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
A resident who required two-person assistance for transfers and protective skin devices was transferred by a single staff member, resulting in a significant skin tear. Facility records and staff interviews confirmed that the transfer was not performed according to the care plan, leading to the injury.
A resident with cognitive impairment and multiple medical conditions was prescribed PRN Lorazepam for itching and anxiety without a required 14-day stop date. The medication was administered multiple times, and the DON confirmed the omission of the stop date in the order.
A resident with multiple chronic conditions and cognitive impairment was given Lisinopril by a nurse despite a systolic blood pressure below the ordered threshold. The medication was administered when the resident's blood pressure was 89/54 mmHg, contrary to the physician's order to hold the medication if systolic blood pressure was under 100 mmHg. The resident subsequently experienced further hypotension and was transferred to the emergency department. There was no documentation of IV normal saline administration prior to transfer, as ordered.
Multiple residents reported that meals were frequently served cold, unappetizing, and lacking in variety, with some meals not meeting specific dietary needs such as those for diabetes and dialysis. Surveyors observed food that appeared slimy, mushy, and bland, confirming resident complaints about poor food quality and temperature.
A resident with dysphagia was found with a pill and pudding left at the bedside without staff supervision, despite lacking a physician's order for self-administration. An LPN confirmed that medications, including a crushed medication and an uncrushed Protonix tablet, were left at the bedside, contrary to facility policy.
A Physician's Assistant failed to perform hand hygiene after removing gloves during a dressing change for a resident with a pressure ulcer. The PA handled a used scalpel and touched personal items and the door knob with bare hands, in direct violation of the facility's hand hygiene policy.
A resident with cognitive impairment and a history of wandering, identified as an elopement risk and wearing a Wander Guard, was able to exit the facility undetected by removing a window and screen in an unmonitored room. The care plan lacked interventions for wandering or supervision, and the Wander Guard did not alarm since the window was not equipped with an alarm. The resident was later found on an adjacent property with minor injuries after a fall, and staff interviews confirmed lapses in supervision and monitoring.
A nurse left a medication cup containing both crushed and whole medications, including a non-crushable pill, unattended at the bedside of a resident with dysphagia who did not have an order for self-administration. The medications were not under direct staff observation or secured, contrary to facility policy, and this issue has been cited in previous surveys.
A resident with dementia and intact cognition reported being physically assaulted by another resident using a walking stick. The incident was documented by staff, but the social worker and DON did not notify the administrator, state agency, or law enforcement as required. No evidence was found of proper investigation, monitoring, or required notifications following the allegation.
A resident with dementia and depression reported being struck multiple times by another resident with a walking stick. Despite the resident's request for police involvement and assurances of increased monitoring, there was no documentation of a thorough investigation, identification of the alleged perpetrator, or evidence of follow-up actions by staff, including the SW and DON.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who had a care plan requiring two staff members to assist with stand pivot transfers and the use of Dermasaver skin tubes while out of bed, was transferred by a single staff member. The resident was found in bed with a large skin tear on the right lower leg after being out of bed in a wheelchair for dinner. Facility records and staff statements confirmed that the assigned LNA transferred the resident out of bed to a chair alone and did not transfer the resident back to bed. The skin tear was discovered by the primary LNA upon the resident's return to bed, and the facility's internal investigation determined that the injury occurred during the unsupervised transfer, which was not in accordance with the resident's care plan.
Failure to Include Required Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications by prescribing an as-needed Lorazepam order for a resident with vascular dementia, chronic kidney disease, and COPD, who was cognitively impaired with a BIMS score of 9. The physician's order for Lorazepam 0.5 mg every 6 hours as needed for itching and anxiety did not include a required 14-day stop date. The resident received Lorazepam eight times over a period of approximately three weeks. The DON confirmed during interview that the order lacked the appropriate stop date documentation.
Significant Medication Error: Lisinopril Administered Despite Low Blood Pressure
Penalty
Summary
A significant medication error occurred when a resident with a history of Type II Diabetes, Alzheimer's Disease, schizoaffective disorder, and anxiety, who was cognitively impaired with a BIMS score of 4, was administered Lisinopril despite a documented systolic blood pressure of 89/54 mmHg. The physician's order clearly stated that Lisinopril should be held if the systolic blood pressure was under 100 mmHg and the provider should be notified. The medication was administered by a licensed nurse during the morning medication pass, contrary to the order and facility policy. Following the administration, the resident experienced hypotension with blood pressure readings dropping as low as 77/45 mmHg. The resident was found on the floor by a CNA, assessed for injury, and subsequently transferred to the emergency department as ordered by an advanced practice nurse. There was no documentation that normal saline was administered via IV prior to the transfer, as ordered. The Director of Nursing confirmed the medication error and the lack of IV administration before hospital transfer.
