VERMONT AGENCY OF HUMAN SERVICES

DEPARTMENT or DISABILITIES, AGING AND INDEPENDENT LIVING

 

Division of Licensing and Protection

HC 2 South, 280 State Drive

Waterbury, VT 05671?2060



Survey and Certification VoiceflTY (802) 241?0480
Survey and Certification Fax (802) 241-0343

Survey and Certification Reporting Line: (888) 700?5330
To Report Adult Abuse: (800) 564-1812

 

April 27, 2018

Ms. Paula Pelkey, Administrator
The Residence At Otter Creek
350 Lodge Road

Middlebury, VT 057534498

Dear Ms. Pelkey:

Enclosed is a copy of your acceptable plans of correction for the survey conducted on March
14, 2018. Please post this document in a prominent place in your facility.

We may followup to verify that substantial compliance has been achieved and maintained. If
we find that your facility has failed to achieve or maintain substantial compliance, remedies
may be imposed.

Sincerely,



Pamela M. Cota, RN
Licensing Chief

 

 

Developmental Disabilities Services Blind and Visually Imparied
Licensing and Protection Vocational Rehabilitation

Division of icensina and Pr tection

RINTED: 0313912018
FORM APPR OVED

 

 

 

 

 

 

 

 


$5.10 Medication Management

5.10.3 Each residential care home must have
written policies and procedures describing the
home's medication management practices. The
paid as must cover at least the following:

(1) Level homes must provide medication

i management under the supervision of a licensed

inurse. Level IV homes must determine whether
the home is capable of and willing to provide
assistance with medications andlor administration
of medications as provided under these
regulations. Residents mUst be fully informed of
the home's policy prior to admission.
(2) Who provides the professional nursing
delegation if the home administers medications to
residents unable to self-administer and how the
process of delegation is to be carried out in the
home.
(3) Quali?cations of the staff who will be
managing medications or administering
medications and the home?s process for nursing
supervision of the sla if.
(4) How medications shall be obtained for
residents including choices of pharmacies.
(5) Procedures for documentation of medication
administration.

 

STATEMENT OF DEFICIENCIES 0(1) (X2) MULTIPLE (X3) SURVEY
ANO PLA 0F CORRECT IO NUMBER A. BUILDING: COMPLETED

1008 SMNQ 03r14r2018
NAME OF PROVIDER oR SUPPLIER STREET cooE
350 LODGE ROAD
THE RESIDENCE AT OTTER CREEK MIDDLEBURY. VT 05753
(m to SUMMARY STATEMENT OF Io PLAN OF CORRECTION (xsl
PREHX (EACH DEFICIENCY .vILIsr as PRECEDED BY FULL PREFIX (EACH UGRRECTWE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC TAG CROSS-REFERENC so TO THE APPROPRIATE ENE
DEFICIENCY)
R100 Initial Comments: R100 R100 Initial comments. The submissmn of this
i plan of correction does not Imply agreement With
An unannounced on-site complaint survey was mt? .BXIStence Of .8 de?crency. It '3 Smemec? the
completed on 3/14118 by the Vermont Division of Spirit Of COOPF??ratlon. to demonstrate The
i Licensing and Protection. The purpose of the Brice. at Otter Creek 5 commitment to
survey was to investigate 2 complaints and a continued Improvement In the quality of our
mandated facility self -report. The following resident's care.
regulatory violations are related to these
Ivestigations.
R150V- CARE AND HOME SERVICES R159 R160 1 Actions to Prevent Recurrence

The current community medication policies as well
as requirements listed in 5.10 will be reviewed and
re?education will be provided to all community
nurses and med techs. to include policies and
procedures for narcotic count, documentation, pre-
pouring and labeling medication, and reporting
errors. The RCD will ensure follow through with
these policies through bi?weekly random
community narcotic counts for 3 months and then
for 3 months then quarterly on-going. The
RCD will perform bi-weekly random audits of the
narcotic count log for 3 months. then for 3
months and then quarterly on-going.

