1EWI11 | Based on interviews and record review the facility failed to assure that all allegations of abuse or mistreatment, including injuries of unknown source, are reported to the State Survey Agency and Adult Protective Services in accordance with State law through established procedures for one applicable resident in the sample. Findings include: Per interview on 12/18/17, Resident #98 stated that there was a staff person who was rough with him/her and it was elder abuse. Resident #98 is described as alert and oriented in progress notes. The resident's Spouse, who was present at the interview and at the incident, confirmed that the incident did happen. The Spouse indicated that it was about a month ago and that the concern was reported to the facility. Furthermore, the Social Worker who had been working on it has left and recently stated that s/he didn't know where things are at according to the Spouse. In an interview with a Social Worker on 12/19/17 at 2:45 PM s/he stated that the resident did have an incident on 11/28/17 when s/he accused an LNA of being rough. In a review of the Grievance report, provided by the Social Worker, the resident stated that the LNA had been rough with morning care and stated that it was Elder abuse. Further investigation documentation shows the SW at that time did begin an investigation and the LNA was removed from providing care for that resident. A decision was made to provide 2 caregivers during care to assure that the resident was moved safely and comfortably. The facility SW stated that a decision was made not to report the allegation to the Division of Licensing & Protection. | 2020-09-01 |
| 304 | 304 | ELDERWOOD AT BURLINGTON | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2017-12-20 | 623 | B | 0 | 1 | 1EWI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to notify 2 of 3 applicable residents in the sample of 27 residents (Resident #108, 131) and the resident's representative(s) of a transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Findings include: 1. Per record review, Resident # 108 was transferred to an acute care hospital on [DATE] and returned to the facility on [DATE]. There is no evidence in the clinical record that the resident, the resident's representative or the Ombudsman was notified in writing of the transfer to the hospital. On 12/20/17 at 9:08 AM, the Unit Manager (UM) confirmed that neither the resident, resident representative or the Ombudsman was notified in writing regarding the transfer to the hospital. 2. Per record review, Resident #131 was transferred to an acute care hospital on [DATE] for evaluation and treatment. The resident did not return to the facility and there is no evidence in the clinical record that written notification was provided to the resident, the resident's representative or the Ombudsman regarding the transfer to the hospital. Confirmation was made by the Administrator on 12/20/17 at 2:06 PM that written notification was not provided to the resident, resident representative or the Ombudsman regarding the hospital transfer. | 2020-09-01 |
| 305 | 305 | ELDERWOOD AT BURLINGTON | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2017-12-20 | 625 | B | 0 | 1 | 1EWI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to provide written information to the resident or resident representative for 2 of 3 applicable residents, (Residents #131 and #108) that specifies; (i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under 447.40 of this chapter, if any; (iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and (iv) The information specified in paragraph (e)(1) of this section. 483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section. Findings include: 1. Per record review, Resident #108 was transferred to an acute care hospital on [DATE] and returned to the facility on [DATE]. There is no evidence in the clinical record that the resident or the resident's representative was provided written notice which specifies the duration of the bed-hold policy. On 12/20/17 at 9:08 AM, the Unit Manager (UM) confirmed that neither the resident or resident's representative was provided written notice which specifies the duration of the bed-hold policy after transfer to the hospital. 2. Per record review, Resident # 131 was transferred to an acute care hospital on [DATE] for evaluation and treatment and was admitted . There is no evidence in the clinical record that the resident nor the resident's representative was provided with written notice which specifies the duration of the bed-hold policy. The administrator confirmed during an interview on 12/20/17 at 2:06 PM that a notice of bed hold was no… | 2020-09-01 |
