ANERMONT

AGENCY OF HUMAN SERVICES

 

DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING

Division of Licensing and Protection
103 South Main Street

Waterbury, VT 05671?2306


Voice/T TY (802) 871 -331 7

To Report Adult Abuse: (800) 564-1612
Fax (802) 871-3318

December 22, 2014

Ms. Paula Patorti, Administrator

Our House Too Residential Care Home
69 1/2 Allen Street

Rutland, VT 05701

Dear Ms. Patorti:

Enclosed is a copy of your acceptable plans of correction for the survey conducted on
November 24, 2014. Please post this document in a prominent place in your facility.

We may follow-up 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 Adult Services Blind and Visually Impaired
Licensing and Protection Vocational Rehabilitation

 

01/04/2006 20:20 FAX 8022654587 OUR HOUSE HQ .002
PRINTED: 1210112014

 

 

 

 

 

 

 

 

 

 

. . FORM APPROVED
Division of Licensing and Protection
STATEMENT OF oar-"Immoral; (Xi) ore) MULTIPLE ixai DATE SURVEY
AND PLAN OF CURREGHON NUMBER: 
A BUILDING.

. 0377 SI WING . I 11?f24i2014
NAME or PROVIDER on SUPPLIER STREET ADDRESS. CITY. STATE. ZIP sons
69 ALLEN STREET

0 1'00 5 

UR HOUSE RE CARE HOME RUTLAND, VT 05701

10 SUMMARY STATEMENT OF DEFICIENGIEB pm 0F 

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

mo neeumoav on Lac INFORMATION) Tno caose-asreaahoeo To THE APPROPRIATE DATE
DEFICIENCY)
R100 initial Comments: R100 33'4- L's dippn? Lick-fer} 038V
and (phone do a 
An unannounced on-site complaint Investigation )5 For: . mi
. . adds no,
waa conducted on mew-=1 by the Division of f3,? 4 
LL11 +odce7 222/; 7/055 -

Licensing and Protection. The foliowmg regulatory

Violations wereidentifiad: [Mud/'1 apprauei-Jan PP

R167 V. RESIDENT CARE AND HOME SERVICES 


5,10 Medication Management

 

5.10.d ifa resident requires medication 92?? . 

administration. uniicensed staff may administer get-admit ?ee?i M7230

medications under the renewing conditions: we gamma; Ice/?n and

(5) Staff other than a nurse may administer PRN fit/Ml: yfr?f all 
medications only when the home - .

has a written plan for the use of the PRN M5 0"ij ?43 0dr
medication which: describes the specific aim: I a; ?duoms of
behaviors the medication is intended to correct or - c. 
address; specifies the circumstances that 30mm? l/?G Um
indicate the use of the medication; educates the cf. .0, and KW a re ?Mm
staff about what desired effects or undesired aide man I NW3
effects the staff must monitor for; and documents 741a?" 7?24!? i" 

the time_of. reason for and specific reauits of the and +0 be plow: al? Awe .
medication use, Asher.- ?97, 
This REQUIREMENT is not metas evidenced Kid is: - J?tit

- . i RC we ?at W1
Base on Interwew and record rewew. no i-i mpm?r ML e219 

faiied to assure a written pian for the une of PRN
(as needed) medication was
developed by the RN and provided to staff for the
administration ofVaiium for 1 applicable resident.
(Raeidentiti) Findings include;

1. Resident admitted to the RCH on 11!13!14
with a diagnosis of Dementia. DiabetBS, and
seizures had a physician order for Valium 5 mg.
every 8 hours as needed for anxiety. From 11i14

Division of Licensing and Protection" 
mooanroav Di on Free - . e. suppose SIGNATURE TITLE om

tJamilwhims)titration" /aR//7At/

25iL11 ?Ir continuation a?oat 1 a4

 

 

 

 

 

  

 

NM, ixi'i?i haw BCt?Pkd elem WW

 

01/04/2006 20:20 FAX 8022654587 OUR HOUSE HQ .003

12i?0112014
FORM APPROVED
Division of Licensing and Protection

owamem or (x1; rnowoenraurnuanrotn (x2) nut-irate consrnuorioii no) DATE sewer
mo PLAN on coaneonon NUMBER: A auiLomo GOMPLETED

