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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2517 | 2517 | CEDAR HILL HEALTH CARE CENTER | 475046 | 49 CEDAR HILL DRIVE | WINDSOR | VT | 5089 | 2011-12-14 | 428 | D | Y28911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the pharmacist failed to report irregularities regarding indications for PRN (as needed) medications for 2 of 11 residents in the targeted Stage 2 sample. (Residents #6 and #16) Findings include: 1. Per interview and record review, Resident #6 has 2 PRN medications used for anxiety without adequate indications to staff as to which one to utilize for the Resident's most common un-redirectable behavior of yelling out. Per review of the Medication Administration Records (MARs), staff are administering 2 different classes of PRN (as needed) medication for the same documented behavior of yelling and anxiety. The current physician's orders [REDACTED]. a) Haldol (an anti-psychotic medication) 1 milligram by mouth every 2 hours as needed for anxiety, belligerence, or threatening; b) Haldol 5 milligrams via intramuscular injection every 4 hours as needed for severe agitation/combativeness behaviors, slapping; c) Lorazepam (an anti-anxiety medication) 0.5 milligrams by mouth twice a day as needed for anxiety, yelling, or agitation. Per review of the MAR for October 2011, Haldol was administered by mouth on 3 occasions for yelling and agitation and Lorazepam was given on 5 occasions for yelling and anxiety. Per review of the MAR for November 2011, Haldol was given by mouth on 1 occasion for yelling and anxiety, and Lorazepam was given on 2 occasions also for yelling and anxiety. During an interview on 12/14/11 at 12:40 PM, the Assistant Director of Nursing Services (ADNS) verified that the PRN Haldol and Lorazepam both list anxiety as an indication for use and that staff are giving them both interchangeably for yelling and anxiety. Per review of the pharmacy Consultation reports, there is no evidence this irregularity was identified. See also F329. 2. Per interview and record review, PRN (as needed) pain medications for Resident #16 did not contain adequate indications for use to direct staff which medication to giv… | 2014-01-01 | ||
| 2516 | 2516 | CEDAR HILL HEALTH CARE CENTER | 475046 | 49 CEDAR HILL DRIVE | WINDSOR | VT | 5089 | 2011-12-14 | 329 | E | Y28911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assure 3 of 11 applicable residents in the targeted stage 2 sample were free from unnecessary drugs. (Residents #12, #6, and #16) Findings include: 1. Per interview and record review, Resident #6 has 2 PRN medications used for anxiety without adequate indications to staff as to which one to utilize for the Resident's most common un-redirectable behavior of yelling out. Per review of the Medication Administration Records (MARs), staff are administering 2 different classes of PRN (as needed) medication for the same documented behavior of yelling and anxiety. The current physician's orders [REDACTED]. a) [MEDICATION NAME] (an anti-psychotic medication) 1 milligram by mouth every 2 hours as needed for anxiety, belligerence, or threatening; b) [MEDICATION NAME] 5 milligrams via intramuscular injection every 4 hours as needed for severe agitation/combativeness behaviors, slapping; c) [MEDICATION NAME] (an anti-anxiety medication) 0.5 milligrams by mouth twice a day as needed for anxiety, yelling, or agitation. Per review of the MAR for October 2011, [MEDICATION NAME] was administered by mouth on 3 occasions for yelling and agitation and [MEDICATION NAME] was given on 5 occasions for yelling and anxiety. Per review of the MAR for November 2011, [MEDICATION NAME] was given by mouth on 1 occasion for yelling and anxiety, and [MEDICATION NAME] was given on 2 occasions also for yelling and anxiety. During an interview on 12/14/11 at 12:40 PM, the Assistant Director of Nursing Services (ADNS) verified that the PRN [MEDICATION NAME] and [MEDICATION NAME] both list anxiety as an indication for use and that staff are giving them both interchangeably for yelling and anxiety. See also F428. 2. Per interview and record review, PRN (as needed) pain medications for Resident #16 did not contain adequate indications for use to direct staff which medication to give for complaints of pain. Resident #16 has… | 2014-01-01 | ||
| 2515 | 2515 | CEDAR HILL HEALTH CARE CENTER | 475046 | 49 CEDAR HILL DRIVE | WINDSOR | VT | 5089 | 2011-12-14 | 323 | D | Y28911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and record review, the facility failed to assure that bed side rails were applied in a safe and secure manner to enhance bed mobility and to prevent potential accidents and/or entrapment of body parts for 2 residents in the targeted sample (Residents #5 and #35). Findings include: 1. Per record review, Resident #5 had a Side Rail Assessment, dated 11/1/11, that indicated the resident was able to voice their choice about use of side rails and that the resident used the side rails to position themselves in bed. Per observation, at 10:32 AM on 12/13/11, Resident #5 was lying in a bed that was pushed against the wall with a quarter side rail raised on the wall side of the bed and a half rail raised on the open side of the bed. During interview, at the time of the observation, when questioned about the use of the half side rail, the resident stated s/he did not use it, "I'm afraid of it because it's so loose it moves all over". The resident further stated that if the side rail was securely attached s/he would use it to help move his/her position in bed. Per inspection, at that time, the half rail was very loosely attached, moving about from side to side and easily bowed away from the bed and mattress creating a space large enough for potential entrapment of extremities or other body parts. The Activities Director, who was present and confirmed the observation of the loosely attached rail, reported it immediately to the Maintenance Director. During interview, at 12:45 PM, the facility Administrator stated that the side rail had been tightened by the Maintenance Director, and a subsequent observation and inspection was conducted at that time. Despite the adjustment by the Maintenance Director, the Administrator confirmed that the side rail remained loosely attached to the resident's bed. Per inspection, at 1:40 PM on 12/13/11, the side rail had been replaced by a new rail which was securely applie… | 2014-01-01 | ||
| 2514 | 2514 | CEDAR HILL HEALTH CARE CENTER | 475046 | 49 CEDAR HILL DRIVE | WINDSOR | VT | 5089 | 2011-12-14 | 280 | D | Y28911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interview and record review, the facility failed to revise the comprehensive care plans to reflect the current status of 2 of 15 residents in the targeted sample. (Residents #5 and #33). Findings include: 1. Per record review, Resident #5's comprehensive care plan had not been revised to reflect ongoing psychological counseling initiated on 10/17/11. The resident's medical conditions included Depression and Anxiety for which s/he received [MEDICATION NAME] (anti-anxiety drug) for agitation, belligerence, and discomfort and [MEDICATION NAME] at bedtime to prevent irritability and anxiety. A comprehensive assessment, completed on 1/11/11, identified the resident had anxiety, presenting as frequent ringing of the call light and banging on the bedside table. A psychological consult was conducted on 10/17/11, in accordance with physician orders, and included a follow up plan for ongoing weekly visits with the resident. Although the resident had been receiving weekly visits for psychological counseling the care plan did not reflect this intervention. This was confirmed by the DNS (Director of Nursing Services), during interview on 12/14/11 at 11:28 AM. 2. At 3:40 PM on the afternoon of 12/12/11, Resident #33 was observed sitting in the living room area singing to a group of residents. Per interview, conducted later on the same afternoon, the resident stated that listening to music and singing were activities s/he enjoyed participating in, as well as other activities provided by the facility. Per record review an initial Activities Assessment identified the resident's interests which included: reading, music, group activities, animals, outdoors and religious activities. Despite this information, the resident's care plan did not include any measurable goals related to recreational activities and did not address any of the interests identified by the resident. This was confirmed by the Activities Director, who… | 2014-01-01 | ||
| 2513 | 2513 | GREENSBORO NURSING HOME | 475043 | 47 MAGGIE'S POND ROAD | GREENSBORO | VT | 5841 | 2010-12-01 | 371 | E | NJQQ11 | Based on observation and interviews, the facility failed to store all food under safe and sanitary conditions, as required, for 1 of 2 resident refrigerators. Findings include: 1. During an interview on 11/29/10 at 2:20 PM, the Dietary and Housekeeping Supervisor confirmed that Dietary staff have not been monitoring refrigerator temperatures or doing daily checks for labeling, dating, or discarding of outdated food items for a dorm style resident refrigerator. The refrigerator is located in a kitchenette adjacent to the common activity and dining area where residents, including those with dementia, were observed during the 3 day survey (11/29/10-12/1/10) to frequently congregate for meals, snacks, and activities, and could potentially access the food items. During an observation at 2:25 PM on 11/29/10, the unlocked resident refrigerator contained undated and unlabeled food items, including pickles, butter, frosting, and 2 containers of leftover resident food which were unidentifiable by observation. At 2:30 PM on 11/29/10, the Administrator confirmed that the dorm style resident refrigerator contained undated and unlabeled food items, including pickles, butter, frosting, and 2 tubs of leftover resident foods which were unidentifiable. The Administrator further confirmed during this interview and observation that facility staff had not been assigned to monitor the contents of the refrigerator for safe storage, labeling, dating or discarding. | 2014-01-01 | ||
| 2512 | 2512 | GREENSBORO NURSING HOME | 475043 | 47 MAGGIE'S POND ROAD | GREENSBORO | VT | 5841 | 2010-09-24 | 157 | D | FSI211 | Based upon interview and record review, the facility failed to inform the physician following a physical altercation between two residents (#1, #2). Findings include: 1. Per per medical record review on 9/24/10 for Resident #2, the 8/9/10 nursing note does not contain documentation that the physician was notified that Resident #2 hit Resident #1 on the back without provocation. In addition, the 8/9/10 Facility Incident Report Form does not contain documentation the physician was notified of the incident that occurred between Resident #1 and Resident #2 on that date. Per interview on 9/24/10 at 11:05 AM, the DNS (Director of Nursing Services) confirmed the physician was not notified that Resident #2 hit Resident #1 without provocation. 2. Per record review on 9/24/10 for Resident #1, the 8/9/10 nursing note does not contain documentation that the physician was notified that Resident #1 was hit on back with no injuries resulting by Resident #2. In addition, the 8/9/10 Facility Incident Report Form does not contain documentation the physician was notified of the incident that occurred between Resident #1 and Resident #2 on that date. Per interview on 9/24/10 at 11:05 AM, the DNS confirmed the physician was not notified that Resident #1 was hit on the back with no injuries resulting by Resident #2. | 2014-01-01 | ||
| 2511 | 2511 | GREENSBORO NURSING HOME | 475043 | 47 MAGGIE'S POND ROAD | GREENSBORO | VT | 5841 | 2010-09-24 | 282 | D | FSI211 | Based upon interview and record review, the facility failed to provide services in accordance with the behavioral plan of care for 1 of 2 residents in the applicable sample (Resident #2). Findings include: 1. Per record review on 9/24/10, the Behavioral Plan of Care Approach for 7/11/10 states Resident #2 was "placed on every 15 minute checks to monitor safe interactions with others". Per review of the 8/9/10 "15 Minute Resident Where About Tracker", there is no documentation for every 15 minute checks from 1:00 PM to 3:00 PM. Per interview on 9/24/10 at 11:05 AM, the DNS confirmed that the every 15 minute checks were not documented on 8/9/10 from 1:00 PM to 3:00 PM. | 2014-01-01 | ||
| 2510 | 2510 | GREENSBORO NURSING HOME | 475043 | 47 MAGGIE'S POND ROAD | GREENSBORO | VT | 5841 | 2010-09-24 | 280 | D | FSI211 | Based upon interview and record review, the facility failed to revise the care plan for 1 of 2 residents in the targeted sample (Resident #2). Findings include: 1. Per record review on 9/24/10, the Behavioral Plan of Care was not revised to reflect that Resident #2 hit another resident on the back, unprovoked, on 8/9/10. The 7/11/10 Behavioral Plan of Care approach states "placed on 15 minute checks to monitor for safe interaction with others". In addition, the 8/9/10 Facility Incident Reporting Form states Resident #2 "got up from her chair where she was sitting and with no provocation hit the other individual on her back; no injuries". Per interview on 9/24/10 at 11:05 AM, the DNS confirmed the the Behavioral Plan of Care was not updated to reflect that Resident #2 hit another resident unprovoked on the back. | 2014-01-01 | ||
| 2509 | 2509 | CENTERS FOR LIVING AND REHAB | 475029 | 160 HOSPITAL DRIVE | BENNINGTON | VT | 5201 | 2011-01-12 | 329 | D | FMEG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to assure the drug regimen was free from the use of unnecessary psychoactive drugs for 1 of 11 applicable residents. (Resident #267). Findings include: 1. Per record review and interview, there was no evidence that staff had identified Resident #267's specific symptoms or causes of anxiety/restlessness, had considered non-pharmacological interventions prior to administration of a [MEDICAL CONDITION] medication, or had an indication for use of the medication. Per record review on 01/12/11, Resident #267 has diagnoses of Alzheimer's, [MEDICAL CONDITIONS], malaise and fatigue. There is no [DIAGNOSES REDACTED]. The LNA behavior sheets noted one entry on 12/13/10 for 'uncooperative in P.M. with staff, restless in bed, adapting'. Per nursing notes, there are no assessments for behavior nor do the daily summary nursing notes for the month of December 2010 and January 2011 have documentation regarding behavior monitoring. Per the MAR (medication administration record) and daily nursing notes of 01/05/11 at 8:00 PM, 01/07/11 at 7:00 PM and 01/10/11 at 7:00 PM, [MEDICATION NAME] (a [MEDICAL CONDITION] medication), was given for anxiety/sleeplessness. Per interview on 01/12/11 at 2:00 PM, the DNS and Administrator-in-training confirmed the resident was given a [MEDICAL CONDITION] medication without adequate monitoring, without attempts of non-pharmacological interventions, and without adequate indications for its use. | 2014-01-01 | ||
| 2508 | 2508 | CENTERS FOR LIVING AND REHAB | 475029 | 160 HOSPITAL DRIVE | BENNINGTON | VT | 5201 | 2011-01-12 | 309 | D | FMEG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for 3 applicable residents regarding a medical treatment and medication administration (Resident #44, #168, #267). Findings include: 1. Per record review on the afternoon of 01/11/11, there is no evidence in the medical record for monitoring of Resident #44 pre and post [MEDICAL TREATMENT] treatment, including vital signs and physical condition. During review of the facility's policies, there was no information pertaining to specific [MEDICAL TREATMENT] related care needs, communication with the [MEDICAL TREATMENT] center, [MEDICAL TREATMENT] center protocols and resident refusal of services. In an interview with the Unit Manager on 01/12/11 at 8:45 AM, s/he stated that the facility does not monitor vital signs for the [MEDICAL TREATMENT] resident pre and/or post [MEDICAL TREATMENT] on [MEDICAL TREATMENT] days, and that vital signs are monitored weekly for all residents. S/he further stated that there was no additional monitoring or assessment performed related to [MEDICAL TREATMENT]. She also confirmed that there was no routine communication between the [MEDICAL TREATMENT] center and the facility regarding the [MEDICAL TREATMENT] treatments including labs, weights, resident tolerance of treatment and vital signs while at the center. The Facility Administrator and the Director of Nursing on 01/12/2011 at 10:25 AM confirmed the facility was not evaluating the resident's outcomes pre or post [MEDICAL TREATMENT]. 2. Per observation and interview, nursing staff failed to administer medication in a timely manner and according to accepted standard of practice. Per observation during a medication administration on 01/12/11 at 9:22 AM, nursing staff administered [MEDICATION NAME] 0.075 mg (milligrams) with Resident #267's other morning medications after breakfast . Additionally, p… | 2014-01-01 | ||
