Citations in Vermont
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Vermont.
Statistics for Vermont (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Vermont
An LPN was found to have misappropriated multiple controlled pain medications for ten residents by falsifying controlled drug logbooks and related documentation. A nurse first noticed a drastic change in a resident’s PRN medication count and altered documentation during a shift-to-shift controlled count, prompting review of logbooks and MARs. The review revealed overwritten and out-of-sequence entries, falsified sign-outs, forged staff signatures, altered dates, and removals of medications without corresponding MAR entries for several controlled drugs, including Oxycodone, Tramadol, Morphine, Percocet, and Butalbital/Acetaminophen/Caffeine. Handwriting comparisons linked the irregular entries to the LPN, who did not hold an active nursing license, and facility leadership confirmed that medications were removed but believed not to have been administered to the intended residents.
An LPN’s multistate compact license, which had allowed practice in the survey state, expired and was not renewed for that state, leaving the nurse with only a single-state North Carolina license that was not valid where care was being provided. Despite this, the LPN continued to work 11 shifts, including 6 shifts administering medications as an LPN Team Leader, a role requiring a current state LPN license. The Administrator acknowledged awareness of the licensing issue, cited a vacant HR position and an outdated license-tracking spreadsheet, and the former DON reported that review of the personnel file had revealed the expired state license.
An LPN with an expired state nursing license was assigned to pass medications and was later found, through audits of controlled medication logbooks and MARs, to have falsified sign-outs, forged staff signatures, altered dates, and removed controlled pain medications (including oxycodone, tramadol, morphine, Percocet, and butalbital/acetaminophen/caffeine) without corresponding MAR documentation for ten residents on two units. The issue came to light after a nurse reported that a resident had not received a PRN medication for several months, and subsequent review and staff interviews confirmed that the LPN failed to follow facility policies for controlled substance counts, medication administration, and documentation.
A cognitively impaired resident with dementia and Alzheimer's, dependent on staff for ADLs and hygiene, required two showers after bowel incontinence. During the second shower, the resident became agitated and pulled at the shower hose and pipes. In response, an LNA, feeling frustrated, sprayed the resident in the face with freezing cold water while another LNA assisted as the resident tried to pull the hose away. Both LNAs later laughed about the incident while giving report to another staff member. The resident was later found to have multiple bruises on one forearm, believed to be from staff holding the arm to prevent the resident from grabbing the hose, and the DON confirmed the abuse was substantiated.
A resident reported that during a transfer to bed, an LNA told them to be quiet as their feet began to slide, rather than immediately calling for assistance. The resident had to direct the LNA to get help and then called out for staff personally, and described feeling rushed during the transfer. After the resident was in bed, the staff member asked if they had anything to worry about, which the resident perceived as disrespectful. These actions and statements did not uphold the resident’s right to be treated with dignity and respect.
Surveyors found that food items, including condiments, baking mixes, bread, hot dog rolls, and fish sticks, were stored without expiration dates, and original packaging had been discarded. Kitchen equipment such as a can opener and meat slicer were observed to be unclean with visible residues. Additional issues included unlabeled food containers and snacks in unit kitchenettes, with staff confirming the lack of proper labeling and storage practices.
The facility did not have a clear process or policy in place to allow residents to file grievances anonymously. Two residents and the Social Worker confirmed that the grievance forms required a signature and that there was no documented or communicated option for submitting grievances without revealing the resident's identity.
Surveyors found expired and undated medications and medical supplies in all medication and treatment rooms inspected. Expired IV tubing kits, sterile water, injectable medications, auto injectors, blood collection sets, needleless connectors, foley care wipes, skin protectant ointments, and a catheter kit were confirmed by the Unit Manager, Nursing Manager, and an LPN. Items without expiration dates, such as glucose tablets and Vitamin B-Complex, were also present and acknowledged as needing removal.