 

 

 

 

 


0377 11:2412014

NAME OF PRDVIDEFI DR SUPPLIER QTHEET ADDRESS. CITY. STATE. ZIP 

39 1M ALLEN STREET
OUR HOUSE TOO RESIDENTIAL CARE HOME VT 057-01

 

 

 

.9 SUMMARY STATEMENT or oerrorencie?i in pom/inane PLAN on 
may; DEFICIENGY moor ea Pneceoeo av FULL PREFIX CORRECTNEAGTION SHOULD BE 
TAB REGULATORY on L56 IDENTIFYING INFORMATION) TAG APPROPRIATE DATE

pen to

 

Rio? Continued From page 1 R167

through 'i'ii?21i'i4. Resident #1 was Idminiatered
Valium 11 times by unlicensed staff. For record -
review on 11124f14 there was no evidence a oore

plan was developed by the RN apeoliloeiiy for
behavior monitoring, alternatives to utilize before
administering the medication, speci?c: 
of anxiety and monitoring for adverse effects of
this medication. This was continued with the
House Manager.

RTN V. CAREAND HOME SERVICES R174


5.10 Medication Management

5.10.11. (2)

. 7 i (a
Medications requiring refrigeration oheii be stored 66?? M5 (I 
in a separateriocked container impervious to ?04714? in white Item? of 
water and air if kept tn the some rofngeretor uaod 5+a;F Add 6 eon ?immd?d 

for storage of food. 
I Me :MJJo/fdnn {Caper-14%

Eris lo not motaa evidenced and r2119 {c1053 A ?km ""39me
Booed on observation and interview. the RCH HT 7102 or} ?5 Wm! ?dd-I zg/m/M
[Residential Care Home) failed to aoeuro an mow-Jim or? (ape/1%
modicotiono wore stored separately in a locked . ?g EMF
container in the refrigerator where food was nine mo '7 (MA- 0" 
stored. Findings inoiude: mm Hal/y of a5 were dr? 

During a tour of the RGH with the House
Manager on 11i24i?i4 at 9:20 AM, Letenoproat
Ophthalmic {eye drop medication used in the
treatment of glaucoma) was found stored in the
butter dish compartment of the refrigerator where
food for residents is also stored. This
observation was confirmed with the House

Manager.

 

 

 

 

 

Division of Licensing and Protection

5130,31; FORM on? II Shoot 20M

 

01/04/2006 20:21 FAX 8022654537

OUR HOUSE HQ

004
PRINTED: 12:01:2014

 

 

FORM APPROVED
Division o'f Licensind and Pr otion
STATEMENT or DEFICIENCIES (xi) PnovmenisuppLIenroLIA (x2) MULTIPLE CONSTRUCTION (XS) DATE BUWEY
AND PLAN OF CORRECTION NUMBER: A. BUILDING: COMPLETED

0377 s. WING 11l24i2014

 

 

 

 

NAME OF PROVIDER DR SUPPLIER

GTREET ADDRESS. STATE, ZIP GODE

89 ?2 ALLEN STREET

 

 

ES DE
OUR HOUSE TOO NTIAL CARE HOME: RUTLAND, VT 05701
(X4) ID SUMMARY STATEMENT or: ID mowers-rs PLAN or ooanecnoN {x5}
pagnx DEFICIENCY MUST as Pesosozo av FULL PREFIX connecnve ACTION snooto BE COMPLETE
TAG REGULATORY on Lee IDENTIFYING TAG CROSS-REFERENCED To THE APPROPRIATE 
DEFICIENCY)
Continued From page 2 R266
Ix. PHYSICAL PLANT sass
$825
9.1 Environment
9.1.8 The home must provide and maintain a
safe, functional. sanitary. homeiike and
mfortabla environment. . - 
?80 {9.2.1467 95 Hue Jurwyor Send 

This REQUIREMENT to not met as evidenced
by:

During a tour of the RCH with the House
Manager, a soiled suction machine was dissented
in Patient #2'3 room and there was a failure by
staff to maintain standard Infection controi
practices during the handling of soiled dishes.
(Patient Findings inoiude:

1, Resident #2 has a past history of increased
oral sooretions which sine was unable to oiear
clue physical impainnents? On Bill/13 the RN
received an order for oral auctioning using a
Yankauer device (?rm plastic suction tip device
used in eropharyngeal secretions). During a t0ur
of the ROH on et9125 AM with the
House Manager] a suction machine iooated
beside the resident where elhe set in a reciiner,
was noted to be soiled. The Yankauer tip was
crusted with dried debris and the suction
collection bottle was approximately 1M full With a
milky colored liquid The House Manager was
unaware when the last time the resident was
suctioned and acknowledged the equipment was
soiled.