| 2507 | 2507 | CENTERS FOR LIVING AND REHAB | 475029 | 160 HOSPITAL DRIVE | BENNINGTON | VT | 5201 | 2011-01-12 | 281 | D | FMEG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to meet professional standards for quality by not carrying out physician orders [REDACTED].#168 and #267). Findings include: 1. Per observation and interview, nursing staff failed to administer medication in a timely manner and according to accepted standard of practice. Per observation during a medication administration on 01/12/11 at 9:22 AM, nursing staff administered [MEDICATION NAME] 0.075 mg (milligrams) with Resident #267's other morning medications after breakfast . Additionally, per observation at 9:30 AM, Resident #168 also received [MEDICATION NAME] 0.15 mg with their morning medications after breakfast. Per record review during the medication reconciliation at 10:00 AM for both Resident #168 and Resident #267, the physician's orders [REDACTED]. Per the Lippincott's Nursing Drug Book 2011, page 1167 states '[MEDICATION NAME] is to be given on an empty stomach and/or 1 to 1/2 hour before breakfast.' Per interview at 10:15 AM nursing staff confirmed "I gave all the meds together" and was not aware of why the med was to be given at a different time. Per interview on 01/12/11 at 2:00 PM, the DNS confirmed that the medications were not given as ordered and according to accepted standards of practice. Reference: Lippincott's Nursing Drug Book 2011, page 1167 | 2014-01-01 | ||
| 2506 | 2506 | CENTERS FOR LIVING AND REHAB | 475029 | 160 HOSPITAL DRIVE | BENNINGTON | VT | 5201 | 2011-01-12 | 279 | D | FMEG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a comprehensive care plan for 1 of 28 sampled residents (Resident 44). Findings include: 1. Per record review on 01/12/2011, the Care Plan for Resident #44, who receives [MEDICAL TREATMENT] treatments three times a week, did not address all aspects of care and services for this [MEDICAL TREATMENT] patient. The care plan does not address: A) monitoring of vital signs, weights, and physical condition pre and post [MEDICAL TREATMENT]; B) medication [MEDICAL TREATMENT] interactions and possible adverse effects; C) [MEDICAL TREATMENT] related risk factors D) [MEDICAL TREATMENT] center protocols E) communication between the facility and the [MEDICAL TREATMENT] center F) evidence of attempts to find acceptable alternatives for aspects of [MEDICAL TREATMENT] care when the resident refuses (such as diet). Per staff interviews, the Unit Manager on 01/12/2011 at 8:45 AM and the Facility Administrator and Director of Nursing on 01/12/2011 at 10:25 AM confirmed the lack of developing a comprehensive care plan for this resident. | 2014-01-01 | ||
| 2505 | 2505 | CENTERS FOR LIVING AND REHAB | 475029 | 160 HOSPITAL DRIVE | BENNINGTON | VT | 5201 | 2011-01-12 | 278 | D | FMEG11 | Based on staff interview and record review, the assessment failed to accurately reflect the status for 1 of 28 sampled residents (Resident # 263). Findings include: Per record review for Resident #263 on 1/11/10 at 4:32 PM, the Minimum Data Set (MDS) section F0300 is checked "no", indicating the resident rarely/never is understood and family/significant other is not available, which indicates that an activities interview will not be conducted. The initial nursing assessment indicates that the Resident is alert and oriented and able to make his/her needs known. MDS coding for cognitive status indicates that the Resident has no cognitive deficits. In a 1/11/11, 5:02 PM interview with two MDS Coordinators, one Coordinator confirmed that section "F" on the MDS is a coding error and should have coded as a "yes" which indicates that an activities interview should be conducted. | 2014-01-01 | ||
| 2504 | 2504 | CENTERS FOR LIVING AND REHAB | 475029 | 160 HOSPITAL DRIVE | BENNINGTON | VT | 5201 | 2011-01-12 | 272 | D | FMEG11 | Based on staff interview and record review, facility staff failed to assess 1 of 3 applicable residents in the stage 2 sample who had a potential restraint. (Resident # 267) Findings include: 1. Per observation during the initial tour on 1/10/11 and on the following 2 days of survey (1/11/11 and 1/12/11), Resident #267's bed had 1 half rail in the middle of the bed and 2 deep wedge devices on each side of the mattress. Per interview on 01/10/11 at 2:30 PM, the Unit Manager identified Resident #267 as having quarter rails and no potential restraining devices. Per review of the medical record on 01/11/11, no assessments were documented for the use of the half rail and wedges. There was no care plan for the wedges or other devices used for positioning or bed mobility. Per a nurse note dated 12/31/10 at 6:56 PM, the nurse sent a fax to the physician stating "may we have wedges because resident tries to crawl out of bed, also floor mats in both sides of bed". Per interview on 01/12/11 at 11:59 the DNS (Director of Nursing) and Administrator-in-training confirmed that the half rail and wedges were not assessed and were a potential restraint. Refer F221 | 2014-01-01 | ||
| 2503 | 2503 | CENTERS FOR LIVING AND REHAB | 475029 | 160 HOSPITAL DRIVE | BENNINGTON | VT | 5201 | 2011-01-12 | 221 | D | FMEG11 | Based on observation, record review and interview, the facility failed to assure that residents are free from physical restraints for 1 of 3 applicable residents in the sample. (Resident #267) Findings include: 1. Per observation during the initial tour on 1/10/11 and on the following 2 days of survey (1/11/11 and 1/12/11), Resident #267's bed had 1 half rail in the middle of the bed and 2 deep wedge devices on each side of the mattress. Per review of the medical record on 01/11/11, no assessments were documented for the use of the half rail and wedges. There was no care plan for the wedges, or devices used for positioning or bed mobility. Per a nurse note dated 12/31/10 at 6:56 PM, the nurse sent a fax to the physician stating "may we have wedges because resident tries to crawl out of bed, also floor mats in both sides of bed". Per interview on 01/12/11 at 11:59 the DNS (Director of Nursing) and Administrator-in-training confirmed that the half rail and wedges were not assessed and were a potential restraint. Refer F272. | 2014-01-01 | ||
| 2502 | 2502 | BERLIN HEALTH & REHAB CTR | 475020 | 98 HOSPITALITY DRIVE | BARRE | VT | 5641 | 2010-09-13 | 281 | D | C2PV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide services in accordance with professional standards for one applicable resident in the sample (Resident #1). Findings include: Per record review and staff interview, the facility failed to follow a physician's orders [REDACTED]. On July 12, 2010, a nurses notes states that a 14F Foley catheter was inserted after the indwelling catheter was found on the floor. In an interview at 11:10 AM with the former Unit C Manager, the Unit A Manager and the DNS (Director of Nursing Services), it was confirmed that there was no order found for the placement of a 14F Foley catheter. | 2014-01-01 | ||
| 2501 | 2501 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2010-09-15 | 281 | D | JMRY11 | Based on staff interview and record review, facility staff failed to meet professional standards of quality for 1 applicable resident (Resident #1). Findings include: Per record review on 9/15/10 at 10:48 A.M., staff failed to notify the physician or initiate suicide precautions for Resident #1. The Resident made suicidal statements on 8/6/10, 8/14/10 and 9/3/10. Per facility policy, staff is to notify the Resident's physician of current threat of suicide, initiate 1:1 observation and place the Resident on close supervision with appropriate documentation on every shift. During an 11:15 A.M. interview on 9/15/10, the Unit Manager confirmed that the physician was not notified after the 8/6/10 and 8/14/10 suicidal statements and that the Resident was not placed on 1:1 supervision or close observation per facility policy. | 2014-01-01 | ||
| 2500 | 2500 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2010-09-15 | 280 | D | JMRY11 | Based on observations, interview and record review, the facility failed to revise the plan of care to reflect changes in status for 1 applicable Resident (Resident #1). Findings include: Per record review on 9/15/10 at 10:48 A.M., staff did not update the care plan to reflect Resident #1's verbalizations of suicidal ideation. Per nursing notes of 8/6/10 and 8/14/10, Resident #1 stated to staff that she/he "didn't want to live anymore" and "I just want to die, I'm just going to keep not eating". Per interview with the Unit Manager (UM) at 11:15 A.M. on 9/15/10, the UM confirmed that the care plan had not been revised to reflect Resident #1's suicidal ideation. | 2014-01-01 | ||
| 2499 | 2499 | VERNON GREEN NURSING HOME | 475008 | 61 GREENWAY DRIVE | VERNON | VT | 5354 | 2010-09-09 | 387 | D | SQ6411 | Based on staff interview and record review, the facility failed to assure that all residents were seen by their physicians at least once every 30 days for the first 90 days after admission to the facility and every 60 days thereafter for 2 of 10 resident records reviewed. (Residents #9 & 10) Findings include: Per record review on 9/9/10 at 3 PM, for Resident #9, who was admitted to the nursing home on 1/11/00, there were no documented notes indicating a physician visit during the period from 3/11/10 until 8/25/10. Per review the same day, for Resident #10, who was admitted to the nursing home on 5/10/10, there was no documentation of any physician visits until 7/1/10 and there was also no report of an admission history and physical exam in the record. These omissions were reviewed with the DNS and the Administrator at 4:45 PM on 9/9/10. | 2014-01-01 | ||
| 2498 | 2498 | VERNON GREEN NURSING HOME | 475008 | 61 GREENWAY DRIVE | VERNON | VT | 5354 | 2010-09-09 | 280 | D | SQ6411 | Based on staff interview and record review, the facility failed to revise the current care plan to address the potentially harmful behaviors of 1 applicable resident in the targeted sample. (Resident #1) Findings include: Per record review and care plan review on 9/9/10 at 11:30 AM, Resident #1's care plan was not revised to include the potentially dangerous behavior of handling and disconnecting other residents' call bells, including putting one call bell cord around another resident's arm (Resident #8) on 8/15/10. The care plan was also not updated after the resident was discovered operating Resident #7's electronic bed controls while the resident was in the bed on the evening of 9/7/10. These care plan omissions were confirmed with the DNS and the evening charge nurse during the afternoon of 9/9/10. Refer also to F323 | 2014-01-01 | ||
| 2497 | 2497 | VERNON GREEN NURSING HOME | 475008 | 61 GREENWAY DRIVE | VERNON | VT | 5354 | 2010-09-09 | 226 | D | SQ6411 | Based on staff interview and record review, the facility failed to implement it's Abuse Protocols regarding investigation of resident injuries during the provision of care for 1 applicable resident in the targeted sample. (Resident #1) Findings include: On 9/9/10 at 11:45 AM, per review of a progress note dated 8/9/10 at 11 PM, Resident #1 "obtained a skin tear to the R outer lower arm measuring 5 cm X 2 cm" (centimeters). The resident was in the bathroom with 2 Licensed Nursing Assistants (LNAs) at the time of injury and had reportedly "became combative". On 9/9/10 at 12:45 PM, the RN responsible for monitoring incident reports stated that she did not have a report for this incident. Per interview at approximately 2 PM, the DNS confirmed that she was not previously aware of this incident and she stated that staff should have completed an incident report, per policy. There was no evidence of an investigation to determine the circumstances and possible causes of the incident. | 2014-01-01 | ||
| 2496 | 2496 | VERNON GREEN NURSING HOME | 475008 | 61 GREENWAY DRIVE | VERNON | VT | 5354 | 2010-09-09 | 225 | D | SQ6411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to report an incident of alleged abuse involving 2 residents from the Special Care Unit in accordance with Vermont Statute. (Residents #1 & 2) Findings include: Per interview on 9/9/10 at 11 AM, the Administrator confirmed that the facility failed to immediately report a resident to resident abuse incident, resulting in serious injury to Resident #2, to the licensing agency. During interview on 9/9/10 at 12:30 PM, the evening Charge Nurse said that on 9/3/10 at 5 PM, Resident #1, unprovoked, grabbed and pulled Resident #2 by the back of the shirt, causing the resident to fall into the wall and down to the floor. The resident sustained [REDACTED]. Refer also to F323. | 2014-01-01 | ||
| 2495 | 2495 | VERNON GREEN NURSING HOME | 475008 | 61 GREENWAY DRIVE | VERNON | VT | 5354 | 2010-09-09 | 223 | J | SQ6411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to protect 1 applicable resident in the targeted sample from physical abuse as a result of actions by another resident. (Residents #1 & 2) Findings include: Per record review and confirmed by staff interview, Resident #1 caused serious injury to Resident #2 on 9/3/10 during an unprovoked attack. Staff failed to provide 1:1 supervision (per the care plan) for this resident who had a history of [REDACTED]. Per staff interview at 12:30 PM on 9/9/10, the incident occurred on 9/3/10 at 5 PM when Resident #1 grabbed Resident #2's shirt from behind and pulled the resident to the left and down, causing the resident to fall against the wall, hitting the left side of the head with force, and then fall to the floor. Subsequently, Resident #2 was transferred to the hospital and admitted for treatment. The description of the resident to resident incident was provided during interview with the evening shift LPN Charge Nurse on 9/9/10 commencing at 12:30 PM. During interview with the Director of Nursing Services (DNS), the Evening Charge Nurse and the RN in charge of monitoring resident incidents at 12:30 PM, all were aware of the pattern of intrusive, at times assaultive and potentially dangerous behaviors exhibited by Resident #1 since admission. Per review during the morning of 9/9/10, the resident's care plan stated "physically aggressive towards staff and other residents...episodes of biting staff, may became aggressive without cause, @ times without warning"...monitor interactions with other residents...attempt to redirect if safety issues should arise.., 1:1 with staff...consult with (psych nurse) PRN. Per review of the record, Resident #1 had a history of [REDACTED]. During interviews with the DNS, the day shift Charge Nurse and evening Charge Nurse during the afternoon on 9/9/10, all confirmed that although the resident had these known unpredictable behaviors, he/she was not consistent… | 2014-01-01 | ||
| 2494 | 2494 | VERNON GREEN NURSING HOME | 475008 | 61 GREENWAY DRIVE | VERNON | VT | 5354 | 2010-09-09 | 323 | J | SQ6411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to provide adequate supervision for 1 applicable resident who had a history of [REDACTED]. (Residents #1, 2, 3, 4, 5, 6 & 7). Findings include: Per record review and confirmed by staff interview, Resident #1 caused serious injury to Resident #2 on 9/3/10 during an unprovoked attack. Staff failed to provide 1:1 supervision (per the care plan) for this resident who had a history of [REDACTED]. Per staff interview at 12:30 PM on 9/9/10, the incident occurred on 9/3/10 at 5 PM when Resident #1 grabbed Resident #2's shirt from behind and pulled the resident to the left and down, causing the resident to fall against the wall, hitting the left side of the head with force, and then fall to the floor. Subsequently, Resident #2 was transferred to the hospital and admitted for treatment. The description of the resident to resident incident was provided during interview with the evening shift LPN Charge Nurse on 9/9/10 commencing at 12:30 PM. During interview with the Director of Nursing Services (DNS), the Evening Charge Nurse, and the RN in charge of monitoring resident incidents at 12:30 PM, all were aware of the pattern of intrusive, at times assaultive, and potentially dangerous behaviors exhibited by Resident #1 since admission. Per review during the morning of 9/9/10, the resident's care plan stated "physically aggressive towards staff and other residents...episodes of biting staff, may became aggressive without cause, @ times without warning"...monitor interactions with other residents...attempt to redirect if safety issues should arise.., 1:1 with staff...consult with (psych nurse) PRN. During interviews with the DNS, the day shift Charge Nurse, and evening Charge Nurse during the afternoon on 9/9/10, all confirmed that although the resident had these known unpredictable behaviors, he/she was not consistently supervised on 1:1. Per review of the record, Resident #1 had potentially d… | 2014-01-01 | ||
| 2493 | 2493 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2011-01-05 | 431 | E | LESM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to assure that outdated medications were not available for resident use and failed to assure that all biologicals were secured in a manner that would prevent accessibility by residents. Findings include: During inspection of drug and biological storage units on the morning of [DATE] the following outdated drugs were identified: In the stock drug cabinet located in the nurse's station (all unopened containers); 3 bottles (12 oz each) of Geri Lanta antacid with an expiration dates of ,[DATE] or ,[DATE]; 1 bottle (1000 tablets) Gerard Multivitamins (MV) with an expiration date of ,[DATE]; 3 bottles (100 tablets) GeriCare MVI with/Iron, expiration of ,[DATE]; 2 bottles (16 oz) Docusate Sodium 50 mg/ml with an expiration of ,[DATE]; 1 bottle of same with expiration of ,[DATE]; 3 bottles Guaiasorb DM (expectorant cough suppressant) (4 oz) with expiration of ,[DATE]; 1 bottle of Calcium 600 mg and Vitamin D 200 IU (60 Tablets) with an expiration of ,[DATE]; 3 bottles Aspirin, 100 tablets of 81 mg enteric coated with expiration of ,[DATE]. The Medication cart (2nd floor): 1 opened bottle Docusate Sodium (100 tablets) 100 mg with an expiration date of ,[DATE]; 1 opened bottle Geri Lanta liquid antacid (12 oz) expired on ,[DATE]; 1 opened bottle Aspirin, 81 mg tabs (100 tablets - 3 tablets remaining in bottle) expired on ,[DATE]; 1 opened bottle of Acetaminophen tablets (1000 tablets; 325 mg each) expiration of ,[DATE]; 1 unopened bottle (100 tablets) Aspirin, 325 mg enteric coated with an expiration of ,[DATE]; 1 unopened bottle of Acetaminophen liquid 160 mg/5 ml (16 oz) with no identifiable expiration date. The Medication cart (1st floor): 1 opened box of Ferric x-150 polysaccharide iron 150 mg (100 capsules) with expiration date of ,[DATE]; 1 opened bottle of MVI (1000 tablets) with expiration of ,[DATE]; 1 opened bottle (100 tablets) MVI with iron expired ,[DATE]; 1 opened bottle (100 ta… | 2014-02-01 | ||
| 2492 | 2492 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2011-01-05 | 329 | D | LESM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to assure the drug regimen was free from the use of unnecessary psychoactive drugs for 2 of 9 applicable residents. (Residents #46 and #48). Findings include: 1. Per record review Resident #48, had received an antipsychotic drug on a daily basis from admission on 12/17/10 through the dates of survey, with no indication for its use and no evidence that staff had monitored for potential side effects or evaluated the effectiveness of the drug. In addition, there was no evidence that non pharmacological interventions had been considered to address the resident's psychosocial needs. There was a physician order, dated 12/17/10, that directed staff to administer [MEDICATION NAME] 80 mg PO BID. During interview on the afternoon of 1/5/11, Nurse #1, who was responsible for oversight of the resident's care, stated s/he did not know why the resident was receiving [MEDICATION NAME], stating that the resident was on the drug when admitted to the facility. Per interview, at 2:00 PM on 1/5/11, the DNS confirmed the lack of indication for use, lack of monitoring for effectiveness and lack of consideration of non pharmacological interventions. The DNS stated that s/he had sent a fax to the physician, in response to the consultant pharmacist request for indication for use of the [MEDICATION NAME], and the physician had not responded to the fax, which was dated 12/22/10, as of 1/5/11. The fax was resent on 1/5/11 after the issue was brought to the facility's attention by the surveyor. 2. Per record review Resident #46 had a physician order, dated 12/10/10, for the use of [MEDICATION NAME] 1 mg PO TID PRN for anxiety. Although the resident had received this drug on an almost daily basis, from admission to the facility on [DATE] through the dates of survey, there was no evidence that staff had identified resident specific symptoms or causes of anxiety, had considered non pharmacological interventions… | 2014-02-01 | ||
| 2491 | 2491 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2011-01-05 | 279 | D | LESM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to develop comprehensive care plans to address the dental issues and [MEDICAL CONDITION] drug use for 3 of 13 applicable residents. (Residents #11, #46 and #48). Findings include: 1. Per record review, although the most current care plan, dated 10/27/10, identified Resident #11 as at risk for both weight loss and pain intolerance related to "poor dentition", it did not address the resident's oral or dental needs. During a family interview, on the morning of 1/4/11, the family member confirmed that the resident's teeth were in poor condition. During interview on the afternoon of 1/5/11, the DNS confirmed that although the family had declined a dental consult, and that the resident did suffer from mouth odor as a result of her poor dentition and overall oral condition, the care plan did not address the resident's oral/dental needs. 2. Per record review, the most current care plan for Resident #48, dated 12/17/10, did not address the use of [MEDICAL CONDITION] medications that the resident had received on a daily basis from admission on 12/17/10 to date. The resident had physician orders [REDACTED]. There was no indication for the use of [MEDICATION NAME] and although there was a [DIAGNOSES REDACTED]. 3. Per record review, Resident #46's most current care plan, dated 12/10/10, did not address the use of [MEDICAL CONDITION] medications that the resident had received on a daily basis from his/her admission on 12/10/10 to date. Although there was a physician order [REDACTED]. During interview at 2:00 PM on 1/5/11 the DNS confirmed the lack of care planning for the use of [MEDICAL CONDITION] medications for Residents #46 and #48. | 2014-02-01 | ||
| 2490 | 2490 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2011-01-05 | 272 | D | LESM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to complete an initial comprehensive assessment including the mood and behavior patterns, psychosocial and medication needs for 2 of 13 applicable residents (Residents #46 and #48). Findings include: Per record review, the MDS (Minimum Data Set) initial comprehensive assessments had not been completed for Residents #46 and #48, who had been admitted on [DATE] and 12/17/10, respectively. There was no assessment for the use of the following [MEDICAL CONDITION] medications that each of the resident's had received since their admission to the facility: Resident #48 had a physician order, dated 12/17/10, for; [MEDICATION NAME] (an atypical antipsychotic) 80 mg PO (by mouth) BID (twice a day), [MEDICATION NAME] (antidepressant) 10 mg PO daily and [MEDICATION NAME] (an anti-anxiety drug) 0.5 mg PO every 12 hours PRN (as needed). Resident #46 had physician orders, dated 12/10/10, for the use of [MEDICATION NAME] (anti-anxiety) 1 mg PO TID (three times a day) PRN. Although there was a [DIAGNOSES REDACTED].#48, there was no indication for the use of [MEDICATION NAME] for Resident #48. There was no assessment, for either resident, of mood and behaviors or psychosocial status, to assist in identifying the need for each of the medications and developing a plan of care to address those needs. This was confirmed by the DNS (Director of Nursing Services) during interview at 2:00 PM on 1/5/11. | 2014-02-01 | ||
| 2489 | 2489 | PINES REHAB & HEALTH CTR | 475044 | 601 RED VILLAGE ROAD | LYNDONVILLE | VT | 5851 | 2011-03-23 | 456 | F | UUVM11 | Based on observation and interview, the facility failed to assure that the laundry equipment was kept clean to assure safe operating condition. Findings include: Per observation on 3/23/11 at 8:50 AM, during the environmental tour of the facility, the clothes dryer ventilation pipes had a layer of dust and lint collected on them. The Maintenance Supervisor stated that they were usually cleaned about every two weeks, and were last cleaned about two weeks ago. On 3/23/11 at 8:55 AM, the Maintenance Supervisor confirmed the observation of dust and lint on the dryer ventilation pipes, and stated that the schedule would be changed to clean them more frequently. | 2014-02-01 | ||
| 2488 | 2488 | PINES REHAB & HEALTH CTR | 475044 | 601 RED VILLAGE ROAD | LYNDONVILLE | VT | 5851 | 2011-03-23 | 323 | D | UUVM11 | Based on observation, interview, and record review, the facility failed to ensure the resident environment is as free of accident hazards as possible for 1 applicable resident. (Resident #35) Findings include: 1. Per observation and staff interview on 3/22/11, Resident # 35 had a wedge device placed under the mattress on the open side of his/her bed to prevent the resident from rolling out of bed. Per observation on 3/22/11 at 2:42 PM, the resident was lying in the bed, which was against the wall. On the open side of the bed, a large wedge device was placed under the mattress, raising the side of the bed at least 6 inches, and there was no mat on the floor beside the open side of the bed. Per staff interview on 3/22/11 at 2:56 PM, the LNA confirmed the wedge device placement as described above and stated that it is placed there because the resident "likes to roll out of bed", so they were told to put the wedge there so s/he doesn't. Per record review the care plan stated to use a wedge for safety. There are no falls out of bed listed in her active record's nursing notes to warrant the use of this device. With the placement of the wedge, if the resident were to maneuver over the hump created by the wedge, s/he would fall from a much greater height onto the floor. Per further record review, Resident # 35 does not have a medical condition that warrants the use of a device that restricts movement in the bed, and there was no formal assessment to determine appropriateness of this device. Per observation with the DNS and concurrent interview at 3:52 PM on 3/22/11, the DNS confirmed the wedge placement under the mattress of Resident # 35 and stated that the wedge prevents the resident from rolling out of bed. The DNS stated that this was not the intended use for this device, and that the wedges are supposed to be used for positioning residents. | 2014-02-01 | ||
| 2487 | 2487 | PINES REHAB & HEALTH CTR | 475044 | 601 RED VILLAGE ROAD | LYNDONVILLE | VT | 5851 | 2011-03-23 | 318 | D | UUVM11 | Based on observation, interview, and record review, the facility failed to ensure that a resident with limited Range of Motion (ROM) receives appropriate treatment and services to prevent further decrease in range of motion for 1 of 3 residents in the targeted sample (Resident #29). Findings include: 1. Per observations on 3/22/11 and 3/23/11, Resident #29 has a severe contracture that effects his/her neck and consequently his/her head positioning. Per observations on 3/22/11 at 12:38 PM and 3/23/11 at 9:03 AM, the resident's head/neck was unsupported while sitting in a wheelchair and was hanging to the left and to the front. Per observation from 1:22 PM to 3:33 PM on 3/22/11, the resident was lying in bed, on his/her back, with the resident's head unsupported. At this time, the resident's head was not in physical contact with any surfaces due to the neck contracture and lack of any supports. This observation was confirmed by the nurse at 3:30 PM on 3/22/11. Per record review, there is no care plan that addresses the need for head/neck support related to this contracture. Per record review, there is no written plan that addresses any Range of Motion services provided to the resident's head; however, a Physical Therapy screen dated 11/26/09, indicates the resident had pain and got agitated with Range of Motion attempts on that particular day. There were no re-assessments by Physical Therapy regarding the resident's needs around this contracture. During an interview at 11:00 AM on 3/23/11, the Unit Manager confirmed that there is no care plan around supports or services needed regarding the neck contracture. See also F279, F282. | 2014-02-01 | ||
| 2486 | 2486 | PINES REHAB & HEALTH CTR | 475044 | 601 RED VILLAGE ROAD | LYNDONVILLE | VT | 5851 | 2011-03-23 | 314 | G | UUVM11 | Based on interview and record review, the facility failed to ensure that 1 of 2 residents with pressure sores received the necessary treatment and services to prevent pressure sores from developing and to idenify pressure sores at an early stage. (Resident #44) Findings include: 1. Per record review, a wound consult on 3/8/11 revealed a stage 3 pressure ulcer (an open sore that involves full thickness skin loss) that measured 2 centimeters (cm) by 1 cm on Resident #44's coccyx, and 2 unstageable pressure areas on the resident's bilateral heels. Prior to the 3/8/11 wound consult, nursing staff were documenting completion of a daily skin assessment on the Treatment Record, as indicated by initialing the corresponding box on the Treatment Record every day. Resident #44 is totally dependent on staff for care and is unable to communicate his/her needs. Per record review, there was no documentation prior to 3/8/11 regarding any skin integrity issues on Resident #44's coccyx or left heel. Documentation was present in the record regarding the right heel. During an interview on 3/23/11 at 11:15 AM, the Unit Manager was not able to explain why there was no previous documentation as a result of the daily skin assessments about any skin integrity issues regarding the coccyx and the left heel, despite the daily skin assessment being signed off as completed. See also F272. | 2014-02-01 | ||
| 2485 | 2485 | PINES REHAB & HEALTH CTR | 475044 | 601 RED VILLAGE ROAD | LYNDONVILLE | VT | 5851 | 2011-03-23 | 280 | D | UUVM11 | Based on observation, interview and record review, the facility failed to revise the care plan for 1 resident in the stage 2 sample (Resident # 14). Findings include: Per observation on 3/22/11 at 3:20 P.M., Resident # 14 had a blue fall mat on the floor next to the bed and a bed alarm in place. Per record review on 3/22/11, the care plan for risk of accidents/falls did not include the mat or alarm. On 3/22/11 at 3:45 P.M., a Licensed Nursing Assistant stated that s/he would look on the care plan to determine what the Resident's needs were and that "they shouldn't have things that are not on the care plan". The Unit Coordinator confirmed during a 3:50 P.M. interview on 3/22/11 that the care plan had not been revised to include the mat and alarm. | 2014-02-01 | ||
| 2484 | 2484 | PINES REHAB & HEALTH CTR | 475044 | 601 RED VILLAGE ROAD | LYNDONVILLE | VT | 5851 | 2011-03-23 | 279 | D | UUVM11 | Based on interview and record review, the facility failed to develop a comprehensive plan of care for 2 residents in the stage 2 sample (Residents #14 and #29). Findings include: 1. Per record review on 3/23/11, the plan of care for Resident # 14 did not address needs related to psychoactive medications. Resident # 14 is on a scheduled anti-psychotic medication. The care plan did not contain measurable goals and interventions to fully address the Resident's needs. The Social Services Director, who is responsible for development of behavioral care plans, confirmed during a 9:25 AM interview on 3/23/11 that the care plan did not address the Resident's needs related to anti-psychotic medication. 2. Per observations throughout the 3 days of survey, Resident # 29 has a severe contracture that effects his/her neck and head, which was observed to be unsupported at times. Per record review, the care plan does not address this contracture in terms of supports needed or any Range of Motion services that may assist with preventing further contraction of the neck. During an interview on 3/23/11 at 11:00 AM, the Unit Manager confirmed that the care plan does not address any needed supports or services to address the neck contracture. See also F318. | 2014-02-01 | ||
| 2483 | 2483 | PINES REHAB & HEALTH CTR | 475044 | 601 RED VILLAGE ROAD | LYNDONVILLE | VT | 5851 | 2011-03-23 | 272 | D | UUVM11 | Based on observation, interview, and record review, facility staff failed to conduct a comprehensive assessment regarding skin condition for 1 resident in the Stage 2 Sample. (Resident #44) Findings include: 1. Per record review, a wound consult on 3/8/11 revealed a stage 3 pressure ulcer (an open sore that involves full thickness skin loss) that measured 2 centimeters (cm) by 1 cm on Resident #44's coccyx, and 2 unstageable pressure areas on the resident's bilateral heels. Prior to the 3/8/11 wound consult, nursing staff were documenting completion of a daily skin assessment on the Treatment Record, as indicated by initialing the corresponding box on the Treatment Record every day. Resident #44 is totally dependent on staff for care and is unable to communicate his/her needs. Per record review, there was no documentation prior to 3/8/11 regarding any skin integrity issues on Resident #44's coccyx or left heel. Documentation was present in the record regarding the right heel. During an interview on 3/23/11 at 11:15 AM, the Unit Manager was not able to explain why there was no previous documentation as a result of the daily skin assessments about any skin integrity issues regarding the coccyx and the left heel, despite the daily skin assessment being signed off as completed. See also F314. | 2014-02-01 | ||
| 2482 | 2482 | PINES REHAB & HEALTH CTR | 475044 | 601 RED VILLAGE ROAD | LYNDONVILLE | VT | 5851 | 2011-03-23 | 221 | D | UUVM11 | Based on observation, interview, and record review, the facility failed to assure 1 of 2 residents was free from physical restraints not required to treat the resident's medical symptoms. (Resident #6) Findings include: 1. Per observations and staff interviews during the afternoon of 3/22/11, while Resident #6 was in bed, a wedge device was placed under the mattress of Resident #6, on the open side of the bed, to prevent the resident from falling out of bed. Per observation at 1:43 PM on 3/22/11, Resident #6's bed is against the wall, leaving one side open for exiting the bed. At this time, the wedge device was in place under the mattress and out of the resident's reach, which raised the edge of the open side of the bed at least 6 inches, restricting the resident's ability to roll to that side of the bed or exit the bed. Per interview and observation of the wedge device with an LNA (Licensed Nursing Assistant) at 2:10 PM, the LNA stated that the wedge device was used so that the resident does not roll out of bed. Per observation at 2:17 PM the same day, Resident #6 was observed rocking his/her body to try to get over the hump created by the wedge device, while asking to get up. Per review of Nurses' Notes, the resident was found on the floor beside his/her bed on 3/14/11. Per record review, there was no care plan that directed staff to use the wedge, and no assessment to determine if this was an appropriate measure to use, nor an assessment for the device as a potential restraint. Per observation at 3:56 PM on 3/22/11, accompanied by the DNS (Director of Nursing Services), the wedge remained in place under the mattress on the open side of the bed, while the resident was lying in bed. The DNS confirmed this at the time of observation. At 4:05 PM on 3/22/11, the Unit Manager confirmed that the care plan did not list using a wedge device as a safety measure. | 2014-02-01 | ||