| 306 | 306 | ELDERWOOD AT BURLINGTON | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2017-12-20 | 645 | D | 0 | 1 | 1EWI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) for Mental Illness or Intellectual Disability for 2 of 2 residents in the applicable sample (Resident #27 & #47). Finding Include: 1. Record review indicated that Resident #27 was admitted to the Nursing Facility (NF) on 9/12/17, and had been continually in residence to the present time. The list of [DIAGNOSES REDACTED]. Specialized Services are those services the State is required to provide or arrange, that raise the intensity of services to the level needed by the resident. That is, specialized services are an add-on to NF services-they are of a higher intensity and frequency than specialized rehabilitation services, which are provided by the NF. During an interview on 12/19/17, the Social Worker (SW) confirmed that the facility did not complete the PASARR screening. She provided the surveyor with a copy of the PASARR that was completed while the resident was at the hospital, as part of the discharge process and the form accompanies the resident on admission to the NF. However, the form she provided was unsigned and undated. She confirmed that the facility failed to re-screen the resident as required when it was determined the stay would exceed 30 days. 2. Resident #47 was admitted to the facility 9/20/17 from an acute care hospital with a PASARR completed by the hospital physician that indicated length of stay would be less than 30 days. PASARR was not completed by the facility when it was determined that the resident stay would exceed 30 days. Per interview with case manager/social worker during the afternoon of 12/20/17, s/he confirmed that the follow up was not done as per regulation. | 2020-09-01 |
| 307 | 307 | ELDERWOOD AT BURLINGTON | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2017-12-20 | 655 | D | 0 | 1 | 1EWI11 | Based upon interview and record review, the facility failed to revise 1 of 27 residents' baseline plan of care to address needs for effective, person-centered care to increase one resident's safety following a fall that occurred the evening of admission. (Resident #332) Finding includes: Per staff interview on 12/20/17 at 11:07 AM, the Unit Manager stated Resident #332 fell the evening of admission on 12/14/17. Per review of the baseline care plan, there were no goals or interventions to address resident safety related to falls. Per staff interview, the Unit Manager confirmed on 12/20/17 at 11:12 AM that Resident #332's baseline care plan was not revised to include goals or interventions to prevent falls after the resident fell the evening of admission on 12/14/17. | 2020-09-01 |
| 308 | 308 | ELDERWOOD AT BURLINGTON | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2017-12-20 | 656 | D | 0 | 1 | 1EWI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview and record review, the facility failed to assure that 2 of 27 residents plan of care contained person-centered interventions for communicating with a resident with impaired speech and for positioning a resident to maintain proper alignment while sitting in a wheelchair, eating, and drinking nutritional supplements. (Residents #83, #7). Findings include: 1). Per staff interview and record review of the care plan, the Nurse Manager confirmed on 12/20/17 at 1:34 PM that Resident #7 does not have a care plan for positioning the resident to maintain proper alignment while sitting in a wheelchair, eating, and drinking nutritional supplements. Per resident observation on 12/18/17 at 10:08 AM and staff interview, Resident #7 was sitting in a wheelchair at a table across from the nurses station with an LNA sitting next to him/her. The resident's body was leaning to the right side over the arm of the wheelchair and he/she was not sitting upright. Per observation, the LNA had finished feeding the resident and the plate of food was empty. Per resident observation on 12/19/17 at 08:50 AM, Resident #7 was sitting in a wheelchair in a small room with an LNA sitting next to him/her. Resident was slumped over to right side in his/her wheelchair, leaning on the arm of the wheelchair without support to maintain an upright position. Per resident observation and staff interview on 12/19/17 at 3:30 PM, the resident was sitting in a wheelchair in a small room watching TV with an LNA sitting next to him/her. Resident was slumped over and leaning to right side with facial grimacing. LNA stated resident was having pain on his/her right side and had reported the pain to the nurse. Per resident observation on 12/20/17 at 09:09 AM, Resident #7 was sitting in a wheelchair in a small room with an LNA sitting next to him/her. Resident was leaning to the right side of his/her wheelchair without support; Resident was not in an upright or supp… | 2020-09-01 |
| 309 | 309 | ELDERWOOD AT BURLINGTON | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2017-12-20 | 657 | D | 0 | 1 | 1EWI11 | Based on resident and staff interviews, medical record review and direct observation, the facility failed to revise a care plan for 1 of 27 residents (Resident # 50) to reflect proper assessment of dental issues and the care being provided by the staff. The specifics are detailed below: Per medical record review, Resident #50 was admitted to the facility in (MONTH) (YEAR). The initial assessment and care plan indicate that Resident #50 is edentulous (without teeth), when in fact s/he has teeth that contain thick debris on the lower level. A dental consult note, dated 6/27/2017, indicates that the build-up will require further visits with a dentist and aggressive oral hygiene to remove the matter. The dentist further indicates that, since the resident is unable to make an informed consent, further appointments will be scheduled after a guardian is appointed. Licensed nursing assistants (LNA) report they they daily assist resident # 50 with set-up in using an electric toothbrush, but do not observe whether or not the task is accomplished. The care plan does not reflect that the resident has teeth, uses an electric tooth brush or that s/he needs set up with placing tooth paste on the brush. The care plan has not been revised since the initial plan of care was written in Sept (YEAR). This is confirmed during interview with the unit manager on 12/20/2017. | 2020-09-01 |