Staff did not consistently or correctly wear required face masks during a COVID-19 outbreak, with multiple instances of masks being worn incorrectly or not at all on two units. Interviews confirmed that universal masking was required, but staff failed to adhere to this protocol, resulting in a repeat deficiency.
Surveyors found that multiple residents did not have accessible call lights while in bed, with call bells often out of reach, hidden, or removed entirely. Some residents were unable to locate or use their call bells, despite care plans requiring accessibility. In one case, a resident with dementia had their call light removed due to behavioral issues, but no alternate communication method was provided. Staff interviews confirmed awareness of the requirement for call lights to be within reach, yet deficiencies persisted.
Misappropriation and Falsified Documentation of Controlled Medications by an LPN
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of controlled medications and to ensure accurate, non-fraudulent documentation of controlled drug administration. A concern was first raised when a nurse, during a change-of-shift controlled drug count, noticed that the count for a resident’s PRN medication had drastically changed since her prior shift, and that her own documentation had been altered. Subsequent review of controlled medication logbooks and MARs for multiple residents revealed overwritten entries, out-of-sequence entries, falsified sign-outs, forged staff signatures, altered dates, and removals of controlled medications without corresponding MAR documentation. These irregularities involved six different controlled pain medications, including Oxycodone, Tramadol, Morphine, Percocet, and Butalbital/Acetaminophen/Caffeine, and affected ten residents across two units. Interviews and handwriting comparisons identified an LPN as the individual responsible for the irregular logbook entries. The Administrator confirmed that the LPN’s handwriting matched the questionable entries and that the LPN was involved in ten incidents of removing medications believed not to have been administered to the prescribed residents. The DON and other nursing staff reported that the controlled medication counts themselves were correct, but the signatures and dates in the logbooks did not match staff who had actually worked the shifts, and the sequence of dates was inconsistent with proper administration. The LPN was described as visibly shaky when asked to provide a handwriting sample and did not clearly deny involvement when questioned. It was also confirmed that this LPN did not hold an active state nursing license, and the facility acknowledged a failure to protect residents from this LPN’s misappropriation of medications.
Unlicensed LPN Worked Multiple Shifts and Administered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing care was provided by a nurse holding an active state license as required for the position. Review of credentials for an LPN under investigation for misappropriation of medications showed that the nurse’s multistate compact license, which had permitted practice in the survey state, had expired on a specified date. A nursys.com search confirmed that the LPN then only held an active single-state license in North Carolina, which was not valid for practice in the survey state. Despite this, the LPN continued to be scheduled and worked 11 shifts after the compact license expiration, including 6 shifts in which medications were administered in the role of an LPN Team Leader, a position whose job description requires a current state LPN license in good standing for the state of employment and includes administering medications and treatments as an essential function. Interviews and record review further showed that the Administrator was aware that the LPN’s license status had changed and stated that the LPN had selected the wrong option during renewal, resulting in a single-state license rather than a multistate compact license that included the survey state. The Administrator also reported that the Human Resources position was vacant and that the spreadsheet used to track staff license expiration dates had not been updated. The former DON stated that during a review of the LPN’s personnel file, it was identified that the LPN’s state nursing license needed for the position had expired, and that the Administrator had taken on the task of researching the expired license. Despite the facility’s stated expectation that staff must have an active license in the state to work, the LPN continued to work multiple shifts without a valid license for that state.
Unlicensed LPN and Falsified Controlled Medication Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff administering medications maintained current licensure and followed required procedures for controlled substances. A concern was raised when an oncoming medication nurse reported that a resident had not received a PRN medication for three months, which the nurse confirmed with the resident. In response, the facility reviewed all controlled medication logbooks and medication administration records and identified irregularities involving one LPN on two units and affecting ten residents. The irregularities included falsified sign-outs, forged staff signatures, altered dates, and removals of controlled medications without corresponding documentation on the medication administration records. During the facility’s investigation, it was discovered that the LPN suspected of these irregularities had been working with an expired state nursing license, despite being assigned to medication administration duties. Interviews with the Administrator and the former DON confirmed that the LPN did not hold a current state license required for the position and that the LPN had fraudulently removed controlled medications, including oxycodone, tramadol, morphine, Percocet, and butalbital/acetaminophen/caffeine, without following facility policies for administration and documentation. Facility policies required that a licensed nurse administer medications in compliance with state and federal laws, that controlled substances be counted and verified at shift change, and that documentation corrections be made properly by the original author, but these procedures were not followed by the LPN.