| 2481 | 2481 | ROWAN COURT HEALTH & REHAB | 475037 | 378 PROSPECT STREET | BARRE | VT | 5641 | 2010-10-26 | 441 | D | RKEI11 | Based on family and staff interview and record review, the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary environment to help prevent the transmission of disease and infection for 1 resident in the applicable sample. (Resident #2) Findings include: Per interview and record review, the facility failed to ensure that nursing staff used standard safety precautions and correct procedures around the use of injectable medication. Per family interview and record review on 10/26/10, Resident #2 sustained a needle stick on 10/24/10 at approximately 8 PM with an insulin syringe that was previously used on another resident that same evening. Confirmed in interview on 10/26/10 at 2:08 PM with the Assistant Director of Nursing and the Unit Manager, the Medication Nurse used an insulin syringe to administer insulin to one resident and failed to correctly use the sliding safety device to cover and lock the cap on the syringe needle. The nurse then placed the empty syringe in his/her pocket where there was more than one syringe, instead of disposing of it in the safety needle box provided in the resident's room. The Medication Nurse then transported the syringe to Resident #2, "grabbed the wrong syringe out of the pocket" and stuck the resident with the used insulin syringe. Also confirmed per interview with the ADON and UM on 10/26/10 at 2:08 PM, the Medication Nurse reported the incident immediately to the Evening Supervisor, the family and medical provider were notified, and the facility Accidental Needlestick Injury policy was implemented, including having both residents tested for the blood-borne pathogens identified in the policy. The Medication Nurse received corrective re-education regarding safe administration of medication and a facility wide nursing Staff Development program on this topic was conducted after the incident. Also confirmed, the facility uses only syringes with safety devices and there are safety needle boxes in all resident rooms. | 2014-02-01 | ||
| 2480 | 2480 | ROWAN COURT HEALTH & REHAB | 475037 | 378 PROSPECT STREET | BARRE | VT | 5641 | 2010-10-26 | 281 | D | RKEI11 | Based on family and staff interview and record review, the facility failed to assure that services being provided meet professional standards of practice regarding medication administration and infection control for 1 resident in the applicable sample. (Resident #2) Findings include: 1. Per interview and record review, the facility failed to ensure that nursing staff used standard safety precautions and correct procedures around the administration of injectable medication. Per family interview and record review on 10/26/10, Resident #2 sustained a needle stick on 10/24/10 at approximately 8 PM with an insulin syringe that was previously used that same evening on another resident. Confirmed in interview on 10/26/10 at 2:08 PM with the Assistant Director of Nursing (ADON) and the Unit Manager (UM), the Medication Nurse used an insulin syringe to administer insulin to one resident and failed to correctly use the sliding safety device to cover and lock the cap on the syringe needle. The nurse then placed the empty syringe in his/her pocket, where there was more than one syringe, instead of disposing of it in the safety needle box provided in the resident's room. The Medication Nurse then transported the syringe to Resident #2, "grabbed the wrong syringe out of the pocket" and stuck Resident #2 with the used insulin syringe. Also confirmed per interview with the ADON and UM on 10/26/10 at 2:08 PM, the Medication Nurse reported the incident immediately to the Evening Supervisor, the family and medical provider were notified, and the facility Accidental Needlestick Injury policy was implemented, including having both residents tested for the blood-borne pathogens identified in the policy. The Medication Nurse received corrective re-education regarding safe administration of medication and a facility wide nursing Staff Development program on this topic was conducted after the incident. Also confirmed, the facility uses only syringes with safety devices and there are safety needle boxes in all resident rooms. Lippincott M… | 2014-02-01 | ||
| 2479 | 2479 | CRESCENT MANOR CARE CTRS | 475033 | 312 CRESCENT BLVD | BENNINGTON | VT | 5201 | 2011-07-27 | 456 | D | SW6I11 | Based on observation, interview and record review, the facility failed to maintain the oxygen concentrator filter for 1 of 5 residents using oxygen concentrators (Resident #9). On all days of survey, the cooling air intake filter for the oxygen concentrator being used by Resident #9 was covered with heavy white dust. On 7/27/2011 at 11:00 AM, the resident was observed sleeping in bed using the oxygen concentrator. On 7/27/2011 at 11:30 AM, the Facilities Director stated that the housekeepers were responsible for keeping the filters clean and it was done monthly. The manufacturer's recommendation for routine maintenance of the oxygen concentrator to ensure accurate output and efficient operation of the unit included the cleaning of the filter on a weekly basis and may require daily cleaning if it operates in a harsh environment. | 2014-02-01 | ||
| 2478 | 2478 | CRESCENT MANOR CARE CTRS | 475033 | 312 CRESCENT BLVD | BENNINGTON | VT | 5201 | 2011-07-27 | 441 | E | SW6I11 | Based upon observation, interview and record review, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection per observations including: a pressure ulcer dressing change for one resident in the applicable Stage 2 sample (Resident #1); dining observations; and during environmental rounds. Findings include: 1. Per observation of Resident #1's left foot pressure ulcer dressing change on 7/27/11, and confirmed during interview on 7/27/11 at 9:50 AM, Nurse #1 dropped the television remote on the floor prior to the dressing change, picked up the remote from the floor, and failed to wash or sanitize hands prior to laying out a clean barrier and placing a saline wound flush on the barrier. The Surveyor stopped the dressing change before Nurse #1 opened non-sterile gauze on the barrier. Per interview with the Director of Nursing (DNS) and review of the Infection Control Reminder and Procedure for Clean Dressing Technique on 7/27/11 at 10:45 AM, the DNS confirmed that Nurse #1 should have washed or sanitized hands after picking up the remote from the floor prior to laying out a clean barrier and dressing supplies. 2. Per observation and staff interviews, an LNA was observed on 07/25/2011 at 11:45 AM feeding two residents at a time without sanitizing hands between direct contact. The LNA was observed feeding food and drink, wiping mouths and hands, and repositioning residents during feeding without sanitizing or washing hands. S/he stated in an interview at 12:10 PM on 07/25/2011 that s/he would not sanitize hands between feeding two residents but s/he washed her/his hands before beginning to feed residents and when finished feeding residents. In an interview at 12:20 PM on 07/25/2011 the Unit Manager stated that it is expected that, when feeding two residents, a staff member would feed several bites, sanitize hands and feed the second resident several bites, sanit… | 2014-02-01 | ||
| 2477 | 2477 | CRESCENT MANOR CARE CTRS | 475033 | 312 CRESCENT BLVD | BENNINGTON | VT | 5201 | 2011-07-27 | 428 | D | SW6I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure that the medication regime for 1 of 19 residents (Resident # 80) had adequate indications for use for 1 medication. The facility further failed to assure that the pharmacist reported this irregularity to the attending physician. Findings include: Per medical record review on 07/27/2011 at 8:18 AM there is no indication for the use of Symmetrel for Resident # 80 in the history and physical, on the problem list or on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This medication had been ordered prior to 01/01/2011. Staff confirms during interview on 07/27/2011 at 10:18 AM that no indication for the use of Symmetrel is provided anywhere in the medical record and that the expectation of the facility is that all medications will have a [DIAGNOSES REDACTED]. Per record review on 07/27/2011 at 8:18 AM the required monthly pharmacy consults have been documented as having been done from January 2011 through 7/25/2011. There is no evidence to support that a missing [DIAGNOSES REDACTED].# 80. There is no documentation to indicate that the physician was notified of the missing indication for the use of Symmetrel. Also see F329. | 2014-02-01 | ||
| 2476 | 2476 | CRESCENT MANOR CARE CTRS | 475033 | 312 CRESCENT BLVD | BENNINGTON | VT | 5201 | 2011-07-27 | 356 | C | SW6I11 | Based on observation and interview, the facility failed to post the nurse staffing information, including registered nurses, licensed practical nurses, and licensed nursing assistants and the total resident census. On 7/25/2011 at 11:30 AM, the nurse staffing information could not be found posted in the facility. Interview with the Administrator on 7/25/2011 at 2:00 PM confirmed that they did not post the nurse staffing information as required. | 2014-02-01 | ||
| 2475 | 2475 | CRESCENT MANOR CARE CTRS | 475033 | 312 CRESCENT BLVD | BENNINGTON | VT | 5201 | 2011-07-27 | 329 | D | SW6I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to assure that the medication regime for 1 of 19 residents (Resident # 80) had adequate indications for use for 1 medication. Findings include: Per medical record review on 07/27/2011 at 8:18 AM, there is no indication for the use of [MEDICATION NAME] for Resident # 80 in the history and physical, on the problem list or on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This medication had been ordered prior to 01/01/2011. Staff confirms during interview on 07/27/2011 at 10:18 AM, that no indication for the use of [MEDICATION NAME] is provided anywhere in the medical record and that the expectation of the facility is that all medications will have a [DIAGNOSES REDACTED]. Also see F428. | 2014-02-01 | ||
| 2474 | 2474 | CRESCENT MANOR CARE CTRS | 475033 | 312 CRESCENT BLVD | BENNINGTON | VT | 5201 | 2011-07-27 | 323 | E | SW6I11 | Based on observation and interview, the facility failed to ensure that the resident environment remains as free of accident hazards as possible. Findings include: Per observation of the west unit central bathing room on 7/27/11 at 9:21 A.M., there were several plugged in electrical devices with cords dangling from an approximately 5 inch wide shelf situated over a toilet, creating a potential accident hazard. The Unit Manager and a Licensed Nursing Assistant confirmed at the the time of the observation that the devices were used by residents routinely and that the dangling cords presented an accident hazard. | 2014-02-01 | ||
| 2473 | 2473 | CRESCENT MANOR CARE CTRS | 475033 | 312 CRESCENT BLVD | BENNINGTON | VT | 5201 | 2011-07-27 | 156 | C | SW6I11 | Based on observation and interview, the facility failed to prominently display written information about how to apply for or use Medicare and Medicaid benefits and information about the Medicaid Fraud Unit. On 7/25/2011 at 11:30 am, posting of resident rights and other pertinent information were found on the bulletin board outside the administrative offices. The information concerning Medicaid was outdated and also did not include how to apply for Medicaid including the address and telephone number, and the Medicaid Fraud Unit. Also, there was no information as to how to apply for Medicare. On 7/25/11 at 2:00 PM, the Administrator confirmed that these items were not posted. | 2014-02-01 | ||
| 2472 | 2472 | VERMONT VETERANS' HOME | 475032 | 325 NORTH STREET | BENNINGTON | VT | 5201 | 2010-10-19 | 280 | D | CU7F11 | Based on resident and staff interview and record review, the facility failed to revise the plan of care to reflect the current status and needs of 1 applicable resident. (Resident #1) Findings include: 1. Per resident and staff interview and record review, the facility failed to revise the resident's comprehensive care plan to ensure safe participation in activities of the resident's interest. Per interview with Resident #1 on 10/19/10 at 1:22 PM, the resident describes his/her fall from a wheelchair, which occurred on 9/24/10 at approximately 4 PM, resulting in an injury requiring surgery and hospitalization . The resident, who is confined to a wheelchair, reports that s/he regularly participated in caring for plants in the hallway and in the Plant Room/Sun Room on the unit where the resident resides. The resident stated that as part of the care for these plants, s/he would fill and then hold a 2 liter bucket of water on his/her lap while sitting in the wheelchair and would then move to areas where the plants were located in order to water the plants. Review of the facility's 9/24/10 accident investigation reports, including the Director of Nursing (DNS) investigation report and statements written by staff present at the time of the resident's fall, confirm that at the time of the fall on 9/24/10 Resident #1 was holding a bucket of water on his/her lap while in a wheelchair, stood up, spilled a large amount of water on the floor and fell . Record review also indicates that Resident #1 has several risk factors for falls. On 10/19/10 at 3:15 PM the resident showed this surveyor the 2 liter bucket used on the day of the fall. When filled to the level the resident carried on the day of the fall, the bucket weighs 14 pounds as verified on the unit scale on 10/19/10. Per interview with the unit Clinical Care Coordinator (CCC) and a unit Registered Nurse (RN) on 10/19/10 at 1:47 PM they both confirmed that Resident #1 would sometimes use a shower chair with wheels to move the filled bucket of water to the plants, or st… | 2014-02-01 | ||
| 2471 | 2471 | VERMONT VETERANS' HOME | 475032 | 325 NORTH STREET | BENNINGTON | VT | 5201 | 2010-10-19 | 323 | G | CU7F11 | Based on resident and staff interview and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as possible, and each resident receives adequate supervision and assistance devices to prevent accidents for 1 applicable resident. (Resident #1) Findings include: 1. Per resident and staff interview, and record review, the facility failed to provide adequate supervision and assistance to Resident #1 during his/her participation in a regular activity of interest. Per resident interview on 10/19/10 at 1:22 PM, the resident describes his/her fall from a wheelchair, which occurred on 9/24/10 at approximately 4 PM, resulting in an injury requiring surgery and hospitalization . The resident, who is confined to a wheelchair, reports that s/he regularly participated in caring for plants in the hallway and in the Plant Room/Sun Room on the unit where the resident resides. As part of the care for these plants, s/he would fill and then hold a 2 liter bucket of water on his/her lap while sitting in the wheelchair and would then move to areas where the plants were located in order to water the plants. Review of the facility's 9/24/10 accident investigation reports, including the Director of Nursing (DNS) investigation report and statements written by staff present at the time of the fall, confirm that at the time of the fall on 9/24/10, Resident #1 was holding a bucket of water on his/her lap while in a wheelchair, stood up, spilled a large amount of water on the floor and fell . Record review also indicates that Resident #1 has several risk factors for falls. On 10/19/10 at 3:15 PM the resident showed this surveyor the 2 liter bucket used on the day of the fall. When filled to the level the resident carried on the day of the fall the bucket weighs 14 pounds as verified on the unit scale on 10/19/10. Per interview with the unit Clinical Care Coordinator (CCC) and a unit Registered Nurse (RN) on 10/19/10 at 1:47 PM they both confirmed that Resident #1 would sometimes use a sh… | 2014-02-01 | ||
| 2470 | 2470 | BENNINGTON HEALTH & REHAB | 475027 | 2 BLACKBERRY LANE | BENNINGTON | VT | 5201 | 2011-01-26 | 465 | D | 9Y3U11 | Based upon observation and interview, the Facility failed to ensure a safe environment in two resident rooms located on the second floor. (Rooms # 4 and # 13) Findings include: 1. Per observation of resident room #4 on 1/24/11 at 11:15 AM, a metal lighting fixture located above the base board and next to a resident's bed was not secured, was protruding from the wall, and had metal edges exposed. Per interview on 1/24/11 at 11:50 AM, the Assistant Director of Nursing (ADNS) confirmed the metal lighting fixture in resident room # 4 located above the baseboard and next to the resident's bed was not secured, was protruding from the wall, and had metal edges exposed. 2. Per observation of resident room #13 on 1/24/11 at 11:15 AM, the bathroom heating vent was not covered and the heating fins were exposed to contact. Per interview on 1/24/11 at 11:50 AM, the ADNS confirmed the bathroom heating vent in resident room #13 was not covered and the heating fins were exposed to contact. | 2014-02-01 | ||