Per review of Instructions to RCH staff titled Oral
Secretion Education states ?Cieaning and
disinfecting your equipment is simple. yet very
important Proper ears prevents Infection?. it
further discusses how to clean and store the

 

 

machine Ad!- ?of [seen ?.590?
For (an im?ended porter} 
60.2 are +64:
51C Jmppig? 007'
?Hurt mmhm-? For? a newer
one as C?s/edicribar?r?le
Heel?? has Addams e/wdy.
'Hif but If {Tainan}
ge ed a5 We.? 51.5 +5.9
(Jr, 155/ 1?1" A3 ?ee-ea?c?d4

77K machine 6.2 added 
{v MAE Air mime/y
maidecfz'on or deter PRU
fr'i 60.561. 
Manager? cud-U ?oor} 1710?
and 5" vipmer??
cot {3515+ mom?i/t/ or (as
needed if used.

LL11 dead-?4 4?9 l"633i"

 

 

441:5 u't- hove?? (its 

 

Division of Licensing and Protection

STATE FOR



25IL11 ti cominuatinn sheet 3 or 4

 

 

 

 

 

 

 

 

 

 

 

 

 

01/04/2006 20:21 FAX 3022654587 0UR HOUSE H0 I005
PRINTED: 12/01/2014
FORM APPROVED
ef 
STATEMENT OF DEFICIENCIES (xi) CONSTRUCTION (X3) DATE SURVEY
AND PLAN 01' CORRECTION IDENTIFICATION NUMBER: BUILDING: COMPLETED

0377 e. WING 11i2?2014
NAME OF PROVIDER on SUPPLIER STREET ADDRESS. crrv, STATE. 2.191 cone
as 112 ALLEN STREET
OUR HOUSE TOO RESIDENTIAL CARE HOME RUTLAND. VT 0570?

{x4} ID SUMMARY MATEMENT OF DEFICIENGIES ID PROVI PLAN OF cennecnen {x51
Pne?x DEFICIENCY MUST BE PHEGEDED EIY FULL paemx (EACH CORRECTIVE ACTION SHOULU BI COMPLETE
m3 neeuwenv on Lee IDENTIFYING m3 APPROPRIATE DATE

R256 continued From page 3 R238 {diet 1+ and
equipment to inntude the emptying of the I) kl?m
collection bottle and cleaning or changing, and Staci}: CMJ 
tubingi?suctioning device. A second cheek of the - 19?2 0. need +9 use
suctinn equipment noted a plastic bag had been . . 
plandd over the machine, hewaver the equipment Dr
remained soiled. The House Manager was
notified at the secend observation and made
aware that the equipment required cleaning or
removal if the resident no longer reqUired oral
auctioning of secrettens.

I 2. Per observation at appmximataiy 10:00 AM on . - 
11!241?14 a staff member failed to use proper Rife r? mm? 

 

 

hand washing sanitizing after handling
edited dishes and sliverware from the dining room
tables after the resident's breakfast initial. When
removing the soiled items. the staff member
placed hieiher fingers Inside gtasses and cups

used by individual residents during the

meal. After placing the dishes on the
kitchen counter, the staff mamberfaiied to
sanitize or wash hiaiher hands and proceeded to
touch with sailed hands. other abjects and
residents within the dining roam.

 

 

remmled of; 
(?nd ?him. ?J-G-Iuknis
Ext?(e hand uh?)
and -- L04, Q2150
reminded amt (Beret: tow-S
62,1" dLv?i on il?wi'dt
Manager (tutti-d made 
Qm??lh?j?
Exhct?. Sufd?? (tenet HLLU.
Cer?'mlve. *t-G 

(934)1?}

wimp}

 

 

 

Division of Licensing and Protection

STATE FGRM

0MB

 



If continuation sheet *3 0f 4