Abusive Shower Incident Involving Cognitively Impaired Resident
Penalty
Summary
The facility failed to protect a cognitively impaired resident from abuse during personal care. The resident had a BIMS score of 1 and diagnoses including dementia, Alzheimer's disease, and depression, and was dependent on staff for ADLs and hygiene. According to the facility’s internal investigation and witness statements, during an evening shift the resident required two showers due to bowel incontinence. During the second shower, the resident became agitated and attempted to pull on the shower hose and pipes. In response, one LNA, who reported feeling frustrated, sprayed the resident in the face with freezing cold water while another LNA assisted as the resident tried to rip the hose from the first LNA’s hands and continued pulling on the pipes. Per the witness statement, both LNAs involved in the shower incident later laughed about what had occurred while giving report to another staff member, and the resident expressed a desire to apologize to someone without knowing to whom. A subsequent addendum to the investigation documented that the resident was later noted to have five bruises on the left forearm in healing stages, which were assessed as likely related to staff holding the resident’s arm to prevent them from grabbing the water hose during the same shower incident. The resident was reported as having no recollection of the incident and no pain at the time of assessment. The DON confirmed during interview that the abuse occurred and stated that the allegation was substantiated.
Failure to Maintain Resident Dignity During Transfer
Penalty
Summary
The facility failed to maintain dignity and respect for one resident during a transfer to bed. During the transfer, as the resident’s feet began to slide on the floor, the LNA assisting them told the resident to be quiet (“shh”) instead of immediately calling for additional help. The resident instructed the LNA to call for assistance and then yelled out for staff themselves before the LNA sought help. The resident reported feeling rushed during the transfer. Once the resident was in bed, the staff member asked, “Do I have anything to worry about?”, which the resident perceived as disrespectful. The Administrator later confirmed the resident’s perspective of this interaction, and the facility’s own Resident Rights policy in effect at the time stated that residents have the right to be treated with dignity and respect. This sequence of events, including the LNA’s initial response to the resident’s distress, the delay in calling for help, the resident’s perception of being rushed, and the staff member’s subsequent question implying concern for themselves rather than the resident, led to the determination that the resident’s right to dignity and respect was not upheld.
Deficient Food Storage, Labeling, and Equipment Cleanliness
Penalty
Summary
Surveyors identified multiple failures in food storage, labeling, and equipment cleanliness within the facility's food service operations. During a tour of the kitchen's dry storage area, boxes of condiments and various baking mixes were found without expiration dates, as the original packaging had been discarded. Bread racks in the storage area also lacked expiration dates. The Food Service Manager (FSM) confirmed the absence of expiration dates and was unable to provide this information. In the kitchen, a commercial can opener and meat slicer were observed to be unclean, with visible residues and substances present. The FSM acknowledged that these items had not been properly cleaned after use. Further observations revealed additional deficiencies in food labeling and storage. In the freezer, packages of hot dog rolls and a box of fish sticks were found without expiration dates, which was confirmed by both the FSM and the dietician. In a unit kitchenette refrigerator freezer, a cup containing a pink substance was found unlabeled and covered with a paper towel, with the Activities Director confirming it did not belong to any resident and should be discarded. Another unit kitchenette contained containers of food and a loaf of bread without preparation or expiration dates, as well as bins of individual-sized condiments and snacks lacking expiration dates. An LPN confirmed these findings during the inspection.