| 2469 | 2469 | BENNINGTON HEALTH & REHAB | 475027 | 2 BLACKBERRY LANE | BENNINGTON | VT | 5201 | 2011-01-26 | 431 | D | 9Y3U11 | Based on observation and staff interview, the facility failed to assure that drugs were labeled correctly. Findings include: Per observation on 1/25/11, the third floor medication storage refrigerator contained two opened multi-dose vials of NPH insulin, one with an unreadable date, and one with no date indicating when it had been opened. At 11:28 AM, the nurse administering medications confirmed that the date was unreadable on one vial, and the other insulin was not labeled at all. Also, on 1/25/11 at 11:50 AM, per observation of the second floor medication cart, there was an opened multi-dose vial of Lantus Insulin that had no date written on it to indicate when it was opened. The observation was confirmed by the nurse passing medications from this cart at 11:55 AM. | 2014-02-01 | ||
| 2468 | 2468 | BENNINGTON HEALTH & REHAB | 475027 | 2 BLACKBERRY LANE | BENNINGTON | VT | 5201 | 2011-01-26 | 412 | D | 9Y3U11 | Based upon interview and record review, the facility failed to provide routine dental services to meet the needs of one resident with dental pain in the Stage II sample. (Resident #25) Findings include: 1. Per record review, the Nutrition Care Plan for resident #25 includes a dental evaluation PRN (as needed) and monitoring of dental pain. Per record review, Resident #25's last dental exam was on 8/8/03. In addition, there was no documentation that dental pain was monitored. Per interview on 1/26/11 at 9:48 AM, a Licensed Nurse Assistant (LNA) stated Resident #25's teeth are brushed every day and that Resident #25 expresses concerns about mouth pain on the right side and touches the right cheek during oral care. Per interview on 1/26/11 at 9:50 AM, the unit manager confirmed that Resident #25's last dental exam was on 8/8/03, the Nutrition Care Plan was not implemented to include a dental evaluation as needed, and monitoring of dental pain was not documented. | 2014-02-01 | ||
| 2467 | 2467 | BENNINGTON HEALTH & REHAB | 475027 | 2 BLACKBERRY LANE | BENNINGTON | VT | 5201 | 2011-01-26 | 318 | D | 9Y3U11 | Based on observation, record review and staff interview, the facility failed to assure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 applicable resident in the sample (Resident #76). Findings include: Per observation on 1/25/11, Resident #76 has limited range of motion in both knees and both hands, and the left hand is able to open only slightly before the resident complains of pain. There are no splints or other devices in use. Per record review, the MDS Assessments from April 2010 and December 2010 are inaccurately coded as not having any limitation in functional range of motion. There is no mention in the plan of care for staff to perform range of motion, and no documentation that this was being completed. Per interview on 1/26/11 at 8:05 AM, the Rehab Manager/Physical Therapist confirmed that this resident had some functional range of motion deficits when receiving Physical Therapy services over a year ago, and that there has been further decline of the Resident's range of motion since that time. The therapist also stated that the resident was on a functional maintenance program that would include performing range of motion exercises daily. Per review of the resident's record and the book that documents the provision of functional maintenance exercises, the resident is not on a formal plan, and this was confirmed by the PT Rehab manager. | 2014-02-01 | ||
| 2466 | 2466 | BENNINGTON HEALTH & REHAB | 475027 | 2 BLACKBERRY LANE | BENNINGTON | VT | 5201 | 2011-01-26 | 282 | D | 9Y3U11 | Based upon interview and record review, the facility failed to provide services in accordance with the written plan of care for one resident with dental pain in the Stage II sample. (Resident # 25) Findings include: 1. Per record review, the Nutrition Care Plan for resident #25 includes a dental evaluation PRN (as needed) and monitoring of dental pain. Per record review, Resident # 25's last dental exam was on 8/8/03. In addition, there was no documentation that dental pain was monitored. Per interview on 1/26/11 at 9:48 AM, a Licensed Nurse Assistant (LNA) stated Resident #25's teeth are brushed every day and that Resident #25 expresses concerns about mouth pain on the right side and touches the right cheek during oral care. Per interview on 1/26/11 at 9:50 AM, the unit manager confirmed that Resident #25's last dental exam was on 8/8/03, the Nutrition Care Plan was not implemented to include a dental evaluation as needed, and monitoring of dental pain was not documented. | 2014-02-01 | ||
| 2465 | 2465 | BENNINGTON HEALTH & REHAB | 475027 | 2 BLACKBERRY LANE | BENNINGTON | VT | 5201 | 2011-01-26 | 272 | D | 9Y3U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to assure that an accurate comprehensive assessment was completed for 1 of 41 residents sampled (Resident #76). Findings include: Per observation on 1/25/11, Resident #76 has contractures in his/her hands and legs and is non-ambulatory. Upon review of the MDS Assessments, both the annual full assessment completed in April 2010 and the latest quarterly assessment dated [DATE], the Resident is coded as having no limitations in functional range of motion. Per observation and interview with a Licensed Nursing Assistant, the resident can stretch her legs out but not to the straight position, her right hand is somewhat contracted, and the left hand only opens slightly before the resident complains of pain. Per interview on 1/26/11 at 8:05 AM, the Rehab Manager/Physical Therapist confirmed that this resident had some functional range of motion deficits when receiving Physical Therapy services over a year ago, and that there has been further decline of the Resident's range of motion since that time. Per interview on 1/26/11 at 9:44 AM, the MDS Coordinator and the Assistant Director of Nursing confirmed that this resident was coded inaccurately for functional range of motion status. | 2014-02-01 | ||
| 2464 | 2464 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2010-12-08 | 411 | D | 3WFD11 | Based on record review and interview, the facility failed to assist 1 applicable resident (Resident #15) to obtain routine dental care. Findings include: 1. Per interview on 12/7/10 at 12:36 PM, the responsible party for Resident #15 indicated this resident has a history of chronic, intermittent tongue pain / mouth sores. Per record review on 12/8/2010, there was no evidence that a professional dental exam had been completed during the prior year. Additionally, there was no instruction for professional routine dental evaluation indicated in the physician orders. During interview on 12/8/10 at 11:20 AM, the Unit Nursing Supervisor confirmed that there were no orders for professional dental care and that no professional dental care had been arranged / provided for this resident. Refer also to F279. | 2014-02-01 | ||
| 2463 | 2463 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2010-12-08 | 441 | E | 3WFD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe, sanitary environment and to help prevent the transmission of infection for 1 of 22 residents in the sample (Resident #84). Findings include: Per interview with a family member of Resident #84 on 12/8/10 at 8:32 AM, facility staff have not been following precautions for Resident #84's Clostridium-Difficile (C-diff). Per record review on 12/8/10 at 9:00 AM, Resident #84 was diagnosed with [REDACTED]. Per observation during the first 2 days of survey, there was no contact precaution equipment near the Resident's door and no signage to "see nurse before entering" on the Resident's door. Per review of the facility policy regarding[DIAGNOSES REDACTED] on 12/8/10 at 11:09 AM, it is the facility's policy to institute contact precautions for residents with known[DIAGNOSES REDACTED]. During a 9:45 AM interview with the Unit Manager (UM), s/he confirmed that Resident #84 has had[DIAGNOSES REDACTED] since 11/27/10 and that contact precautions (gowns and gloves) should be in place. Per a 12/8/10 interview at 9:56 AM, a unit Licensed Nursing Assistant (LNA) stated that s/he was unaware of contact precautions for Resident #84. Per record review on 12/8/10 at 10:00 AM, the LNA daily care sheet and the care plan for[DIAGNOSES REDACTED] did not indicate that Resident #84 was on contact precautions. During a 10:05 AM interview on 12/8/10, a Unit Nurse confirmed that Resident #84 has[DIAGNOSES REDACTED] and that s/he did not utilize contact precautions while providing care on 12/6/10 and 12/7/10. | 2014-02-01 | ||
| 2462 | 2462 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2010-12-08 | 279 | D | 3WFD11 | Based on interview, observation, and record review, the facility failed to develop comprehensive care plans for 3 of 22 residents in the sample. (Resident #2, #15 and #16) Findings include: 1. Per interview on 12/7/10 at 12:37 PM, the responsible party for Resident #15 indicated this resident has a history of chronic, intermittent tongue pain / mouth sores. Per record review on 12/8/2010, there was no plan of care directing staff in routine dental assistance for Resident #15. During interview on 12/8/10 at 11:20 AM, the Unit Nursing Supervisor confirmed that there was no dental plan of care for this resident. Refer also to F411. 2. Per resident observation on 12/07/2010 at 10:44 AM, Resident #2 has broken and missing teeth. Per record review on 12/08/2010 at 9:30 AM, there is no individualized care plan to address dental issues for Resident #2. Dental assessments are present in the medical record and dental visits occurred on 02/05/2010, 02/19/2010 and 03/05/2010. None of the recommendations made during those visits were transferred to the care plan. It was confirmed during interview with the charge nurse at 9:55 AM on 12/08/2010, that the care plan for Resident #2 has not been developed to address specific dental health needs. 3. Per record review, Resident #16 had been roommates in the facility with a close friend and partner of many years. The friend passed away in July 2010, and per interview with the resident on 12/8/10, this was a significant loss and saddened the resident deeply. Per review of Resident #16's plan of care, there was no area to address the resident's psychosocial needs related to grief and loss. Per interview on 12/8/10 at 3:25 PM, the Social Worker confirmed that the resident experienced a significant loss, and that no care plan was developed to address this concern. | 2014-02-01 | ||
| 2461 | 2461 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2010-10-27 | 514 | D | KDRM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to maintain accurate and complete medical records for one resident in the applicable sample. (Resident #1) Findings include: 1. Per record review, the facility failed to include as part of the resident's record a complete and accurate medical diagnoses/treatment list and past medical history (PMH) for Resident #1. Per review of the transferring medical center documents, including a History & Physical dated 2/27/08, as well as the Speech Discharge Evaluation dated 3/10/08, the PMH for Resident #1 includes "[MEDICAL CONDITION] dilatation" (a procedure used to treat/resolve [MEDICAL CONDITION].) In the facility's Admission Physical Exam Sheet dated 4/15/08, the facility's admitting physician does not document the resident's prior [MEDICAL CONDITION] dilatation treatment. Neither the facility's current Medical Problem List for Resident #1, which lists resident active and inactive problems, nor the [DIAGNOSES REDACTED]. The above was confirmed in interview on 10/27/10 at 1:45 PM with the facility Director of Nursing (DNS) and the Director of Clinical Services. Also confirmed with the DNS at this time, Resident #1 was discharged from the facility on 10/25/10 to the Emergency Department and required immediate admission and [MEDICAL CONDITION] dilatation treatment. | 2014-02-01 | ||
| 2460 | 2460 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2010-10-27 | 281 | D | KDRM11 | Based on staff interview and record review, the facility failed to provide services in accordance with professional standards of practice regarding evaluation of a skin condition for 1 resident. (Resident #1) Findings include: 1. For Resident #1, facility staff did not inform the resident's physician and family of the failure of a skin condition to improve with treatment, as well as to report the worsening status of the skin condition after a prescribed three month treatment regimen was completed. Per review of the resident's Nurses Notes (NN), the resident had a recurrent skin condition requiring treatment and referral to a medical specialist on 7/20/10. A three month course of therapy was prescribed and was given as ordered by the specialist during which no improvement was documented by nursing staff. Confirmed during interview with the Director of Nursing Service (DNS) and the Wound/Skin Care Nurse on 10/27/10 at 1:58 PM, the resident's skin condition did not improve with treatment and began to worsen further after the completion of the ordered treatment regimen on 10/8/10. The Wound/Skin Care Nurse stated during this interview: "It was my responsibility to inform the resident's physician and family about the failure of the treatment to improve the skin. I should have also informed them when the condition began to worsen." Lippincott Manual of Nursing Practice (9th ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins, pg 17. | 2014-02-01 | ||
| 2459 | 2459 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2010-10-27 | 329 | D | KDRM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure that residents were free from medications used without adequate monitoring for 1 resident in the applicable sample. (Resident #1) Findings include: 1. The facility failed to inform the prescribing physician of the lack of response to a medication treatment regimen for Resident #1. Per record review and staff interview on 10/27/10, Resident #1 received [MEDICATION NAME] (fluconazole, an antifungal medication) 200 mg (milligrams) by mouth weekly from 7/23/10 through 10/8/10, as well on-going treatment with Locoid ([MEDICATION NAME]) 1% cream topically applied to the skin twice daily after warm compresses. The treatment regimen was prescribed by a consulting dermatologist on 7/20/10 for a [DIAGNOSES REDACTED]. Weekly Skin Integrity Checks completed by facility nursing staff during the 12 week treatment period document "No change in skin condition" for 10 of the 12 weeks of treatment. The above was confirmed in interview with the Wound/Skin Care Nurse on 10/27/10 at 1:58 PM. The Wound/Skin Care Nurse stated during this interview: "It was my responsibility to inform the resident's physician and family about the failure of the treatment to improve the skin. I should have also informed them when the condition began to worsen." | 2014-02-01 | ||
| 2458 | 2458 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2010-10-27 | 157 | D | KDRM11 | Based on staff interview and record review, the facility failed to consult with the resident's physician and notify the resident's legal representative regarding a significant change in the resident's physical status for one resident in the applicable sample. (Resident #1) Findings include: 1. The facility did not inform the resident's physician and family of the failure of a skin condition to improve with treatment, as well as to report the worsening status of the skin condition after a prescribed three month treatment regimen was completed for Resident #1. Per review of the resident's Nurses Notes (NN), the resident had a recurrent skin condition requiring treatment and referral to a medical specialist on 7/20/10. A three month course of therapy was prescribed and was given as ordered by the specialist during which no improvement was documented by nursing staff. Confirmed during interview with the Director of Nursing Service (DNS) and the Wound/Skin Care Nurse on 10/27/10 at 1:58 PM, the resident's skin condition did not improve with treatment and began to worsen further after the completion of the ordered treatment regimen on 10/8/10. The Wound/Skin Care Nurse stated during this interview: "It was my responsibility to inform the resident's physician and family about the failure of the treatment to improve the skin. I should have also informed them when the condition began to worsen." | 2014-02-01 | ||
| 2457 | 2457 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2010-10-25 | 250 | D | L2QS11 | Based on resident, family and staff interview, and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical. mental, and psychosocial well-being for 1 resident in the applicable sample. (Resident #1) Findings include: 1. Per resident, family and staff interview, and record review, the facility Social Services (SS) staff failed to make appropriate discharge referrals for Resident #1 to ensure that timely outpatient follow up in the home setting was received. Resident #1 was discharged to home from the facility on 9/2/10 and was to receive skilled nursing services and physical therapy (PT) from the Visiting Nurse Association and Hospice of Vermont and New Hampshire (VNA). Per interview with Resident #1 and his/her spouse on 10/25/10 at 12:35 PM, the VNA did not make a home visit until 9/8/10 because "There was a mix up about the referral." The resident stated that even though the VNA did not make a home visit until 9/8/10, the prescribed medications and medical equipment were sent home at the time of discharge and were used by the resident as directed by the prescribing physician. The resident also stated that PT did evaluate the resident for services in the home on 9/8/10 after the referral was sent to the VNA, but that the resident no longer qualified for PT services. Per interview with facility SS staff on 10/25/10 at 12:50 PM, SS submitted a referral to another home health agency, not the VNA, in error. The error was not reported until a community case manager had contact with the resident on 9/8/10 and reported the error to SS at the facility. Social Service staff confirmed on 10/25/10 at 12:50 PM that because of the error made, the resident did not receive skilled nursing service or PT until 9/8/10, six days after discharge from the facility, and that the resident should have been seen within 24 to 48 hours after discharge. | 2014-02-01 | ||
