NNERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING Division of Licensing and Protection HC 2 South, 280 State Drive Waterbury, VT 05671?2060 Survey and Certification Voicefl TY (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 March 15, 2016 Ms. Beth Peer, Manager Our House Too Residential Care Home 89 1/2 Allen Street Rutland, VT 05701?4501 Dear Ms. Peer: Enclosed is a copy of your acceptable plans of correction for the survey conducted on February 3, 2016. 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 @3fl4f2EllEu 11: 25 882??2??33 Division of Licensinq and Protection . BUR HDUSE PIEGE 02/16/2015 FORM APPROVED STATEMENT OF DEFICIENGIES MULTIPLE CONSTRUCTION (XS) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION A COMPLETED I BUILDING: 0377 8- Gems/2016 NAME OF PROVIDER OR SUPPLIER OUR HOUSE T00 RESIDENTIAL CARE HOME VT 05701 STREET AooREes. CITY. STATE, ZIP CODE 69112 ALLEN STREET (344) ID SUMMARY STATEMENT OF DEFICIENOIES I In PROVIDERS PLAN OF CORRECTION (st DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD as COMPLETE TAG REGULATORY OR Lso INFORMATION) TAG TO THE APPROPRIATE DATE 1 DEFICIENCY) I R100 Initial Comments: i R100 I: . An unannOunoed on?site re-Iicensure survey was i conducted by the Division of Licensing and Protection in conjunction with two entity reports and an anonymous complaint between the dates 01'2/2/16 ~2/3/16. There were regulatory findings with both the survey and the complaint investigations. The ?ndings are as follows: R136 V. RESIDENT CAREAND HOME SERVICES R136 I I 5.7. Assessment i 5.7.1: Each resident shall also be reassessed annually and at any point in which there is a 5 change in the resident's physical ormentai {213,5 condition. 1 5,3 50;? Ayers Hindi/1:335 VLAE I . . 1" has 53*? This REQUIREMENT Is not met as evidenced Cl ?jejgmew by: cw statesmen? Based on record review and Con?rmed by staff (lamp hard as T33 interview the facility failed to reassess 1 of 10 (1W1 +0 bi Kept Culver?: sampled residents (Resident#2)_ annually or at pp}, totrm any point in which there is a change in the [1,0 @ujal?l a: residents physical or mental condition, The ,9 more ,5 ?nger)? pz/y/wait it fIndIngs Include the followmg. .4 I. with)!" II RI t#2 muaem??m Ll Per record review 6'13. ,5 i admitted to Our House Too, on 1/8/15. State 6155?? Smart: d+ assessment form identifies that the assessment I be: ITEVWMQ it I was completed and signed by the Registered I 1 U6, clot. ,3},th I Nurse (RN) on 1/20/15. 2 03+ 3,33% monJcM Per interview with the RN on 2/2l16 at I use :12: approximately 4:45 PM, the resident has not had i CHILI Shit?? Sel?- an annual review assessment as of today 5 at Immed 1 Therefore the modal assessment is 13 days i e-I-o los CA reds I Division of Licensing and Protection meager DIRE on PnovzoenzsuPPLIsa REPRESENTATIVES slowness TITLE we fit? Memo-m 3 [cf/I'd; WJOWW tats: PQJVII It contlnontion sneer, 1 of 26 by ?uid-1m {OT/raz?T Rose mi Poe?s motel alum Bewitmlm/ 8314/2815 11:25 882??2??33 DUE HOUSE 85/13 PRINTED: 02f18f2015 . FORM APPROVED of chensmo and Protection - STATEMENT OF (X1) no: MULTIPLE CONSTRUCTION AND PLAN or IOENTIFICATION NUMBER: A Flu? DINC. ?xs?g?irifEFE?EEY 0377 WING . . 02/03/2016 NAME OF oa SUPPLIER CITY, STATE, ZIP cops 69 ALLEN STREET OUR HOUSE TOO RESIDENTIAL CARE HOME RUTLAND, VT 05701 per) In I SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF i [st PREFIX (EACH MUST BE FRECEDED av FULL FREHX (EACH CORRECTIVE ACTION SHOULD are i COMPLETE TAO REGULATORY OR L30 JDENTIFYING I TAG CROSS-REFERENCED TO THE APPROPRIATE DATE R136 Continued From page 1 I R136 - - i overdue. R142 v, RESIDENT CARE AND HOME SERVICES R142 33:0 . 5.8 Level of Care and Nursing Services The followin services are not a mitted in - user-T Gem .4909 a residential ca re home except under-a variance ?3'?th (amends mr??b 3/317?? granted by the licensing agency: intravenous 1 Prav?zd therapy; ventilators or respirators; daily catheter is.) an reap Ff?! Jaime irrigation; feeding tubes; care of stage or iv Varanasi Ware (2 decubitus; sectioning; sterile dressings. pm In Jazz! New . ?e ThIs REQUIREMENT is not met as evidenced My") by: )5 Pr?om?as - Based on staff interview and record review, the fret/7? Is I failed to Obtain a variance for 1 of 6 5,557, Cc) 9/ residents reviewed in the survey sample, le??i?lct?"; LU be. ?fr?u??d Resident# 7. Findings include: C?t' I mod-H1 [La manage? . . or.) During observation on day one ofthe survey, W?hh? Iii/aid stare 4&3 . Resident #7 was receiving feedings through a Varl?nw$ mLUt be. i ?4 feeding tube, placed in the abdomen. The - my and Immediatelt) medical record did