Completion date: 511 l2018 RED

(3. WC) POC aim \r?g
m-BOii?Co?u? Chet/21. 91p

 

 

 

ol Licen sin 9 and Protection

LABORATORY DIRECTOREGR RROVIDERTSURPLIER SIGNATURE TITLE (X6) DATE
DMD ., won ILii Wig-Oi?
STATE FORM 9? 2v'9x11

 

ll coniinuall on sh eel 1 c? if:

 

Division of Licensing and Protection

PRINTED 032912018
FORM APPROVED

 

 

 

 

 

 

 

STATEMENT OF DEFICIENCIES (X1) PROVIDERISU A (X2) MULTIPLE CONSTRUCTION DA SURV E?t?
AND PLAN OF connecrtou ION A ea

1003 8 - 0311412018
NAME OF PROVIDER CIR SUPPLIER ADDRESS, CITY. STATE. ZIP CODE
350 LODGE ROAD
ES EE

THE I an ATOTTER MIDDLEBURY, vr 051,53

X4) ID SUMMARY STATEMENT OF DEFICIENCIES PLAN OF CORRECT ION .-. AIXSET

FIREFIX MUST BE PRECEDED BY FULL PR CORREC TNE ACTION SHOULD Br?. ?0 p; 
TAG REGULATORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DA 

DEFICIENCY)

 

R160 IContinued From page 1 I R160

i (6) Procedures for disposing of outdated or
unused medication, including designation of a
person or persons with for disposal.
I (7) Procedures for monitoring side effects of
medications.

This REQUIREMENT is not met as evidenced
i 

Byased on observation, staff interview and record
nursing staff failed to manage controlled

medication accountability in accordance with the
facility's policies and procedures. This failure had
the potential to affect 1 resident in the targeted
sample and other residents receiving narcotic
medications. 1). Findings include;

Based on information reviewed subsequent to a
facility mandated self-report regarding missing
. narcotic medications, it was determined that
Medication Technicians (MTs) and Licensed
iPractical Nurses (LPNs) were not following the
facility's policyiproce dures "1 . 11 Narcotic Count"
I and "1.14 Assisting with Controlled Medication"
tend "1.13 (Vermont) Medication Pro-Pour? poiicy.

1. This investigation reveaied a problem with staff
not doing the narcotic count process per the
policy. The facility did not have the forms I
described in the policy for use in this facility. The
form in Use by the home included insuf?cient
information to include on each line, the amount of
medication on hand, the amount given, and the
amount remaining. Per review of controtted count
sheets. issues identi?ed included the fotiowing
practices: sta? made errors and drew lines
through recorded medication administrations with
no written explanation of why (Resident 
staff skipped tines on count sheets and started
counts on new sheets before the current sheet
was ?tted up; nurses who were pro-drawing up

 

 

 

 

Division oi Licensing and Protection

TATE FORM some 2Y9X11

 

Ii continuation sheet 2 of it}

PRINTED: 031292018

 

 

 

 

 

 

 

 

FORM APPROVED
Division of Licensing and Protection
STATEMENT OF DEFICIENCIES PROVIDERISUPPLIERICUA (X2) CONS TRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER A BWDING COMPLETED

1008 03I14I2013
NAME OF PROVIDER oR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE
350 LODGE ROAD
RESIDENCE A 0 CREE
HE TTER MIDDLEBURY, VT 05?53
Ixai 10 SUMMARY STATEM ERT oF 1o PLAN OF CORRECTION (st
pREle IEACH MUST BE PRECEDEO a? FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR TAG CROSS-REFERENCED To THE APPROPRIATE DATE
DEFICIENCY)
R160Continued From page 2 I R160

liquid morphine used different processes; some
continued the count of morphine left in the bottle
until count sheets were full (correct process);
others started a new sheet each time they drew
up more morphine. For Resident who was
admitted in early January, 201 8, staff completed
2 Controlled Drug Records, one for 7 tabs of
oxycodone. and one sheet for 109 tabs of
oxycodone; there was no explanation of why the
medications were recorded on 2 separate sheets.
The medications were brought into the facility
upon admission to the home. There was no
explanantion on either sheet of what the
numbers represented, the total amount the
resident had upon admission, and the process
failed to clearly show how the controlled
medication was being accounted for on a daily
basis.