| 2456 | 2456 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2010-10-25 | 204 | D | L2QS11 | Based on resident, family and staff interview, and record review, the facility failed to provide sufficient preparation and orientation to 1 resident in the applicable sample to ensure a safe and orderly discharge from the facility. (Resident #1) Findings include: 1. Per resident, family and staff interview, and record review, the facility failed to make appropriate discharge referrals for Resident #1 to ensure that timely outpatient follow up in the home setting was received. Per record review Resident #1 was discharged to home from the facility on 9/2/10 and was to receive skilled nursing services and physical therapy (PT) from the Visiting Nurse Association and Hospice of Vermont and New Hampshire (VNA). Per interview with Resident #1 and his/her spouse on 10/25/10 at 12:35 PM, the VNA did not make a home visit until 9/8/10 because "There was a mix up about the referral." The resident stated that even though the VNA did not make a home visit until 9/8/10, the prescribed medications and medical equipment were sent home at the time of discharge and were used by the resident as directed by the prescribing physician. The resident also stated that PT did evaluate the resident for services in the home on 9/8/10 after the referral was sent to the VNA, but that the resident no longer qualified for PT services. Per interview with facility Social Service (SS) staff on 10/25/10 at 12:50 PM, SS submitted a referral to another home health agency, not the VNA, in error. The error was not reported until a community case manager had contact with the resident on 9/8/10 and reported the error to SS at the facility. Social Service staff confirmed on 10/25/10 at 12:50 PM that because of the error made, the resident did not receive skilled nursing service or PT until 9/8/10, six days after discharge from the facility, and that the resident should have been seen within 24 to 48 hours after discharge. | 2014-02-01 | ||
| 2455 | 2455 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2011-02-16 | 425 | D | N98G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pharmaceutical services were provided that assured the accurate dispensing of all medications for 1 of 10 residents in the applicable sample (Resident # 9). Findings include: 1. Per record review on 2/16/11, the pharmacy incorrectly transcribed a January 2011 physician's orders [REDACTED]. Per record review, the February 2011 physician's orders [REDACTED]. Per record review on 2/16/11, Resident #9 has a [DIAGNOSES REDACTED]. On 2/16/11 at 9:51 AM, the Director of Nursing (DNS) confirmed the January 2011 physician's orders [REDACTED]. Per telephone interview on 2/16/11 at 10:14 AM with the Pharmacy and DNS, a data entry error occurred when the code for Nitroglycerin was entered into the computer for Resident #9. The February 2011 physician's orders [REDACTED]. On 2/16/11 at 10:24 AM, the DNS confirmed that following a pharmacy data entry error, the order and indication for use of Nitroglycerin for Resident #9 was incorrectly transcribed by the pharmacy. Also see F386. | 2014-02-01 | ||
| 2454 | 2454 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2011-02-16 | 441 | D | N98G11 | Based on observation and staff interview, the facility staff failed to wear gloves when required by facility policy while providing care to 1 applicable resident (Resident #220). Findings include: 1. Per observation of a medication pass on 2/15/11 at 8:47 AM, the medication nurse administered an insulin injection to a resident with un-gloved hands. Per interview on 2/15/11 at 8:47 AM, the medication nurse stated s/he did not know if gloves should be worn when administering injectable medications and confirmed that gloves were not worn when the insulin injection was administered to Resident #220. Per interview on 2/15/10 at 8:50 AM, the charge nurse confirmed that the facility policy is to wear gloves when administering injectable medications. Per review of the facility manual, Infection Prevention Manual 2010 Exposure Determination PPE (Personal Protection Equipment) Needs, gloves are necessary for injection of medication. Per interview on 2/15/11 at 9:10 AM, the DNS confirmed that gloves should be worn during an injection of a medication to a resident. | 2014-02-01 | ||
| 2453 | 2453 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2011-02-16 | 431 | D | N98G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and review of facility policy, the facility failed to monitor the safe storage of medications for 3 applicable residents (Residents #187, 32, 96). Findings include: 1. Per observation on [DATE] at 11:25 AM, a medication cart on the facility's 5th floor unit contained 3 vials of insulin which had been opened for greater than 28 days, assigned to residents #187, 32, and 96. The facility's policy states that insulin can be used up to 28 days after the vial is opened. The 28 day limit for the Novolog insulins expired on [DATE], [DATE], and [DATE], respectively. Per interview on [DATE] at 11:30 AM with the 5th floor Unit Manager (UM), the UM confirmed that the insulins had gone past the 28 day date since being opened. | 2014-02-01 | ||
| 2452 | 2452 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2011-02-16 | 386 | D | N98G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the physician reviewed the total plan of care for 1 of 39 residents in the Stage 2 sample. (Resident # 9) Findings include: 1. Per record review on 2/16/11, the physician signed an incorrect transcription of a medication order on the February 2011 Physician's Orders on 2/15/11. The printed Physician's Orders included an entry for [MEDICATION NAME] 0.4 mg (milligrams) one tablet sublingual (SL) as needed for chest pain, may repeat every 5 minutes up to 3 doses. Per record review, the January 2011 Physician's Orders, signed on 1/3/11 for Resident #9, state [MEDICATION NAME] 0.4 mg SL four times per day (QID) as needed with meals for [MEDICAL CONDITION] spasms. Per record review on 2/16/11, Resident #9 has a [DIAGNOSES REDACTED]. On 2/16/11 at 9:51 AM, the Director of Nursing (DNS) confirmed the February 2011 Physician's Order signed on 2/15/11 by the physician, which states [MEDICATION NAME] 0.4 mg one tablet SL as needed for chest pain, was incorrect due to a data entry error by the pharmacy. Per telephone interview on 2/16/11 at 10:14 AM with the Pharmacy and DNS, a data entry error occurred when the code for [MEDICATION NAME] was entered into the computer for Resident #9. The February 2011 Physician's Orders for Resident #9 were automatically generated and approved by the Pharmacist for [MEDICATION NAME] 0.4 mg one tablet SL as needed for chest pain, may repeat every 5 minutes, which was then signed by the physician. Also see F428. | 2014-02-01 | ||
| 2451 | 2451 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2011-02-16 | 329 | D | N98G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that 1 of 10 residents in the applicable sample (Resident #219) had a complete order for an as needed (PRN) inhaled medication. The findings include: Per medical record review of Resident #219 at 9:44 AM on 02/16/2011, an order for [REDACTED]. It has not been corrected as of the date of record review, 02/16/2011. When brought to the attention of the facility staff by the surveyor, the physician was contacted for clarification of the medication order. This is confirmed by by staff during an interview on 02/16/2011 at 9:48 AM. | 2014-02-01 | ||
| 2450 | 2450 | THE MANOR, INC | 475057 | 577 WASHINGTON HIGHWAY | MORRISVILLE | VT | 5661 | 2010-11-10 | 323 | D | RGCS11 | Based on record review and interview, the facility failed to assure that 1 of 3 residents (Resident #1) received adequate supervision and assistive devices to prevent accidents. Findings include: Per record review, Resident #1 was discovered by staff to have slid to the floor while unmonitored and unalarmed in a reclining chair on 9/23/10 at 4:57 PM. The written plan of care for falls prevention specified the use of bed and chair alert alarms to address a history of falls and poor trunk control. In an interview on 11/10/10 at 11:35 AM, the Director of Nursing Services (DNS) confirmed that the reclining chair was not equipped with an alert alarm as specified in the care plan for falls prevention. | 2014-03-01 | ||
| 2449 | 2449 | THE MANOR, INC | 475057 | 577 WASHINGTON HIGHWAY | MORRISVILLE | VT | 5661 | 2010-11-10 | 282 | D | RGCS11 | Per record review and interview, the facility failed to assure that staff correctly implemented the written plan of care for falls prevention for 1 of 3 residents (Resident #1) in the sample. Findings include: Per record review, on 9/23/10 Resident #1 was transferred to a reclining chair (which was not equipped with an alert alarm) and subsequently slid to the floor while unmonitored. Per further record review, Resident #1 had a written plan of care (updated 9/21/10) for falls prevention which included the use of bed and chair alarms. In an interview on 11/10/10 at 11:35 AM, the Director of Nursing Services (DNS) confirmed that Resident #1 had not been monitored with a chair alarm as specified in the written care plan. | 2014-03-01 | ||
| 2448 | 2448 | THE MANOR, INC | 475057 | 577 WASHINGTON HIGHWAY | MORRISVILLE | VT | 5661 | 2010-11-10 | 280 | D | RGCS11 | Per record review and interview, the facility failed to revise the care plan to reflect changes in care for 1 of 3 applicable residents in the sample (Resident #1). Findings include: Per record review, on 9/23/10 the staff changed the seating for Resident #1 who slid to the floor while unmonitored. The resident had a written plan of care which included the use of bed and chair alarms. During an interview on 11/10/10 at 11:35 AM, the Director of Nursing Services (DNS) confirmed that the plan of care had not been revised to reflect the use of the reclining chair (which was not equipped with an alarm). | 2014-03-01 | ||
| 2447 | 2447 | FRANKLIN COUNTY REHAB CENTER LLC | 475047 | 110 FAIRFAX ROAD | ST ALBANS | VT | 5478 | 2011-04-06 | 280 | D | SFEK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the care plan to reflect a change in condition for 1 applicable resident (Resident #88). Findings include: 1. Per record review on 4/4/11 at 1:00 PM, for Resident #88, who was admitted on [DATE] with intact skin, there was no care plan revision with goals/interventions or a treatment plan after the resident acquired two Stage 2 pressure sores on his/her buttocks on 3/26/11. Per interview on 4/5/11 at 11:30 AM, the staff nurse who first identified these pressure sores confirmed that since s/he was the first to identify the pressure sores for Resident #88, s/he would have been expected to revise the care plan at that time, but failed to do so. | 2014-03-01 | ||
| 2446 | 2446 | FRANKLIN COUNTY REHAB CENTER LLC | 475047 | 110 FAIRFAX ROAD | ST ALBANS | VT | 5478 | 2011-04-06 | 456 | B | SFEK11 | Based on observation and interview, facility staff failed to ensure all essential patient care equipment was maintained in a safe operating condition. Findings Include: On 4/6/11 at 9 A.M. an observation was made that 2 mattress covers on the beds in Rooms 410 (both beds) and 1 mattress cover in Room 408 (bed closest to the door) were badly torn on both sides exposing the foam mattress below. Per interview on 4/6/11 at 10:35 A.M. with the maintenance person s/he confirmed the observation and had the mattress covers changed. | 2014-03-01 | ||
| 2445 | 2445 | FRANKLIN COUNTY REHAB CENTER LLC | 475047 | 110 FAIRFAX ROAD | ST ALBANS | VT | 5478 | 2011-04-06 | 425 | D | SFEK11 | Based on interview and record reviews, the facility failed to ensure pharmaceutical services were provided that assured the accurate dispensing of antibiotics for 3 of 3 residents: (Residents #11, #71, & #125) Findings include: 1. Per observation of a medication administration pass on 4/4/11 at 11:00 A.M., an antibiotic was administered by a staff nurse for Resident # 71. The antibiotic caplet, which was not scored, had been cut in half and had jagged edges so that the dosage could not be assured. Also, the medication had no information on the MAR (Medication Administration Record) that the antibiotic is absorbed better if taken with food and it was not administered with food. 2. Per observation of a medication pass on 4/4/11 at 11:20 A.M., the staff nurse attempted to administer a dose of an antibiotic for Resident # 11. The antibiotic pill that was sent by the pharmacy was in an individual unit dose pack and was a caplet that was not scored and needed to be 'cut in half' for the resident to receive the appropriate dose. The staff nurse stated that s/he 'had no way to cut the pill in half' so the nurse called the pharmacy to request another pill with the 'correct dose.' The pharmacy delivered the antibiotic unit dose to the facility at 12:30 P.M. and the pharmacy had sent a unit dose package which contained a half of a caplet (cut in half although unscored) with the edges jagged where the pill had been cut. 3. Per observation on 04/05/11 at 10:15 A.M., the staff nurse was cutting in half a non-scored antibiotic (Vantin 200 mg) for Resident # 125. The antibiotic was noted to have jagged edges and the protective film coating compromised. The staff nurse stated to the nurse surveyor that s/he "called the pharmacy and they said that it was o.k. to split it." An interview on 4/5/11 at 10 A.M. was conducted with the pharmacist that has a contract with the facility, that provides the medications. S/he confirmed that the antibiotic that was prescribed for the residents (above) were available from the manufacturer in the… | 2014-03-01 | ||
| 2444 | 2444 | FRANKLIN COUNTY REHAB CENTER LLC | 475047 | 110 FAIRFAX ROAD | ST ALBANS | VT | 5478 | 2011-04-06 | 371 | E | SFEK11 | Based on observations, interviews, and record reviews, the facility failed to maintain safe and sanitary food storage practices. Findings include: 1. During the initial tour of the facility on 4/4/11 at 9:52 AM, the following food items were observed with the Food Service Director: a) one open and uncovered, multi-serving box of hot cereal mix (potentially allowing contamination prior to the next serving preparation) in the kitchen's dry food storage area. b) 2 separate bowls of tossed salad, covered with clear plastic wrap, each unlabeled and undated; 3 separate bowls of salad dressing, out of the original containers and covered with clear plastic wrap, each unlabeled and undated; one bowl of grated cheese in a dish covered with clear plastic wrap, unlabeled and undated, was observed in the kitchen's walk-in cooler. In addition, on 4/5/11 at 10:30 AM, the Food Service Director provided this surveyor with a copy of the facility's written Labeling Policy (Effective 10/18/2007) and confirmed that the above unlabeled and undated foods were not in compliance with the policy. The facility's Labeling Policy (Effective 10/18/2007) states that "Any food that is left over and needs to be refrigerated due to potential contamination shall be dated as follows: today's date, item name, throwaway date (no longer than 7 days); items that are opened and removed from original package need to be labeled as following: item name, expire date that is on package" . The Food Service Director confirmed at the time of the observation on 4/4/11 at 9:55 AM that the open cereal box should have been placed in a sealed container to prevent contamination of its contents and food items labeled and dated. | 2014-03-01 | ||
| 2443 | 2443 | FRANKLIN COUNTY REHAB CENTER LLC | 475047 | 110 FAIRFAX ROAD | ST ALBANS | VT | 5478 | 2011-04-06 | 332 | E | SFEK12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview for the Medication Pass Observation(s) on 6/1/11, 4 of 5 sampled residents received medications out of the scheduled time frame or not in accordance with accepted standards of practice (Residents #1, 2, 3 and 4), which calculated to a 56% error rate. Findings include: 1. Per observation on 6/1/11 at 10:00 AM during a medication administration pass for Resident #1, the nurse administered an Alzheimer's medication, a vitamin, and a liquid dietary supplement scheduled to be administered at 8 AM. At 10:48 AM on 6/1/11, the nurse confirmed that the medications were administered more than one hour after the time written on the Medication Administration Record (MAR). 2. Per observation on 6/1/11 at 10:15 AM during a medication administration pass for Resident #2, the nurse administered 2 medications scheduled for 8:00 AM (heart and Alzheimer's), as well as 7 medications and 2 vitamins which were scheduled for 9:00 AM. At 10:48 AM on 6/1/11, the nurse confirmed that the medications were administered more than one hour after the time written on the Medication Administration Record (MAR). 3. On 6/1/11 at 9:50 AM during a medication administration pass for Resident #4, the nurse administered 8 medications that were scheduled on the MAR to be given at 8:00 AM. Per review of the MAR and physician orders, Glimeperide ([MEDICATION NAME]) 4 mg (milligrams) was ordered to be given with breakfast, and the [MEDICATION NAME] 25 mg was to be given with meals. Per interview on 6/1/11 at 10:05 AM, the LNA stated that the resident ate breakfast at about 7:30 AM. Per interview on 6/1/11 at 10:10 AM, the nurse confirmed that the medications were administered more than an hour past the scheduled time, and not given with a meal. 4. Per observation on 6/1/11 at 10:15 AM during a medication administration pass for Resident #3, the nurse was observed opening a capsule of [MEDICATION NAME] LA (Long Acting) 4 mg (milligrams)… | 2014-03-01 | ||