Failure to Provide Anonymous Grievance Process
Penalty
Summary
The facility failed to support residents' rights to file grievances anonymously, as required by regulation. Observations revealed that the grievance policy and procedure posted in the lobby only displayed the first page, which included the grievance officer's contact information but did not provide instructions for filing grievances anonymously. The grievance forms and the facility's written policy required a resident's signature, and there was no indication on the forms or policy that anonymous grievances were permitted. Interviews with three residents confirmed that they were unaware of any process to file grievances without revealing their identity, and they reported using the facility-provided form and submitting it to the Social Worker. The Social Worker, identified as the Grievance Official, stated that while envelopes were available for anonymous grievances, the posted policy and procedure did not include this option, and she was unable to locate any documentation of an anonymous grievance process in the facility's policies. She acknowledged the difficulty in handling anonymous grievances and confirmed that providing an option for anonymous grievance submission is a requirement.
Expired and Undated Medications Found in Medication Storage Areas
Penalty
Summary
The facility failed to ensure that medications and biologicals were removed from storage areas once their expiration dates had passed, as required by facility policy and professional standards. During observations and interviews, expired items were found in all three medication and treatment rooms inspected. In the west wing medication room, the Unit Manager confirmed the presence of expired IV tubing kits, sterile water for injection, Piperacillin and Tazobactam for injection, Epinephrine auto injectors, a blood collection set, and needleless connectors. Additionally, a bottle of glucose tablets was found without an expiration date, and the Unit Manager acknowledged that undated items should be discarded. In the north wing medication room, an LPN confirmed that a bottle of Vitamin B-Complex lacked an expiration date and should be thrown out. In the medication treatment room near the south/west nursing station, the Nursing Manager identified expired foley care wipes, skin protectant ointments, and a catheter kit. These findings demonstrate that the facility did not consistently remove expired or undated medications and supplies from storage, contrary to its own policy and accepted professional principles.
Repeat Failure to Ensure Proper PPE Use During COVID-19 Outbreak
Penalty
Summary
Staff failed to consistently and correctly wear required personal protective equipment (PPE), specifically face masks, during an active COVID-19 outbreak in the facility. Observations on two separate units revealed multiple instances where staff, including licensed nursing assistants and registered nurses, were either not wearing masks at all, wearing masks under their chins, or wearing masks below their noses. These observations occurred both at the nurse's station and in the memory care unit. Interviews with staff and the Infection Preventionist confirmed that universal masking was required at the time due to the outbreak, but staff were not adhering to this protocol. The deficiency was further substantiated by staff interviews, where it was acknowledged that masks were required and that staff were not following the correct procedures. The Infection Preventionist confirmed multiple observations of improper mask use, which did not provide adequate protection against infection for residents or staff. This issue was noted as a repeat deficiency, having been cited in previous recertification surveys.
Failure to Ensure Accessible Call Light System for Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure that a working call system was accessible to residents in their beds or other sleeping accommodations in five out of six rooms where residents were care planned for call bell use. Observations revealed that call bells were often out of reach, such as being hung on walls, hidden behind curtains, or placed on the floor under beds. Interviews with residents confirmed that some were unable to locate or access their call bells when needed, despite care plans specifying that call lights should be within reach and residents encouraged to use them. Staff interviews corroborated that call bells were not always accessible, and that staff were aware of the expectation to keep call lights within reach. In one case, a resident with dementia and behavioral issues had their call light removed due to repeated disconnection and aggressive behavior when staff attempted to restore it. The care plan and Kardex for this resident indicated that staff should anticipate needs because the resident could not use the call bell appropriately, but no alternate means of communication was provided after the call light was removed. The resident's medical history included dementia, wandering, delusional and adjustment disorders, depression, and anxiety, and the care plan noted risks related to communication and self-care deficits. Additional observations included a resident whose call light was found on the floor and another whose bed placement made the call light inaccessible. Staff confirmed these situations during interviews. The Staff Development Coordinator stated that staff are educated to ensure call lights are within reach and to respond promptly, and confirmed that call light cords should not be pinned up or removed. Despite these policies, the deficiency persisted across multiple rooms and residents.
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