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)
Some of the Latest Corrective Actions taken by Facilities in Vermont
Latest Citations in Vermont
Surveyors observed that medications and biologicals were left unattended on medication carts, expired medications and supplies were present in medication storage rooms and carts, and some medications had missing or illegible expiration dates. Staff confirmed these findings, and a pill cutter with medication debris and food items were also found in medication carts.
Staff did not follow infection control protocols for a resident on contact isolation, including failing to wear PPE and perform hand hygiene after resident contact and handling soiled linens. During a medication pass, a nurse handled medications with bare hands and did not perform hand hygiene between administrations to two residents, contrary to infection prevention standards.
Three residents with significant mobility and cognitive impairments experienced falls, but the facility did not complete required fall risk assessments or update care plans with new interventions after each incident, despite repeated falls and a policy mandating these actions. The DON confirmed that these steps were not taken as required.
A resident with cancer and swallowing difficulties, identified as at risk for malnutrition, did not receive physician-ordered nutritional supplements and an appetite stimulant on multiple occasions. Documentation incorrectly stated these items were unavailable, despite confirmation from pharmacy and dietary staff that they were accessible. The resident experienced significant weight loss during this period, and the DON confirmed the failure to administer the ordered interventions.
A resident's medical chart was missing required documentation of monthly medication regimen reviews for several months, despite pharmacist recommendations being made. Facility policy requires these records to be maintained and easily retrievable, but staff confirmed the documents were not available during review.
A resident with advanced dementia had a notarized advance directive requesting comfort care only, but subsequent COLST forms listed the resident as Full Code without signatures from the resident or POA, and there was no documented consultation with the POA regarding this change. The DON confirmed the lack of communication with the family and absence of required signatures.
Two residents with significant fall risks experienced multiple unwitnessed falls, including one resulting in a hip fracture and another causing a skin tear. The facility did not promptly update care plans or implement effective, timely interventions after these incidents, and was unable to provide evidence of adequate supervision or timely care plan revisions as required by policy and leadership expectations.
The facility failed to provide adequate nursing staff, leading to frequent delays in medication administration and assistance with ADLs. Multiple residents reported long wait times for care, especially on weekends and evenings, and an LPN confirmed being consistently late with medications due to having to help with non-nursing tasks. Family members also experienced difficulty reaching staff, highlighting the impact of staffing shortages on resident care and communication.
Surveyors observed unsanitary conditions in the kitchen, including food debris on equipment and surfaces, cobwebs on storage racks, and expired food items in both dry storage and the cooler. The Dietary Manager confirmed the expired items.
The facility did not complete or document a facility-wide assessment to determine necessary resources for competent care, as required. The assessment provided was incomplete, unsigned, undated, and had not been reviewed by leadership. Interviews with the DON, RDCO, and Administrator confirmed the assessment was still in progress and referenced documents that did not exist.
Improper Storage and Expired Medications Found in Medication Carts and Storage Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to accepted professional principles, as evidenced by multiple observations of improper medication storage and the presence of expired medications and supplies. On several occasions, nurses left medications unattended and unsupervised on top of medication carts, including blister packs, over-the-counter medications, and a bottle of Metamucil. Additionally, expired blood culture vials and expired topical creams were found in medication storage rooms, with staff confirming their availability for use. Medication carts were also found to contain expired medications, a pill cutter with visible medication debris, and a container of food items, all of which were confirmed by staff interviews. Further observations revealed that some medications had missing or illegible expiration dates, and expired medications were present in multiple medication carts. Staff interviews consistently confirmed the presence of these expired or improperly stored medications and supplies. The report does not mention any specific residents affected or their medical conditions at the time of the deficiency, but the findings indicate a systemic failure to maintain proper medication storage and labeling practices throughout the facility.