| 2442 | 2442 | FRANKLIN COUNTY REHAB CENTER LLC | 475047 | 110 FAIRFAX ROAD | ST ALBANS | VT | 5478 | 2011-04-06 | 323 | E | SFEK11 | Based on observation, interview, and record review, the facility failed to ensure the resident's environment is as free of accident hazards as possible and the facility failed to use a preventative device correctly to prevent an accident for 1 applicable resident (Resident #123). Findings include: 1. Per record review on 04/05/11 at 4:30 PM, Resident #123's chart noted a fall on 04/02/11. Review of the resident's care plan dated 3/25/11 for Falls directed staff to maintain safety, call bell in reach, siderails for safety, alarm systems (as noted specifically on the LNA care plan for bed, chair and tab alarms) as well as other preventative measures. Per review of the incident report and nursing note of 04/02/11 on 11-7 shift, it stated the resident had to go to the bathroom and " the bed alarm did not go off, no injuries''. Per review of the LNA ALARM DOCUMENTATION sheet on evening shift of 04/01/11 - 04/02/11, the bed alarm/batteries were not checked by 2 LNAs, as well as not being consistently checked on the night shifts of 04/02 -04/05/11 and days shift of 04/02 -04/04/11. Per interview on 04/06/11 at 8:30 AM the Resident stated that "the bed alarm never went off and I wouldn't remove it, although it screeches, its important". Per interview with the DNS at 8:45 AM and the subsequent telephone interview with the LNA, stated that the bed alarm was not working at that time, as the battery was not working. The DNS confirmed the bed alarm was not adequately monitored nor working properly at the time of the Resident's fall. 2. Per observation during the initial tour of the facility on 4/4/11 at 9:45 AM the unlocked whirlpool/tub room on the Maplewood Wing and the unlocked soiled utility room had sanitizers/deodorizers/ant & roach spray and spray disinfectant found on the floor, counter and in unlocked cabinets under the counter. In the whirlpool/tub room, there was a half sprayer bottle filled with a sanitizer called Ecolab TB/Disinfectant/Deodorizer cleaner that was placed on the floor next to the whirlpool tub. In … | 2014-03-01 | ||
| 2441 | 2441 | FRANKLIN COUNTY REHAB CENTER LLC | 475047 | 110 FAIRFAX ROAD | ST ALBANS | VT | 5478 | 2011-04-06 | 309 | D | SFEK11 | Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain the highest practicable well-being for 1 applicable resident regarding skin care. (Resident #123) Findings include: 1. Per observation during initial tour on 04/04/11 at 3:30 PM, Resident #123 had a red rash/rough skin noted on the chin area. The Resident stated 'oh it burned/itched but its getting better' and said that a family member applied an Avon product for hair removal several days ago. Per record review on 04/05/11 at 4:47 PM, there was no assessment for skin irritation nor a nursing note regarding the facial skin issue. Per interview at 10:15 AM on 04/06/11, the LNA stated that usually the LNA's would check the skin on bath day, however OT (Occupational therapy) "is working with the resident for bathing and washing". Per interview on 04/06/11 at 10:38 AM the Occupational Therapist stated that s/he'd been working with Resident #123 on washing and bathing, however denied seeing a rash. Per interview at 11:00 AM, the staff nurse said s/he was not aware of the reddened chin area nor use of a product by the family. After being brought to the attention of the facility by the nurse surveyor, medicated cream will now be applied to the red chin area. Per interview at 11:35 AM on 04/06/11 the DNS confirmed that care and services was not provided to this resident for the reddened area. | 2014-03-01 | ||
| 2440 | 2440 | FRANKLIN COUNTY REHAB CENTER LLC | 475047 | 110 FAIRFAX ROAD | ST ALBANS | VT | 5478 | 2011-04-06 | 281 | E | SFEK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to assure that staff met professional standards of quality during medication administration for 2 residents in the total sample. (Residents #11, 71) Findings Include: 1. Per observation on 4/4/11 at 11 AM during a medication administration pass with the staff nurse, for Resident # 71, the nurse administered a dose of an antibiotic that had been cut in half by the pharmacy. The pill had a hard outer coating, no scoring on the tablet for cutting and had jagged, uneven edges after being cut and it was not given with food. (to enhance absorption) In addition, three vitamins were administered to Resident # 71 at 11:00 AM, although the MAR (Medication Administration Record) had the medications scheduled to be given at 8 AM. The MAR indicated although this surveyor observed the resident taking the vitamins with a glass of water. Directly after the staff nurse administered the above medications, s/he confirmed that the medications for Resident # 71 were not administered at 8 AM (per the MAR) and stated that s/he was unable to administer all of the med's at 8 AM because there was a ' large volume of meds that needed to be administered at 8 AM on that wing.' In addition, s/he was unable to assure that Resident # 71 was getting the physician ordered dose of the antibiotic because the unscored pill had been cut in half and had jagged edges. 2. Per observation on 4/4/11 at 11:20 A.M. during the medication administration pass, for Resident # 11, the MAR indicated [REDACTED]. In addition, the staff nurse was unable to administer 2 additional vitamins that were prescribed because the medications were not in the resident's medication drawer. The staff nurse confirmed that the vitamin and Alzheimer medication was not administered per the MAR (scheduled for 8 AM) and that the other 2 vitamins could not be administered because the facility staff had failed to order the medications from the pharmacy w… | 2014-03-01 | ||
| 2439 | 2439 | FRANKLIN COUNTY REHAB CENTER LLC | 475047 | 110 FAIRFAX ROAD | ST ALBANS | VT | 5478 | 2011-04-06 | 279 | D | SFEK11 | Based on record review and interview the facility failed to develop comprehensive care plans for 1 of 9 applicable residents (Resident #123). Findings include: Per observation and interview on 04/05/11 at 11:49 AM, Resident #123 stated to the nurse surveyor that s/he doesn't participate in activities or get out of the room much because of a related eye condition, and stated "hopefully I can get books on tape". Per record review on 04/05/11 there was no comprehensive care plan to address specific interventions related to activities. The care plan for self-care deficit and falls listed basic safety measures related to the eye condition. Per interview on 04/06/11 at 3:30 PM the Unit Manager and the Activities Director confirmed there was no comprehensive care plan to address the needs, likes or interventions for this resident's activities preferences. | 2014-03-01 | ||
| 2438 | 2438 | ROWAN COURT HEALTH & REHAB | 475037 | 378 PROSPECT STREET | BARRE | VT | 5641 | 2010-11-02 | 203 | D | 58FI11 | Based on staff interview and record review, the facility failed to provide the resident, and a family member or legal representative of the resident, with notice of discharge in writing and in a language and manner they understand, which includes the effective date of discharge, the location to which the resident is discharged , a statement that the resident has the right to appeal the action to the State, and contact information for the State long term care ombudsman for 2 residents in the applicable sample. (Resident #1, Resident #2) Findings include: 1. Based on staff interview and record review, the facility did not provide written notification of discharge from the facility to Resident #1 and Resident #2, or their legal representatives, as soon as practicable after they were transferred and discharged to an outside health care facility. Per record review both residents experienced a change in their condition which necessitated evaluation and treatment at an outside health care facility. Per interview with the Assistant Director of Nursing (ADON) and the Admission Director on 11/2/10 at 1:48 PM, the facility did not give written notification of discharge to these two residents, even though the facility's own Admission Agreement document, which is given to all residents prior to their admission, states on page 5, under 11 d. "Transfer or Discharge by the Center: The Patient will receive written notification of the Center's plan to discharge or transfer the Patient and the reasons such a discharge or transfer is necessary, in accordance with the requirements of state and federal law." | 2014-03-01 | ||
| 2437 | 2437 | ROWAN COURT HEALTH & REHAB | 475037 | 378 PROSPECT STREET | BARRE | VT | 5641 | 2010-11-02 | 202 | D | 58FI11 | Based on staff interview and record review, the facility failed to provide written documentation by the resident's physician of the reasons for transfer or discharge for one of three resident's in the applicable sample. (Resident #1) Findings include: 1. Per staff interview and record review, there is no documentation by the physician in the clinical record of Resident #1 stating the reasons for transfer or discharge to another facility. Per interview with the Assistant Director of Nursing (ADON) and record review on 11/2/10 at 1:30 PM, Resident #1 was transferred and then discharged from the facility on 1/31/10 in order to be evaluated and treated at another health care facility. While the Nurse's Notes on 1/31/10 indicate that there was a change in the resident's condition, there is no documentation by the resident's physician of the reasons for the transfer or discharge. This was confirmed with the ADON in interview on 11/2/10 at 1:30 PM. | 2014-03-01 | ||
| 2436 | 2436 | UNION HOUSE NURSING HOME | 475036 | 3086 GLOVER STREET | GLOVER | VT | 5839 | 2010-11-10 | 205 | B | VJ1411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to issue written notice of bed-hold policy upon transfer to a hospital for 2 of 2 residents sampled. (Resident#1, #2) Findings include: 1. Per record review, Resident #1 was transferred to an acute care hospital for an exacerbation of illness. There was no documentation of a written notice issued to inform the resident and the family of the facility's bed-hold policy at the time of transfer. Per record review, Resident #2 was transferred to an acute care hospital on [DATE], also without any evidence to indicate a written notice of bed-hold policy was provided to them at the time of transfer. Per interview on 11/10/10 at 11:45 AM, the Social Services Manager confirmed that they were not aware of the regulatory requirement to issue the written notice, and that it was not done for any residents who were transferred out of the facility. | 2014-03-01 | ||
| 2435 | 2435 | UNION HOUSE NURSING HOME | 475036 | 3086 GLOVER STREET | GLOVER | VT | 5839 | 2010-11-02 | 492 | E | R8OK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services, regarding nursing licensure of employees. Findings include: Per personnel record review and interview, the administration failed to identify and/or act upon a lapse of licensure for a Practical Nurse from [DATE]-[DATE]. In an interview on [DATE] at 9:15 AM, the Director of Nurses (DON) confirmed that the previous license for one LPN had expired on [DATE] and that the renewed license had an effective date of [DATE]. In this same interview, the DON confirmed that the unlicensed Practical Nurse had been assigned to 65 individual shifts on one of two resident care units from [DATE]-[DATE]. Duties included charge nurse, medication administration and treatments as ordered by a physician. | 2014-03-01 | ||
| 2434 | 2434 | UNION HOUSE NURSING HOME | 475036 | 3086 GLOVER STREET | GLOVER | VT | 5839 | 2010-11-02 | 281 | E | R8OK11 | Based on record review and interviews, the facility failed to provide services in accordance with professional standards of practice by employing a Licensed Practical Nurse (LPN) with an invalid Vermont nursing license. Findings include: Per personnel review and interview, the facility had on staff an LPN without a valid Vermont nursing license from 2/1/10 to 5/21/10. Upon examination, the effective date on the LPN license of one employee is 5/21/10. As confirmed by the Vermont Board of Nurses during a telephone consultation on 11/2/10 at 2:00 PM, the previous biannual licensing period for Licensed Practical Nurses ended on 1/31/10. In an interview on 11/2/10 at 9:15 AM, the Director of Nurses (DON) confirmed that a gap in valid licensure for one LPN on staff went unnoticed from 2/1/10-5/21/10. The DON further confirmed in the interview that the unlicensed Practical Nurse had been assigned to charge nurse duties on one of two resident care units for 65 separate shifts during the 2/1/10-5/21/10 period. Reference: VSA Title 26, Chapter 28, Section 1584 (a)(3) | 2014-03-01 | ||
| 2433 | 2433 | STARR FARM NURSING CENTER | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2010-11-17 | 282 | D | WEOZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to meet the requirement to implement the care plan for 1 resident (Resident #1) in the applicable sample. The findings include: Per medical record review on 11/16/2010 at noon, the care plan for Resident #1 stated that redirection for aberrant behaviors be attempted by the staff prior to the use of an anti-anxiety medication. Per review of staff documentation, on 08/31/2010 at 23:30 hours and on 09/01/2010 at 03:45 hours, Resident #1 received [MEDICATION NAME] without evidence that redirection was attempted prior to the medication being given. On 09/09/2010, the Nurses' Notes reflect that the resident is compliant after redirection and there was no medication needed to be given at that time. This discrepancy in care plan implementation was confirmed by the DNS (Director of Nursing Services) during interview on 11/16/2010 at 2:41 PM. | 2014-03-01 | ||
| 2432 | 2432 | STARR FARM NURSING CENTER | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2010-11-17 | 329 | D | WEOZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that 2 residents (Residents #1 and 2) received the proper doses of medications that were ordered. The findings include: 1. Per record review on 11/16/2010 at noon, Resident #1 had an order for [REDACTED]. 2. Per record review on 11/16/2010 at noon, Resident # 2 had an order for [REDACTED]. Both of these occurrences are confirmed during interview with staff nurses and the DNS (Director of Nursing Services) on 11/16/2010 @ 2:41 PM. Refer also to F281. | 2014-03-01 | ||
| 2431 | 2431 | STARR FARM NURSING CENTER | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2010-11-17 | 281 | D | WEOZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to meet professional standards for quality by not carrying out physician orders [REDACTED]. (Residents #1 and #2). Findings include: 1. Per record review on 11/16/2010 at noon, Resident #1 had an order for [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This was confirmed during interview with the DNS (Director of Nursing Services) on 11/16/2010 at 2:41 PM. 2. Resident #2 had an order for [REDACTED].@ 2:41 PM. 3. Per record review, Resident #1 had a physician's orders [REDACTED]. Per nurses' note of 10/07/2010 at 10:20 AM, Resident #1 had an O2 sat (oxygen saturation) of 83% on 3.5 l/min of O2. The oxygen flow rate was not changed to the ordered 4 l/min until 7 hours after the order was received. This was confirmed by the DNS during interview on 11/16/2010 at 2:41 PM. Refer also to F329. Reference: Nettina, S.M., (2006), Lippincott Manual of Nursing Practice, 8th Edition, p 18, Lippincott, Williams & Wilkins, Philadelphia | 2014-03-01 | ||
| 2430 | 2430 | MT ASCUTNEY NURSING HOME | 475024 | 289 COUNTY ROAD | WINDSOR | VT | 5089 | 2010-11-03 | 323 | D | UNFJ11 | Based on staff interview and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accidents for one resident in the applicable sample. (Resident #2) Findings include: 1. Per staff interview and record review the facility failed to assess the potential safety risks to Resident # 2 related to the use of an electronic lift chair. Per interview on 11/3/10 with the facility Administrator (ADM) and the Director of Nursing (DON), and review of facility documents, Resident #2, who was non-ambulatory due to a medical condition, was provided a facility electronic lift chair equipped with an attached remote hand control. On 10/15/10, while sitting in his/her private room unattended by staff , Resident #2 used the remote hand control to activate the lift feature of the chair and fell to the floor sustaining a head injury which required hospitalization and treatment. Confirmed in interview with the ADM and the DON on 11/3/10 at 1:30 PM, the chair did not have a lock-out feature, the hand control was within the resident's reach when sitting in the chair, and facility staff did not assess the potential safety risk to the resident at the time the chair was provided. | 2014-03-01 | ||