During interview on 311 2/niinn ed thatsfhe documented on
2I11HB that they had drawn up liquid morphine
into 5 mg. doses per syringe for oral
administration for Resident According to the

i count sheet. there were 15 doses remaining at

31615 hr. on 2liil18. Sometime on 21'11l18. the
LPN stated that slhe was told by a MT that were
only 5 syringes left and more were needed. Slhe 
veri?ed that they never tooked at the narcotic .
count sheets, Slhe just started drawing up more 5
doses of morphine at the desk at the Meadows
unit. Slhe stated that sihe and the MT couldn't
?nd the count sheet for the bottle of morphine.
which is kept in a locked box in the med cart lock
box. Sihe started a new sheet and didn't write
how much morphine was left in the bottle at that
time. Slhe said slhe drew up 34 syringes and
there was only a little morphine left in the bottle
so sihe wasted it by adding hot water to it and
pouring it down the draine witnessed by the MT on

ivisionof Licensing and Protection

STATE FORM 2Y9x11

 

 

 

 

ll continuation sheet 3 of 10

 

PRINTED: 03299018

 

 

 

 

 

 

 

 

FORM APPROVED
Division Of Licensing and Protection
STATEMENT OF DEFICIENCIES Om PROVIDERISUPPLIERICUA 0:2) MULTIPLE CONSTRUCTION (xa) DATE SURVEY
AND PLAN OF CORRECTION NUMBER A Hummus. COMPLETED

1003 03r14r2018
NAME OF eeovroen oesuppuen smeemooness, STATE. zrecooe
350 LODGE ROAD
TH RESIDENCE ER CREEK
AT 0? MIDDLEBURY, VT 05753
(xii ID SUMMARYSTATEMENT 0F in PeovroER-s PLAN or CORRECTION 0:5}
PR Fix (EACH DEFICIENCY MUST as PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE commem-
EAPP PRIATE DATE
TAG REGULATORY OR LSCIDENT TAG i ejrggea?r?gg? no

 

R160 Continued From page 3 i R160

duty. When she wrote the amount drawn up on
the new controlled sheet, she wrote "211/18,
17 50 hr., dose 5 mgi'mi. 12 under 'remaining'.
There was no documentation Of adding the 34
I syringes to the count anywhere. The number 12
did not match any other syringe co Lint sheet, the
LPN did not know how they came by this numb er.
but believed it was in error.
iThe morphine bottle was missing from the locked box

where it was stored because the nurse stated ?that

after wasting the remaining small amount, 
sihe threw the bottle Into the trash. The missmg

morphine count sheet was later found and the
last date of a count had been Eta/'1 by LPN #2
and stated ?drew up 35 (doses). 14 ML leit' in
the bottle).

I
Additionally, per Observation of plastic bags
antaining the Dre-drawn morphin medication on

3! 12i18. not all bags were labeled in accordance

with the facility procedure "1.13 (Vermont)
Medication Pre-Pour" which stated at the
nurse shell label the unit dose container with the
resident name. name of medication, dose of
medication, medication. and reasonlindication for
the medication. One bag of Dre-drawn morphine

syringes was not labeled as stated in the

procedure per observation duri ng a count with a i
MT on duty on the morning of 3i12i18.

During interview with LPN #2 an afternoon of
311811 8, the LPN con?rmed that on 2l12i18 at 6
PM when sihe wasted 11 syringes with 3 MT 
sihe just asked the MT to get them out of the
locked boxes from the med cart and bring them
to hitter, however. they did not watch or validate
the number of syringes being pulted, sine "trusted
h/hei". LPN #1 stated that alter drawing up the
34 syringes on 2111r18, she handed the syringes,
with the count sheet wrapped around them tothe

 

 

 

 

ivislon OiLlcensing and Protection
STATE FORM 2Y9X?lt

if continuation shes 4 ONO

Division of Licensinq and Protection

03I29i2018
FORM APPROVED

 

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

PROVIDE RISU PPLI ERICUA
IDENTIFICATION NUMBER

1008

 

 

(X21 MULTIPLE CONSTRUCTION
A BUILDING

.. 

DATE SURVEY
COMPLETED

 


03f1412013

 

 

NAME OF 

THE RESIDENCE AT OTTER CREEK

ROVIDER OR SUPPLIER

STREET ADDRESS. STATE, ZIP CODE
350 LODGE ROAD

MIDDLE BURY, VT 05753

 

(X4) ID
PREFIX
IAU

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL

IUHI UH. I I INU 

I
PR FIX

PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE

I I H: I I:
DEFICIENCY)

IXSI
COMPLETE

Lrnih

 

Riso



th

 

RESIDENT CARE AND HOME SERVICES

Continued From page 4 I R160

MT and asked hlher to lock them up and put the 
new sheet into the binder; the LPN did not
personally observe this process. counter to facility
procedure:

"Narcoti count", Daily Narcotic count. Both
med techs will visualize the actual 
the individual narcotic record and against the
index for the narcotic record Both med

te will visualize and con?rm the presence of
an intact lock on the narcotic back up 

The failure of nursing staff to adhere to the
facility's for daily counting of
narcotic medications and ensuring that all
narcotic records show an accurate accounting of
amounts on hand verses the amounts
administered to speci?c residents was con?rmed
during interview with the RN Resident Director on

13113118 at 2 PM.