Failure to Implement Infection Control Measures for Isolation Precautions and Medication Pass
Penalty
Summary
Facility staff failed to implement required infection control measures for a resident on contact isolation precautions. Observations revealed that staff entered the resident's room without donning gowns or gloves, handled the resident and their personal items, and removed soiled linens with bare hands. Staff did not perform hand hygiene after leaving the isolation room and were seen carrying used linens down the hall. The Infection Preventionist confirmed that these actions did not comply with the facility's contact isolation protocols, which require the use of personal protective equipment and hand hygiene after resident contact and PPE removal. Additionally, during a medication pass, a nurse was observed pouring tablets from blister packs directly into his ungloved hand and then placing the medications into cups for administration to two residents. The nurse did not perform hand hygiene between medication administrations. In an interview, the nurse acknowledged these actions and stated he believed gloves were not permitted in the hallway. These practices were not consistent with infection control standards for medication administration.
Failure to Update Care Plans and Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure that three residents received adequate supervision and timely, effective interventions to prevent future falls, as required by their own Fall Prevention and Protocol policy. For one resident with Parkinson's Disease, impaired mobility, and visual deficits, a fall occurred while attempting to transfer to bed, and the resident was found with saturated clothing and had reportedly refused care. Despite a high fall risk score and a policy requiring a fall risk evaluation and care plan update after each fall, no such evaluation or care plan revision was completed following the incident. The Director of Nursing confirmed that these steps should have been taken but were not. Similarly, another resident with hemiplegia, aphasia, and a history of multiple falls did not have a fall risk assessment or care plan update after a fall, despite repeated incidents and a policy mandating these actions. A third resident, who required a Hoyer lift and experienced a fall, also did not have any new interventions added to their care plan after the event. In all cases, the Director of Nursing acknowledged that care plans should have been updated after each fall, but this was not done, resulting in a failure to implement effective measures to reduce the likelihood of future accidents.
Failure to Administer Ordered Nutritional Supplements and Appetite Stimulant
Penalty
Summary
A resident with diagnoses including prostate and bone cancer and difficulty swallowing was identified as being at risk for malnutrition due to increased nutritional needs, poor appetite, and altered skin integrity. The resident's care plan included interventions such as providing nutritional supplements and an appetite stimulant as ordered by the physician. Physician orders specified a daily house shake and Megestrol Acetate Oral Suspension for appetite stimulation. However, review of the Medication Administration Record (MAR) revealed that the resident did not receive the Megestrol Acetate Oral Suspension on multiple dates, with nursing notes incorrectly documenting the medication as unavailable, despite pharmacy records confirming its delivery and availability. Additionally, the resident did not receive the ordered house shake supplement on several dates, with nursing notes again indicating it was not available, while the Dietary Manager confirmed that house shakes were always prepared and distributed daily. During this period, the resident experienced a 6.9-pound weight loss, representing a 4.3% decrease in total body weight. The Director of Nursing confirmed that both the medication and supplement were available but were not administered as ordered.
Missing Medication Regimen Review Documentation
Penalty
Summary
The facility failed to maintain complete drug regimen review (MRR) documentation for one out of five sampled residents. For this resident, medication regimen reviews were conducted by the pharmacist in several months, and recommendations were made. However, copies of the MRRs for three specific months were missing from the resident's medical chart. According to the facility's own policy, all drug regimen review recommendations and prescriber's responses should be maintained in an easily retrievable location and filed with the permanent medical record. During interviews, the Director of Nursing, MDS Coordinator, and an RN confirmed that the MRRs for the specified months were not present in the resident's chart and were not available in the facility for review.
Failure to Involve POA in Advance Directive and Code Status Decisions
Penalty
Summary
The facility failed to ensure that a resident's power of attorney (POA) was involved in developing and updating advanced directives in accordance with the resident's previously stated wishes. The resident had a notarized advanced directive specifying a desire for comfort care only and authorizing the agent to decline or terminate life-prolonging treatments in the event of a terminal condition with no reasonable prospect of recovery. Despite this, subsequent Clinicians Orders for Life Sustaining Treatment (COLST) forms indicated the resident was a Full Code, and these forms were not signed by the resident or the POA. There was no documented evidence that the resident or POA was consulted regarding the change to full code status. Physician notes indicated awareness of the need to review the resident's health care proxy and discuss goals of care and code status, especially in light of the resident's decline and inability to make medical decisions due to advanced dementia. The Director of Nursing confirmed that the COLST forms were not signed by the resident or POA and acknowledged that the family had not been contacted about the code status change, citing disagreements and hope that the resident would regain decision-making capacity.
Failure to Provide Adequate Supervision and Timely Interventions After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that residents remained as free from accidents as possible by not providing adequate supervision and not implementing effective, timely interventions to reduce the likelihood of future falls for two residents. One resident, with a history of falls, impaired mobility, Alzheimer's disease, and other conditions, experienced multiple unwitnessed falls over a period of time. After a fall resulting in a hip fracture that required surgery, the resident's care plan was not revised promptly, and interventions added were either delayed or duplicative, with no new measures to increase supervision. The resident's spouse reported concerns about insufficient staff checks and ongoing pain following the fall. Another resident, also at risk for falls due to cognitive loss, impaired mobility, Parkinson's disease, and other factors, experienced several unwitnessed falls, including one that resulted in a skin tear. The care plan for this resident was not updated following several of these incidents, and the facility could not provide evidence of timely or effective interventions after the falls occurred. Facility policy required post-fall interventions to be implemented and documented according to individual risk factors, but did not specify a timeframe for care plan updates. Interviews with facility leadership indicated that care plan interventions should be immediate or within 24 hours, but documentation showed that this expectation was not met for either resident. The facility was unable to produce evidence of timely, effective care plan interventions following multiple falls for both residents.
Insufficient Staffing Resulting in Delayed Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in delays in medication administration and assistance with activities of daily living (ADLs). Multiple residents reported waiting over an hour for as-needed medications or personal care, with some stating that staff sometimes forgot to return at all. Observations confirmed that medications were frequently administered late, with a medication administration audit revealing approximately 3,400 late medications over a 15-day period for 64 residents. An LPN reported being consistently late with medication administration due to having to assist with non-nursing tasks such as passing trays and feeding residents because of short staffing. The issue was noted to be particularly severe on weekends and evenings. Several residents with care plans indicating dependence on staff for ADLs, including transfers requiring a Hoyer lift, reported that staff discouraged them from choosing their preferred bedtimes or getting up in the evening due to time constraints. Family members of a newly admitted resident were unable to reach staff by phone on the night of admission, and reported that no staff were available to take contact information during the admission process. These findings, based on interviews, observations, and record reviews, demonstrate a pattern of insufficient staffing impacting resident care and safety.
Failure to Maintain Sanitary Kitchen and Proper Food Storage
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety and did not maintain a sanitary kitchen environment. During an observation of the kitchen, surveyors noted food debris on the steam table, stainless-steel covers, and under the stove burners, as well as cobwebs on the coffee pot and carafe storage rack. The inside of the microwave door appeared burned, and there was food debris inside and beneath the microwave, as well as water marks and food debris on all stainless-steel counters. Additional findings included food debris on the clean plate holding device and remnants of food on the kitchen floor under all stainless-steel working surfaces and in front of the stove and grill. In the dry storage area, several containers of spices (turmeric, ground ginger, ground allspice, and dried chives) were found to be expired, as well as two plastic pitchers of juice in the cooler. The Dietary Manager confirmed the presence of expired items during an interview.
Failure to Complete and Document Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. After a change in ownership, surveyors requested the facility assessment during the recertification entrance conference, but the document provided was incomplete, undated, unsigned, and had not been reviewed by the leadership team. Interviews with the DON, Regional Director of Clinical Operations, and Facility Administrator confirmed that the assessment was still a work in progress, had not been implemented, and referenced a staff development and training plan that did not exist. The Administrator also acknowledged that he had not reviewed the assessment and planned to do so at a later date.