| 2429 | 2429 | MT ASCUTNEY NURSING HOME | 475024 | 289 COUNTY ROAD | WINDSOR | VT | 5089 | 2010-11-03 | 225 | D | UNFJ11 | Based on staff interview and record review , the facility failed to ensure that an alleged violation of abuse involving one resident was reported in accordance with State law. (Resident #1) Findings include: 1. Per staff interview and record review, the facility failed to report an alleged incident of resident abuse to the State within the mandatory reporting timeframe in accordance with State law. Per facility report and interview with the facility Administrator (ADM) on 11/3/10, an alleged incident of inappropriate physical contact occurred on 9/19/10 at approximately 11:30 AM involving Resident #1 and another resident's family member. The incident was reported immediately to facility nursing staff by the family member of Resident #1. While the nursing staff promptly took measures to protect Resident #1 and initiated a facility investigation, the facility ADM was not made aware of the incident until 9/27/10. Confirmed in interview with the ADM on 11/3/10 @ 1:25 PM the alleged incident occurred on 9/19/10 and was not reported to State agencies until 9/28/10, outside of the mandatory reporting timeframe of 24 hours. | 2014-03-01 | ||
| 2428 | 2428 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2010-11-02 | 323 | D | VZZT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 2 Residents in the targeted sample. (Resident #1, #4) Findings include: 1. Based on interview and record review, the facility failed to provide the recommended constant supervision to Resident #1 to prevent accidents. Per record review, Resident #1 was heard calling for help and found on the floor in his/her room at 9:15 PM on 10/12/10. The resident was assessed and a new skin tear was observed on the left elbow, for which treatment was ordered. Per Nurses' Notes (NN) at 7 AM and 8:30 AM that same day, staff documented that the resident was requiring 1:1 monitoring due to anxiety. Per NN dated 10/8/10, the resident is anxious and agitated and required 1:1 monitoring until his/her spouse arrived. The NN states "Advised management...and requested 1:1 for pt through the night for pt safety and floor safety until medication effectiveness assessed." Per staff interview on 11/2/10 at 3:30 PM and 3:35 PM with 2 different nurses, the "management" identified in the note refers to the current administrator and a former supervisor. During the same interview, the staff members stated, respectively, that the fall could have been avoided if staff for 1:1 was provided, that management was informed about the need for 1:1 for this resident, and that there was no additional staff provided to assist with 1:1 supervision for the resident's safety. 2. Per interview and record review on 11/2/10, Resident #4 fell on [DATE], sustaining facial injuries due to lack of staff to provide timely assistance. Per interview with Resident #4 on 11/2/10 at 11:05 AM, the Resident stated that s/he stated that s/he had dropped something on the floor and could not reach the call bell to call for help. S/he also stated that s/he yelled for help but no one came. The Resident stated that h/she doesn't like to bother staff… | 2014-03-01 | ||
| 2427 | 2427 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2010-11-02 | 281 | D | VZZT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, staff failed to meet professional standards of quality regarding implementation of physician's orders and/or specialist recommendations for 2 of 4 residents in the targeted sample (Resident #3, #2). Findings include: 1. Per record review on 11/2/10 at 11:30 AM, staff failed to follow a physician's order by leaving Resident #3 unsupervised in his/her room. The order, dated 9/30/10 read " Do not leave in room in wheelchair unsupervised". Per staff interview on 11/2/10 at 10:50 AM, Resident #3, who requires assistance of 2 staff for transfers, moved him/herself from his/her wheelchair to the bed. Per interview with Resident #3, who is alert and oriented, on 11/2/10 at 12:00 PM, s/he stated that s/he used the call bell but no one came to help and stated that s/he "waits a long time a lot" for assistance from staff. At 12:05 PM on 11/2/10, a Unit Nurse confirmed that the physician's order was not followed and that the Resident was left unsupervised in his/her room. 2. Per interview and record review, staff failed to implement recommendations regarding a exacerbation of a chronic medical condition for Resident #2. On 10/20/10, Resident #2 saw a specialist for the chronic medical condition, at which time specific recommendations were made regarding treatment for [REDACTED].#2 around the chronic condition, the recommendations have not been implemented. Per interview with a Unit Nurse on 11/2/10 at 2:40 PM, staff was still awaiting clarifications of the recommendations from the specialist. Per review of the documentation from the visit on 10/20/10, not all recommendations require clarification, and some could have been implemented immediately. Per interview with Resident #2 on 11/2/10 at 10:50 AM, the recommendations voiced by the specialist during the 10/20/10 visit had not been implemented by the facility staff, and s/he is experiencing difficulty with ambulation and experiencing discomfort as a result of the ex… | 2014-03-01 | ||
| 2426 | 2426 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2010-11-02 | 360 | D | VZZT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide each resident with a diet that meets the special dietary needs of the resident for 1 applicable resident in the targeted sample. (Resident #2) Findings include: Per observation, interview, and record review, Resident #2, who has [DIAGNOSES REDACTED]. Per resident and family interview on 11/2/10 at 10:50 AM, Resident #2 is not receiving a diabetic diet at the facility. During the interview, the resident stated that due to not receiving the correct diet, s/he has had to have injections of insulin, which s/he did not have prior to the recent hospitalization and admission to this facility. The resident reported having blood glucose levels that averaged around 100 mg/dl (milligrams per deciliter) in the home setting with oral medication and strict diet. The resident reported receiving breaded oven-fried chicken for the evening meal the prior night, french toast with maple syrup and bacon for breakfast the morning on 11/2/10, and per observation of the noon meal on 11/2/10, the resident was served a large portion of macaroni and cheese, and also offered a regular (non-diabetic) dessert that was reported by staff to be chocolate mousse with whipped cream. Per review of the current physician's orders [REDACTED]. Per interview with the dietician on 11/2/10 at 2:35 PM, she stated that in a long-term care setting, they prefer to offer a liberal diet and treat high blood glucose levels with medications. When the dietician was informed that Resident #2 is at the facility for short-term rehab, the dietician stated that the resident would be assessed the next day. Per review of the nutrition assessment sheets, the resident did not express that s/he did not want to continue a diabetic diet. Per review of the insulin sliding scale flowsheet for October, 2010, Resident #2 had blood glucose levels above 150 mg/dl, which required insulin injection for 91 of 123 opportuniti… | 2014-03-01 | ||
| 2425 | 2425 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2010-11-02 | 353 | E | VZZT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family, staff and resident interviews and record review, the facility failed to assure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (including Resident #1, #2, #3, #4). Findings include: 1. Per resident interview on 11/2/10 at 10:50 AM, Resident #2, who is alert and oriented, reported that there is not enough staff to meet his/her needs in a timely manner. Resident #2, who is dependent on assistance from staff to transfer to the toilet, reported that in the past week, s/he rang the call bell to request assistance to use the toilet, had to wait for around 15 minutes for staff to arrive, and as a result was incontinent of urine. S/he stated that this same thing has happened "a couple of times" since admission to the facility within the past 2 months. When the resident was asked how this made them feel, s/he responded "embarrassed." Per medical record review, no type of urinary incontinence is listed in the medical diagnoses. 2. Per interview and record review, the facility failed to assure adequate staff to provide necessary and recommended care and services for Resident #1 to prevent accidents. Per record review, Resident #1 was heard calling for help and found on the floor in his/her room at 9:15 PM on 10/12/10. The resident was assessed and a new skin tear was observed on the left elbow, for which treatment was ordered. Per Nurses' Notes (NN) at 7 AM and 8:30 AM that same day, staff documented that the resident was requiring 1:1 monitoring due to anxiety. Per NN dated 10/8/10, resident is anxious and agitated and required 1:1 monitoring until his/her spouse arrived. The NN states "Advised management...and requested 1:1 for pt through the night for pt safety and floor safety until medication effectiveness assessed." Per staff interview on 11/2/10 at 3:30 PM and 3:35 PM with 2 different nurses, the "manageme… | 2014-03-01 | ||
| 2424 | 2424 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2010-11-02 | 280 | D | VZZT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise each plan of care to meet the resident's current needs for 1 resident in the targeted sample. (Resident #2) Findings include: 1. Per interview and record review, staff failed to revise Resident #2's care plan to assure appropriate monitoring and treatment of [REDACTED]. On 10/20/10, Resident #2 saw a specialist for the chronic medical condition, at which time specific recommendations were made regarding treatment for [REDACTED].#2 around the chronic condition, the plan of care was not revised to include any of the recommendations made by the specialist. Per interview with a Unit Nurse on 11/2/10 at 2:40 PM, staff was still awaiting clarifications of the recommendations from the specialist. Per review of the documentation from the visit on 10/20/10, not all recommendations require clarification, and some could have been implemented immediately. Per interview with Resident #2 on 11/2/10 at 10:50 AM, the recommendations voiced by the specialist during the 10/20/10 visit had not been implemented by the facility staff, and s/he is experiencing difficulty with ambulation and experiencing discomfort as a result of the exacerbated chronic condition. . | 2014-03-01 | ||
| 2423 | 2423 | HELEN PORTER HEALTHCARE & REHAB | 475017 | 30 PORTER DRIVE | MIDDLEBURY | VT | 5753 | 2011-03-16 | 371 | F | MUO811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation and interview, the facility failed to store foods under sanitary conditions, by not monitoring refrigerated foods to ensure that foods were used by their "use-by-date" or discarded if outdated, in 4 refrigerators. Findings include: Per observation of the Dessert Refrigerator in the kitchen on 3/14/11 at 11:28 AM, the following foods were outdated: 7 puree fruits with an outdate of 3/8/11; 5 dishes of prunes with an outdate of 3/6/11; and 2 ham sandwiches with an outdate of 3/10/11. On 3/14/11 at 11:31 AM, the Director of Nutrition Services confirmed the above listed foods were outdated in the Dessert Refrigerator and should have been discarded. Per interview on 3/14/11 at 11:31 AM, the Director of Nutrition Services stated the facility policy is that perishable foods are considered outdated in 3 days, canned fruit & Jello outdate in 5 days. In addition, the Director of Nutrition Services stated there are no refrigerator monitoring logs to check for outdated foods. On 3/14/11, per review of the facility guidelines for food storage, perishable foods are outdated in 3 days and canned fruit & Jello are outdated in 5 days. Per observation of the Drink Refrigerator in the kitchen on 3/14/11 at 11:45 AM, the following food items were not dated: 2 small salads, a covered dish containing 2 sausage patties and 4 strips of bacon, 2 8 oz.(ounce) glasses of 1/2 & 1/2 not in the original containers, 1 half filled 8 oz glass with a liquid that appeared to be chocolate milk and labeled as tea, 2 4 oz. glasses of 1/2 & 1/2 cream not in the original containers, 49 4 oz. glasses of orange juice; 6 4 oz. glasses of cranberry juice, 5 4 oz. glasses of apple juice, 1 4 oz. glass of grape juice, 1 4 oz. glass of regular chocolate milk, 1 8 oz. chocolate milk, 1 8 oz. ice tea, 3 8 oz. glasses of [MEDICATION NAME] milk; 4 8 oz glasses of regular milk, 1 4 oz. glass of skim milk, 2 4 oz. glass of cranberry juice; 1 4 oz. glass of grape juice, an… | 2014-03-01 | ||
| 2422 | 2422 | HELEN PORTER HEALTHCARE & REHAB | 475017 | 30 PORTER DRIVE | MIDDLEBURY | VT | 5753 | 2011-03-16 | 272 | D | MUO811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to initially conduct a comprehensive assessment of functional capacity for 1 resident in the stage 2 sample (Resident #78). Findings include: Per record review and interview, the facility failed to conduct an initial physical therapy and occupational therapy assessment for Resident #78, as ordered by the physician on the admission orders [REDACTED]. On 3/16/11 at 10:30 AM, the Rehabilitation Director confirmed that PT/OT initial assessments were not available in the written or electronic medical records of Resident #78. | 2014-03-01 | ||
| 2421 | 2421 | KINDRED TRANSITIONAL CARE & REHAB BIRCHWOOD TER | 475003 | 43 STARR FARM RD | BURLINGTON | VT | 5408 | 2010-11-08 | 309 | D | VCCB11 | Based on record review the facility failed to assure that appropriate care and services were provided for 1 of 6 applicable residents regarding care after a fall (Resident #1). Findings include: Per record review conducted on 10/26/10, on 6/3/10 Resident #1 was found on the bathroom floor after falling. The Resident was assessed by the RN (Registered Nurse), who identified that the Resident complained of back, left hip and left leg pain. The Resident's left leg was also rotated outward and shorter than the right leg. This was documented by the nurse in the facility Event Assessment, which was identified as the facility documentation practice by the DNS during the entrance conference. In the facility policy "Care of a Resident with Possible Injury" it is stated "Warning: If there is a question of hip, or spinal fracture do not move the resident. Stabilize only." According to the Event Form the Resident was moved back to bed via Hoyer Lift prior to the arrival of Rescue Services. This was confirmed in an interview with the DNS at 3:15 PM on 10/26/10. Refer also to F281. | 2014-03-01 | ||
| 2420 | 2420 | KINDRED TRANSITIONAL CARE & REHAB BIRCHWOOD TER | 475003 | 43 STARR FARM RD | BURLINGTON | VT | 5408 | 2010-11-08 | 281 | D | VCCB11 | Based on record review and staff interview, the facility failed to assure that services provided met professional standards of quality regarding following facility policy for 1 of 6 applicable residents (Resident #1). Findings include: Per record review conducted on 10/26/10, on 6/3/10 Resident #1 was found on the bathroom floor after falling. The Resident was assessed by the RN (Registered Nurse), who identified that the Resident complained of back, left hip and left leg pain. The Resident's left leg was also rotated outward and shorter than the right leg. This was documented by the nurse in the facility Event Assessment, which was identified as the facility documentation practice by the DNS (Director of Nursing Services) during the entrance conference. In the facility policy "Care of a Resident with Possible Injury" it is stated "Warning: If there is a question of hip, or spinal fracture do not move the resident. Stabilize only." According to the Event Form the Resident was moved back to bed via Hoyer Lift prior to the arrival of Rescue Services. This was confirmed in an interview with the DNS at 3:15 PM on 10/26/10. Refer also to F309. | 2014-03-01 | ||
| 2419 | 2419 | KINDRED TRANSITIONAL CARE & REHAB BIRCHWOOD TER | 475003 | 43 STARR FARM RD | BURLINGTON | VT | 5408 | 2010-11-23 | 312 | D | MRFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide necessary services to maintain good grooming and personal hygiene for 1 of 7 residents in the sample (Resident #1). Findings include: Per observation on 11/23/10 at 12:30 PM, Resident #1's fingernails were long and had a buildup of a brownish substance under the nails. The Resident has a history of scratching his/herself and is being treated for [REDACTED]. On 11/23/10 at 12:50 PM, the Unit Manager confirmed that Resident #1's fingernails were long and dirty and that the Resident was dependent on staff for grooming and personal hygiene. | 2014-03-01 | ||
| 2418 | 2418 | THE MANOR, INC | 475057 | 577 WASHINGTON HIGHWAY | MORRISVILLE | VT | 5661 | 2011-02-09 | 431 | E | YU9Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to assure that expired and/or undated medications were not available for resident use. Findings include: 1. Per observation on [DATE], the Spruce Unit medication refrigerator contained a vial of opened and undated PPD tuberculin innoculant. This medication should be discarded 30 days after opening according to manufacturer's recommendation. The refrigerator also contained a vial of tetanus toxoid, labeled with an expiration date of [DATE], and a vial of Pneumovax vaccine labeled with an expiration date of [DATE]. The above findings were confirmed by the Medication RN (Registered Nurse) at 1:15 PM on [DATE]. 2. Per observation on [DATE], the Elmore Unit medication refrigerator contained 1 vial of PPD tuberculin innoculant which was opened and undated. This refrigerator also contained three vials of Pneumovax vaccine, all of which expired on [DATE]. Additionally, several culturettes expired in 2009 and 2010 were found on the medication storage room shelf with laboratory supplies. The above findings were confirmed with the Unit Manager on [DATE] at 1:30 PM. | 2014-04-01 |
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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 );