R162

5.10 Medication Managem ent

5. 0.c. Staff will not assist with or administer any I

medication, prescription or over?the?counler a
medications for which there is not a physician's .
written. signed order and supporting diagnosis or?
probiem statement in the resident?s record.

This REQUIREMENT is not met as evidenced
by:

Based on staff interview and record review,
facility nursing staff administered medication to a
resident after the physician had.discontinued the
medication due to a failure to note orders and
transcribe the orders timely onto the MAR
(Medication Administration Record). The practice

R162 Actions to prevent recurrence

The current community policies and requirements
listed in 5.10c will be reviewed and reeducation
with be provided to all community nurses to
include policies regarding medication order
transcription procedures for discontinuing
medications, and process for reporting errors. The
RCD will ensure follow through with bi?weekly
random audits of the medication administration
records for 3 months.

Completion Date 5/1/2018 RCD
Q- Hell HIMIK .
Beltane?w (5111qu .w

 

 

STATE FORM

wrsron oi Licens and Protection

2Y9X11

It can tlnuatlon sheet 5 0110

 

 

Division of Licensing and Protection

PRINTED: 03.323120 18
FORM APPROVED

 

STATEM ENT OF DEFI CIEN ores
AND PLAN oF coanecrrou 

{Xi} PROVIDERISU PP LIEFU CUA
IDENTIFICATION NUMBER

 

1008

 


A. BUILDING.



X3) DATE SURVE 
COMPLETED

 


s, 43201 8

 

 

NAME OF OR SUPFUER

350 LODGE RDA 

THE RESIDENCE AT OTTER CREEK

STREET AQORESS, STATE. ZIP CODE

MIDDLEB unv, VT 05793

 

SUMMARY STATEMENT OF DEFICIENCIES
DEFICCENCY MUST BE PRECEDEDBY FULL
REGULATORY OR LSC 

(X4) ID
PREFIX
TAG

ID
PREFIX

TAG

PLAN OF CORRECTION
(EACH CORRECTIVEACUONSHOULD BE
TO THE APPROPRIATE




CDMHETE
DATE

 

 

 

R162 Continued From page 5

affected 1 applicable resident in the sample.
(Resident Findings include:

Per record review. Resident who had
pre-existing routine (daily) orders for the
medication Haldoi upon
re-admissionto Hospice Services on 1!26!18, had
a change in medications ordered by the physician
after a care conference on the afternoon of
1.26118- Per staff interviews on the afternoon of
31318, after the care conference had ended on
1(26l18, the physician met with members of the
resident's family and wrote new orders for
medications, The order dated 1/2611 8 stated:
Admit to Hospice See Standing Orders. The
order also discontinued 8 routine (daily) orders.
including Haidol, 0.5 mg. P0 twice daily.
diagnosis. anxiety/agitation-
Per interview with the LPN on duty on the
afternoonievening of 1I26118, sine had started to
note and transcribe the new orders to the MAR-
(medication administration record) and was
interrupted from that process . The nurSe veri?ed
that sihe did not go back to the orders to ?nish up
transcribing them that day and she later
administered a dose of the Haldot at 1826.
The following day. the nurse on duty did not
transcribe the new orders and on 1/28118. when
the Hospice RN arrived, it was discovered that
there had been orders to discontinue the Haidol
I Due to lack of timely transcription of
the new physician order, the resident received a
total of 4 doses of the Haldoi in error over a 3 day
period. The error was con?rmed during interview
with the LPN on 311 41'18 at 

R165 V. RESIDENT CARE AND HOME SERVICES


R162

R165

R185 Actions to prevents recurrence

Current Community policy and requirements listed
in 5.10 will be reviewed with all filled Techs. To
ensure follow through and evaluate med tech
competence the RCD will randomly audit the
medication administration record as well as the
Narcotic log. All Med Techs will receive a
supervised medication pass at minimum one time

 

I .
year red? (Pan/v.3
1 

 

 

 

Completion DateMd: m4?-

 

 

 

 

 

wlslon oi Licensmg and Protection

STATE FORM ll comm um Inn sheet 6 a! 10

Division of Licensing and Protection

PRINTED: 0312912013
FORM APPROVED

 

 

 

 

 

 

 

 

 

I

5.10 Medication Management

5.10.d if a resident requires medication
administration, unlicensed staff may administer
medications under the following conditions:

(3) The registered nurse must accept
reaponsibiilty tor the proper administration of
medications, and is responsible for:

i. Teaching designated staff proper techniques
for medication administration and providing
appropriate information about the resident?s
condition, relevant medications, and potential
side effects;

ii. Establishing a process for routine
communication with designated staff about the
resident's condition and the effect of medications,
as well as changes in medications;

Assessing the resident's condition and the
need for any changes in medications; and
Monitoring and evaluating the designated staff
performance in carrying out the nurse's
instructions,

This REQUIREMENT is not met as evidenced
by?

 

3 Based on staff interview and record review, the

RN (Registered Nurse) failed to develop a

i process to monitor and evaluate staff

1' performance in carrying out the nurse's

instructions related to procedures for accounting

for controiied medication per facility poiicy. This
practice had the potentiai to affect residents
receiving controlled medications, Findings
include:

Based on a mandatory report to the
licensing agency on 2f21f18 at 155?. the facility
was missing controlled narcotic medication,
morphine sulfate. dose ordered as 5 mg.!0.25 ML

 

 

STATEMENT OF DEFICIENCIES PROVIDERISUPPLIERJCLIA MULTIPLE DATE SURVEY
AND PLAN OF NUMBER: A BUILDING: COMPLETED

1005 BI 03l14i2018
NAME OF PROVIDER DR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE
35:3 LODGE ROAD
5 cs .2 
TH on REE MIDDLEBURY, VT 05753
(X4) ID STATEMENT OF in PROVIDERS PLAN OF CORRECTION [x53
PREFIX DEFICIENCY MUST BE PRECEDED BY FULL 9 CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR L56 INFORMATION) TAG TO THE APPROPRIATE i DATE
i 
Continued From page 6 R165 

 

 

Division of Licensing and Protection
STATE FORM

am 2Y9X11

It continuation sheet 7 of 10

PRINTED: 032951018

 

 

FORM APPROVED
Division of Licensinq and Protection
STATEMENT or DEFICIENCIES (x1) Pnovmenrsuppuemcm {x21 MULTIPLE CONSTRUCTION {x3} DATE SURVEY
AND PLAN or connecnou IDENTIFICATION NUMBER: A BUILDING COMPLETED

1008 8- WING D3i14l2018

 

 

 

 

NAME OF PROVIDER 0R SUPPUER

350 LODGE ROAD

THE RESIDENCE AT OTTER CREEK MIDDLEBURY, VT 05753

STREET ADDRESS. CITY. STATE. ZIP CODE

 

 


(milliliters) liquid medication. During an 
i investigation regarding missing controlled
medications on 3i12i1 8. the missing morphine 5
was discovered on 2i14i1B at 1:15 PM when the
LPN asked the Med. Tech. (MT) to 'puii the
narcotic box from the Meadows unit medication
cart' so slhe could draw up additional doses of
the medication for Resident The LPN lound
that the box containing the morphine .had no
numbered red zip tag lock (provided by the
pharmacy per policy) and was unlocked in the
medication cart lock box. The LPN could not
account for a missing bottle of morphine that
should have contained 14 ml. of morphine. per
review of the morphine amounts count sheet. The
count was con?rmed with the RN (registered
nurse) RCD (Resident Care Director).
Per review of the narcotic medication count
sheets used by the iacility for this resident and
interviews with 2 LPNs who had drawn up 5 mg.
dose syringes for MTs to administer to Resident
there had been missing count sheets and the I
count for morphine could not be veri?ed as to the i
exact amount of morphine that was missing. it .
.3 was discovered during the investigation that MTs 
i and LPNs were not foliowing the facility?s 
for "Narcotic Count" and
"Assisting with Controlled Medications" and the
I 'Vermont Medication Pre-Pour 
During intervierv with the RN RCD on 3113/18 at 2 i .
PM, staff failures to follow the facility's narcotic
count PIP was confirmed; the RN also con ?rmed
that they had not performed any random audits of
the narcotic count process with MTs to assure
that staff were properly accounting for all
controlled medications. including narcotic
medications.

 

 

 

 

in} ID i SUMMARY STATEMENT OF DEFICIENCIES Io PROVIDERS PLAN OF CORRECTION :st
pREle (EACH DEFICIENCY MUST as PRECEDED BY FULL PREFIX (EACH CORRECTWE SHOULD BE COMPLETE
mg Rsoumronv on Let: INFORMATION) TAG CROSSREFEHENCED TO THE APPROPRIATE DATE

.
Continued From page 7 . R165

 

Division oiLicensing and Protection

STATE FORM zygx?

ll continuation sheet at to

 

 

Division of Licensing and Protection

PRINTED 03f29l2018
FORM APPROVED

 

 

 

 

 

 

 

 

For residents requiring nursing care, including
nursing overview or medication management. the
record shall also contain: initial assessment;
annual reassessment; signi?cant change

i assessment; physician?s admission statement
and current orders; staff progress notes including
changes in the resident's condition and action
taken; and reports of physician visits, signed
telephone orders and treatment documentation;
and resident plan of care.

This REQUIREMENT is not met as evidenced
by:
Based on staff interview and record review. a
facility nurse failed to document the reason for
administration of a PRN medication
for 1 applicable resident in the sample receiving
Hospice services, in accordance with the facility?s

i policy. (Resident Findings include:

Per review of the MAR (medication administration
record) on 3i14I18. Resident #2 had Hospice
physician orders done on 1128/18 for Hatdoi, 0.5
mg. (milligrams) by mouth every one hour as
needed PRN agitation. Per review of the MAR for
February. 2018, on 211i18 at 1333 HR. the
resident received 0.5 mg of Haidol. The PRN
medication note (for the reason for administration
ofthe Haldol) did not state that the resident was
experiencing any of agitation. The note
stated: "resident slowing 

respirations were 54. .. now down to 43." During
interview on the afternoon of 3/14118. the
licensed nurse who wrote the note stated the the
resident was moaning and moving around as if

STATEMENT or osncreucrss (X1) (x2) MULTIPLE consmucnou (xai DATE sunvev
AND PLAN OF CORRECTION IDENTIFICATION NUMBER A COMPLETED
NG 
1008 - 03:1412018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE
350 LODGE ROAD
THE RESIDENCE AT OTTER CREEK MIDDLEBURY, VT 05753
[x41 ID STATEMENTOF ID PROVIDERS PLAN OF CORRECTION (x5)
anFrx DEFICIENCY MUST as PRECEDED av FULL PREFIX (EACH connecnve acme SHOULD as con PLETE
TAG REGULATORY 0R LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCEDTO THEAPPROPRIATE DATE


R189V. RESIDENT CARE AND HOME SERVICES R189
ss=D . . . .
Community polices as well as requirements listed
I 5 12 (3) in 5.12.b will be reviewed with all community

nurses and med techs. Reeducation on
documenting PRN medication notes will be
provided. The RCD will ensure follow through with
random audits of at Ieast 3 different resident
progress notes and the medication administration
records bi-weekly for 3 months and then 
for 3 months and then quarterly on-going.

Completion date: 511/2018 RCD

\?E?Sci Po CL [cup Rd

EH PAWS ?i?Ia/

 

 

 

 

Divlsron of Lie 9 and Protection
STATE FORM

2Y9X11 i contin nation sheet 9 or to

 

 RINTED: 035192018

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM APPROVED
Division of Licensing and Protection
STATEMENT OF DEFICIENCIES Ixn CONSTRUCTION 943} DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A COMPLETED

1003 3? ??146 03:1412018
NAME OF PROVIDER OR SUPPUER STREETADDRESS, STATE, ZIP COOE
350 LODGE ROAD
HE SIDENCE 
RE AT OTTER MiooLeeU RY. VT 05753
(x4119 SUMMARY STATEMENT OF DEFICIENCIES PLAN OF CORRECTION (x5;
poem (EACH DEFICIENCY MUST BE PRECEDED av FULL Imam (EACH CORRECTNE ACTION SHOULD BE COMPLETE
TAG REGULATORY on LCD me CROSSTREFERENCED To THE APPROPRIATE DATE
DEFICIENCY)
R139. Continued From page 9 R189
agitated at that time and that is why slhe
administered the Hatdot. Sihe veri?ed that they
failed to include the reason! indication for use
(per physician orders) of the medication in the 
PRN medication note. i
i
Division olr Licensing and Protection
STATE FORM It continuation sheet 10 of To



VERMONT A GENCY OF UMAN ERVICES

01': ISABILITIES, AGING AND DI NT 

?ivis i9 ofLice nsiu and Emigction
MC 2 South, 280 State Drive
Water bury VT 0567 I ?2060 h;
i .ve on . ov
Survey and Certi?cation Voice ITT (802) 24l~0480
urvey and Certi?cation Fax (802) 241-0 343
Survey and Certi?catio Reporti ng L. ine: (888) 700-5330
To Report Adu It Abuse (800) 564-1612

March 29, 2018

Paula Pelkey, Manager

he Residence At Otter Creek
350 Lodge Road

Middl ebury, VT 05753-4498

Dear Ms. Pelkey:

The Divisio ofLicensing and Protection completed a complain I investigation at your facility on
March 14, 2018. The purpo se ofthe surve was to determine ifyour Facility was in cman iance
with Vermont Assisted Living Residence Regulations. The aurvey sta temth is nclose d. This

urvey found the most serious de?ciency in your facility to be iso lated delicie ncies that coust itut 
no actual harm with pot ntial For more than minimal harm that is not iln med iatejeopardy. You
must 5 ohm it a plan ofeorrection. Please writer?type the Plan of CoLTeetion in the space provided

to the right. A comp letion date for each plan ofco rrec tio must be indica ted in the far righ I hand
column. Attach additional ages ifnecessa ry.

Please 5 ign, date, and indicate your title on the bottom ofthe ?rst page of the repo rt and retu rn
this report to this of?ce no later than April 11, 2018.

Plan of Correction (POC)
Your POC must contain the to Ho wing:
What action yo will take to correct the de?cie ncy;

What measures will be put into place orwhat systemic changes you will make to ensure
that the dc ficie at practice does not recur; and,

 

 

How the corrective aclio ns will be me nitored so the de?ci ent prac tic does not recur.
0 he dates correctiv action will be comp leted. 
Developmental Disabilities Services Blind and Vis ualiy lmparied

Licensing and Protection Vocational Rehabilitation

You may also request an informal review of all or part ofthe co ntents of the notice at any tim (3
prior to April It, 2018 by calling Suzanne Leavitt, RN MS, Assistant ivi 5 io Directo r, or
Clayton Clark, Divis io Director at (802) 24l-0480. lfyou are not satis?ed with the utco me of
the informal revie with the Division, you may request a review by the Commissioner of

Disa bilities Aging and independent Living. To request a review with the Co mm iss lo we r, call
(802) 241 -2401.

The Department is authori zed to impose sanctions for failure to correct a de?ciency and for failure
to provide proof of correction by the speci?ed Correction Date. Depending on the natur of the
-viola tions, the following sanctions may be im po 5 ed: administrative pena [ties of up to $l0.00 per
res ident 01$ 1 00 .00 whichever is greater, for each day the violation remain s. unco rrected:
suspens io n, revocation or modi?cation of an existing licen 5e; refusal to rene a license;
suspension ofadmiss ion or transfe of residents to an alternative placement; injun cl ive re li efto
enjoin any act or omission and the appointment ofa receiver for a facility. Ifyou feel strict
compliance with the law or reg ulation 5 would impose a substantia hardship, you may apply to
the Department for a variance as stated under Section ofthe Residential Care Home Licensing
Regulations. You must do so prior to April Il, 2018.

A ppeal 

As noted above, you may seek an informal review from Suzanne Leavitt, RN, MS, Ass is tant Division
Direeto r, or a Commiss ion er?s review ofthis decision. In add it ion you have a right to request a fair
hearing with the Human Services Board. Decisions by the Department ofDisa bili ties, Aging and
Independent Living can be appealed to the Human Services Board pursua at to 3 V.S.A. ?309l. The
request for a fair hea ring before the Human Services Board must be made within thirty (30) days of
your receipt ofthe notice ofthis decision, and can be made by writing to the Board at 14-16 Baldwin
Street, Montpelier VT 05633-2536. You have a right to appear before the Board and to prese nt
witness es and other evidence with regard to the case. You also have a rig lit to be represe nted by an
attorney at the Human Services Board fair hearing.

Plea se contac t_ me at (802) 24l?0480 ifyou have any question 5 .

Sincerely,

Pamela M. Cola, RN
Lice ns in Chief