| 310 | 310 | ELDERWOOD AT BURLINGTON | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2017-12-20 | 661 | B | 0 | 1 | 1EWI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to complete a discharge summary that recapitulates the resident's stay at the facility for 2 of 3 applicable residents, Resident #131 and 132. Findings include: 1. Resident #131 was transferred to an acute care hospital on [DATE] for evaluation and treatment after a fall sustained at the facility. There is no evidence of a discharge summary being completed. During an interview with the administrator and Director of Nurses on 12/20/17 at 2:06 PM, the administrator stated that a discharge summary is not completed when a resident transfers to the hospital, but only when they are discharged . Further review of the medical record with the administrator at this time presented that per a progress note written 10/9/17, the resident was no longer a resident of the facility. S/he stated that the resident did not return to the facility after the hospital stay and confirmed that a discharge summary had not been completed. 2. Per record review, Resident #132 was discharged from the facility on 9/26/17 and the Administrator confirmed on 12/20/17 at 2:06 PM that a summary of clinical course while at the facility was not completed. | 2020-09-01 |
| 311 | 311 | ELDERWOOD AT BURLINGTON | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2017-12-20 | 684 | D | 0 | 1 | 1EWI11 | Based upon observation, interview, and record review the facility failed to assure that 1 of 27 residents received person centered care and services to maintain proper body alignment while sitting in a wheelchair, eating, and drinking nutritional supplements (Resident #7). Finding includes: Per staff interview and record review of the care plan, the Nurse Manager confirmed on 12/20/17 at 1:34 PM that resident #7 does not have a care plan for positioning the resident to maintain proper alignment while sitting in a wheelchair, eating, and drinking nutritional supplements. Per resident observation on 12/18/17 at 10:08 AM and staff interview, Resident #7 was sitting in a wheelchair at a table across from the nurses station with an LNA sitting next to him/her. The resident's body was leaning to the right side over the arm of the wheelchair and he/she was not sitting upright. Per observation, the LNA had finished feeding the resident and the plate of food was empty. Per interview on 12/18/17 at 10:08, the LNA stated the resident is not able to feed him or herself. Per resident observation on 12/19/17 at 08:50 AM, Resident #7 was sitting in a wheelchair in a small room with an LNA sitting next to him/her. Resident was slumped over to right side in his/her wheelchair, leaning on the arm of the wheelchair without support to maintain an upright position. Per resident observation and staff interview on 12/19/17 at 3:30 PM resident was sitting in a wheelchair in a small room watching TV with an LNA sitting next to him/her. Resident was slumped over and leaning to right side with facial grimacing. LNA stated resident was having pain on his/her right side and had reported the pain to the nurse. Per resident observation on 12/20/17 at 09:09 AM, Resident #7 was sitting in a wheelchair in a small room with an LNA sitting next to him/her. Resident was leaning to the right side of his/her wheelchair without support; Resident was not in an upright or supported position. Per resident observation on 12/20/17 at 08:28 AM, Resident #7 w… | 2020-09-01 |
| 312 | 312 | ELDERWOOD AT BURLINGTON | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2017-12-20 | 712 | D | 0 | 1 | 1EWI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Staff interview and record review, the facility failed to ensure that 1 of 27 applicable residents (Resident # 130) was seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. Findings include: Per record review, Resident # 130 was not seen by a physician between 12/19/16 - 9/22/17. The last physician progress notes [REDACTED]. The Resident was seen every 60 days by a Nurse Practitioner. The Resident should have been seen in (MONTH) and (MONTH) (YEAR) by a physician. On 12/20/17 at 1:48 PM, the Director of Nurses confirmed that there is no evidence in the clinical record that Resident # 130 was seen by a physician as required. | 2020-09-01 |
| 313 | 313 | ELDERWOOD AT BURLINGTON | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2017-12-20 | 758 | D | 0 | 1 | 1EWI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure that as needed (PRN) orders for [MEDICAL CONDITION] drugs are limited to 14 days for 1 of 27 sampled residents (Resident #114). Findings include: Per record review, Resident # 114 had a physician's orders [REDACTED]. There was no evidence in the clinical record that the physician documented their rationale for extending the medication beyond 14 days. On 12/20/17 at 11:20 AM, the Unit Manager confirmed the order above and that there was no physician documentation regarding rationale for extending the medication beyond 14 days as required. | 2020-09-01 |
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CREATE TABLE [cms_VT] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );