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
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.
Surveyors found that a sharps container in the memory care unit's shower room was overfilled and could not close, with uncovered disposable razors left unsecured on top. Additionally, the dining/activity room had a baseboard radiator with missing covers, exposing sharp fins. An LPN and the Unit Manager confirmed these issues during interviews.
A resident with a critical sodium level was not promptly reported to the provider as required by facility policy. Nursing staff became aware of the abnormal lab value but did not immediately notify the provider or DON. The resident was only sent to the emergency department after a Nurse Practitioner was informed of the result, and staff interviews confirmed the delay in notification.
A resident was repeatedly addressed by an LPN using a term of endearment instead of their preferred name during a request for pain medication. The resident indicated discomfort with this form of address, and the LPN acknowledged using such terms as a general habit rather than based on the resident's preference. The administrator confirmed that staff are expected to use residents' preferred names or pronouns.
A resident with chronic pain and osteoarthritis reported severe back pain and requested both repositioning and pain medication. Staff delayed transferring the resident to bed and did not provide PRN pain medication or offer non-pharmacological interventions, despite standing orders and documented options. The resident's pain was not adequately addressed until much later, and the DON and Administrator confirmed that the response was insufficient.
A resident with multiple medical conditions, including chronic pain and lymphedema, was observed unable to reach the call bell while in their room. The call bell was pinned to the bed out of reach, and the resident had to use a cell phone to contact a friend for help, who then called the nurse's station. An LPN confirmed the incident and noted the resident's need for two-person assistance with transfers.
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.
Unsafe and Unclean Environment in Memory Care Unit
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment for residents on the licensed memory care unit. During an initial tour, a sharps container in the shower room was found to be full and unable to close properly, with a bundle of disposable razors—three of which had no covers—left unsecured on top of the container. An LPN confirmed that the sharps container should have been removed and that razors should not have been left exposed. Additionally, in the dining/activity room, the baseboard radiator had three areas where the covers were missing, exposing sharp fins. The Unit Manager confirmed the exposed areas, and the Maintenance Director noted that the radiator covers frequently get bumped off.
Failure to Promptly Notify Provider of Critical Lab Result
Penalty
Summary
The facility failed to promptly notify the provider of a critical laboratory result for one resident. According to facility policy, staff are required to immediately inform the ordering practitioner of laboratory results that fall outside the clinical reference range. In this case, a progress note documented that the resident had a critical sodium level of 161, but there was no evidence that the provider was notified immediately after nursing staff became aware of this result. Interviews with both an LPN and the Director of Nursing confirmed that the provider was not made aware of the critical lab value at the appropriate time. The delay in notification was further substantiated by a Nurse Practitioner note, which identified the resident's severe hypernatremia and documented that the resident was sent to the emergency department only after the Nurse Practitioner became aware of the critical lab value. The LPN confirmed during interview that both the provider and DON were not immediately informed, and acknowledged that critical lab values should be reported to the provider right away, as per facility policy.
Failure to Address Resident by Preferred Name
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) addressed a resident by the term 'Boo' multiple times during an interaction in response to the resident's request for pain medication. The resident expressed that their name was not 'Boo' and questioned why the LPN used that term. In an interview, the LPN stated that 'Boo' was not the resident's nickname but rather a general figure of speech used for everyone. The facility administrator confirmed that it is not appropriate for staff to use terms of endearment and that residents should be addressed by their preferred name or pronoun. This incident demonstrates a failure to honor the resident's right to dignity and respect, as the resident was not addressed according to their preference during the interaction.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A resident with chronic pain syndrome and osteoarthritis, who was cognitively intact, experienced inadequate pain management during their stay. The resident repeatedly expressed severe back pain, rating it as 9 out of 10, and requested to be transferred to bed for relief. Staff initially denied the request, instructing the resident to remain in their chair for dinner. When the resident was eventually transferred to bed, they continued to report severe pain and requested pain medication. The resident stated that the scheduled Tylenol was ineffective and that they were not receiving it as needed. Upon assessment, the LPN confirmed that there were no PRN pain medications available and that the next scheduled dose of Tylenol was not due for several hours. Although the resident's pain was assessed and the provider was notified, no immediate pharmacological or non-pharmacological interventions were offered at the time, despite standing orders for topical pain relief and documented non-pharmacological options such as repositioning, back rubs, music, or diversional activities. The DON and Administrator later confirmed that a pain level of 9 should be addressed promptly and that non-pharmacological interventions should have been implemented.
Resident Unable to Access Call Bell in Room
Penalty
Summary
A deficiency occurred when a resident with chronic pain syndrome, morbid obesity, lymphedema, and osteoarthritis did not have access to the call bell while in their room. The resident, who was cognitively intact per their MDS assessment, was observed sitting in a wheelchair and calling out for help with increased volume. The call bell was found pinned to the top sheet of the resident's bed, out of their reach. The resident reported that after being brought to their room following an activity, they requested to go to bed, but staff said they would return and did not provide the call bell within reach. Unable to summon assistance, the resident used their cell phone to contact a friend, who then called the facility's nurse's station to request help. Upon staff intervention, the resident was repositioned and the call bell was placed within their reach. An LPN confirmed that the resident's friend or family member had called the facility, prompting staff to assist the resident. The LPN also stated that the resident requires two-person assistance for transfers and had provided re-education to the resident regarding this requirement. The deficiency was identified through both observation and interviews, demonstrating that the facility failed to ensure the resident had access to the call bell as required.
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