Failure to Provide Palatable and Properly Heated Food
Penalty
Summary
The facility failed to provide palatable, appealing, and appropriately heated food to 10 of 19 sampled residents. Multiple residents reported that their meals were frequently served cold, with some stating that food remained cold even after attempts to reheat it. Several residents described the food as unappetizing, lacking in variety, and not meeting their dietary preferences or needs. Specific complaints included the prevalence of fish and chicken, limited beef options, and dissatisfaction with the quality and taste of the food, such as meat described as tasting like rubber and vegetables appearing slimy and mushy. One resident, who is diabetic and on dialysis, reported that meals were high in carbohydrates and snacks were sugary, which did not align with their dietary requirements. Observations by surveyors confirmed that food was served at unappetizing temperatures and appearances, such as green beans that looked slimy and mushy with a thin white sauce, and rice and asparagus that were bland and overcooked. Residents also noted a reduction in menu variety, such as the discontinuation of certain breakfast items and the lack of preferred condiments. These findings were based on direct interviews with residents and observations of meal service, indicating a pattern of inadequate food quality and service.
Failure to Assess and Supervise Medication Self-Administration
Penalty
Summary
The facility failed to determine whether it was clinically appropriate for a resident with dysphagia to self-administer medications. According to the facility's policy, medications are to be administered by licensed nurses or authorized staff as ordered by a physician. Record review showed that the resident did not have a physician's order for self-administration of medications. During observation, a pill in a medicine cup with pudding was found left at the resident's bedside without nursing staff present. Interview with the assigned nurse confirmed that medications, including a crushed medication and an uncrushed Protonix tablet, were left at the bedside, and the nurse acknowledged this should not have occurred.
Failure to Perform Hand Hygiene After Dressing Change
Penalty
Summary
A deficiency was identified when a Physician's Assistant (PA) failed to perform proper hand hygiene during a dressing change for a resident with an unstageable pressure ulcer on the coccyx. The PA donned gloves and conducted a wound assessment and debridement using a disposable scalpel. After completing the procedure, the PA removed the soiled gloves but did not sanitize or wash their hands before handling the used scalpel with bare hands, placing it inside a removed glove, and then touching personal items and the room's door knob. The PA confirmed in an interview that hand hygiene was not performed after glove removal. The facility's hand hygiene policy specifically requires hand hygiene immediately after removing gloves, and this incident represents a repeat deficiency from a previous survey.
Failure to Prevent Elopement and Provide Adequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and accident hazard prevention for a resident assessed as an elopement risk. The resident, who had impaired cognitive function, restlessness, agitation, and a traumatic brain injury, was identified as an elopement risk upon admission and was fitted with a Wander Guard device. However, the resident's care plan did not include interventions related to wandering or supervision. The resident was able to remove a window and screen in an empty room under maintenance, exit the building undetected, and was later found on an adjacent property after having fallen and sustaining scrapes to both knees and complaining of head and knee pain. The Wander Guard did not alarm because the window was not equipped with an alarm system. Interviews with staff confirmed that the resident was last seen over an hour before being found and that the Wander Guard was still in place when the resident was located. The Director of Nursing acknowledged that the window used for the exit was not alarmed, and the resident was able to leave without staff noticing. Additionally, during an observation, the same resident was seen exiting through an alarmed door while staff were preoccupied assisting another resident, and no intervention or redirection was provided by the employee present.
Medications Left Unattended at Bedside for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a nurse left a medication cup containing both crushed and whole medications, including Protonix (Pantoprazole), on a resident's bedside table without supervision. The resident, who has dysphagia and no physician order for self-administration of medications, was left alone with the medications, and there was no nursing staff present in the room at the time of observation. Facility policy requires that medications be administered by licensed staff and remain under their direct observation or be locked away during medication passes. The incident was confirmed by the nurse assigned to the medication cart, who acknowledged that the medications should not have been left at the bedside. The observation revealed that the medication storage and administration practices did not align with the facility's policies or professional standards, as medications were not kept secure or under direct supervision. This deficiency has been cited in the facility's previous three recertification surveys.
Failure to Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident physical abuse as required by regulation. A resident with a history of dementia, depression, and insomnia, but with intact cognition and judgment, reported being struck multiple times by another resident using a walking stick. The resident expressed distress over not being informed about the incident's consequences and stated a desire for police involvement. Documentation in the progress notes indicated the resident's complaint but did not identify the alleged perpetrator or document any monitoring of the involved residents. The social worker followed up with the resident but did not notify the physician, family, state agency, or law enforcement about the allegation. Interviews with facility staff revealed that the social worker did not report the abuse allegation to the administrator or appropriate authorities. The DON, after interviewing the alleged perpetrator, determined the abuse was unlikely and did not report the incident to the State Survey Agency, despite acknowledging that all abuse allegations are required to be reported. There was no evidence of required notifications or investigations being conducted or documented as per regulatory requirements.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated for a resident with a history of dementia, depression, and insomnia, who was assessed as having intact cognition and judgment. The resident reported being struck multiple times by another resident using a walking stick, expressing distress over not being informed about the incident or its consequences, and requesting police involvement. There was no documentation that the police were contacted or that the resident was communicated with by management regarding the incident. Progress notes indicated that the nurse did not witness any physical aggression and found no injuries, but stated that both residents would be monitored closely. However, there was no documentation of the identity of the alleged perpetrator or evidence of increased monitoring for either resident. The social worker confirmed knowledge of the alleged perpetrator's identity but did not document it or contribute to a formal investigation. The DON acknowledged that an investigation was required but confirmed there was no written record of interviews or evidence that the abuse allegations were thoroughly investigated.
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