not provide evidence that a - 54? variance has been obtained, but the House what} i {Cf-5 1 Manager was sure there was one. A call was HAmlm?ier?ar? wad placed to the State Agent at 4:20 PM and they reported there was no evidence that a variance had been given. On 2/3/16 at approximately 9: 30: AM the senior manager stated that the Ownerfadministrator would have that information and she did not know the whereabouts of the variance and the owner/administrator would not be avaiiabie until next week. Further interview with the house manager at 4:30 PM, s/he was unable to locate a variance for care for Resident i #7 1 WI on {afar Per Co expirame- i Division Of Licensing ahd Protection STATE FORM 0599 If sheet 2 of 26 11:25 8827727733 HDUSE E16713 PRINTED: . . . . FORM APPROVED of and ProtectIoh STATEMENT OF DEFICIENCIES no} no) MULTIPLE CONSTRUCTION {an OATE AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED (3 0377 WING cams/201s NAME OF PRovIosR OR SUPPLIER Aoonese, CITY. STATE, ZIP as we ALLEN STREET OUR HOUSE in 00 RES ENTIAL CAR HOME RUTLAND, VT 05701 ID SUMMARY STATEMENT OF ID I PLAN OF CORRECTION {st (EACH DEFICIENCY MUST ea eT FULL PREFIX (EAOH CORRECTIVE AOTION eE COMPLETE m3 OR IDENTIFYING ma oneseREPsRewcr-zo To THE APPROPRIATE: . DATE i R155 COntinued From page 2 R155 I SEst 55 V. RESIDENT CARE AND HOME SERVICES R155 5,9,0. 12) I - g" - Rig Kill 075- J-Lese bet/en?s 57:11; AssUme responsibility for staff performance in the .. Lg; - 5 Il/admInIstratron of or seeistance With reeldent beam Wm?; CI medication in accordance with the home's can cf. mm 4.34: If DOIICIES. . a rec-17? :fg (in d?aanr This REQUIREMENT is not met as evidenced p/dh 41) Cerrec'r . by: Based on observation, staff interview and record it Main} o-{clar? 7?77"" review, the nurse failed to ensure that the - administering of medication was done in Pharm?t'm?l I) accordance with the home's policies for 5 of 9 IL: 11-3 hip eta-EH? residents observed, Residents 7, s, a TI. To). a rears Findings include: +0 ?1550?? Vr?mh?mc ill/I/M; . who 1.) Per observation, ResIdent #4 was or leg-h n3, :3 beer Ct 4: ?3 administered enteric coated Ferrous Sulfate 325 adv?: ?I'mb med (er I?jne milligrams by mouth on 2/2/16 at 5:25 PM. The 15? ?emm we? medication delegated staff member crushed the fo'I'ti t) ed .. ..Fe.rrous Sulfate and placed it in applesauce and gr? ?afpj aware ?4,53 administered it to Resident The staff member :3 rah-doe .. confirmed immediately after the administration. 0 - that the Ferrous Sulfate had been crushed, s/he PM (and I?Yk?mt?-?Er poem. stated that they did not know that it couldn?t be . crushed because it was not indicated on the men Its-r fir! ?agrant packet that came from the pharmacy. The .. moo-e. .u Registered Nurse (RN)?stated at the time of w?d I . discovery, that the packet did not indicate not to 9043??; atoll-s be cruahed, but confirmed the enteric errous . CJ It: 1. Sulfate should not be crushed. 1 0)de 4, bares damage 70"- 2.) Per observation, Resident #administered Leveouin Solution at 4:30 PM on I) and it 2/211 6. The order is for Levaquin 750 mg I QM Mom'l'ti?r? ["350 a; (milligrams) and the label reads 25 mgh?nl [31% agar- I (milliliter) and to give .30 ml. The medicatIOn I . Division of Licensing and Protection STATE FORM unite pg JV11 lfcontiI-IuatIorI sheet 3 of 2S r?2lZilEa 11:25 Division ofLicensino and Protection - BUR HOUSE PAGE 1217713 FORM APPROVED STATEMENT OF DEFICIENCIES (Xi) PROVIDERKSUPPLIERTCLIA (X2) (X3 ft AND . . DATE URVEY LAN IDENTIFICATION NUMBER. A BUILDING: COMPLETED WING 0377 - 02I03IZD16 NAME OF OUR HOUSE T00 RESIDENTIAL CARE HOME oR SUPPLIER STREET CITY, STATE, ZIP coos 59 1h? ALLEN STREET RUTLAND, VT [15701 delegated staff member prepared and administered Only 10 ml via feeding tube. After administration the label and order was reviewed with the staff member and s/he confirmed that only 10 ml instead of the ordered 30 ml was given and sihe then prepared and administered the remaining dose of 20 ml. Reviewed with the RN at this time and s/he stated that the staff member needs to read the label closer. 3.) Per observation, Resident 9 was administered Acetaminophen topically on 2/2! 16 at 12:15 PM, the medication delegated staff member applied two squirts from the pump bottle into his/her gloved hands and applied it to the chest of the resident. After administration the staff member was asked when the medication expired and s/he stated that they did not know because there is nothing on the label to indicate expiration. The order and the label on the bottle state that the dose is 325 mgi2 ml. The staff member was asked how they knew that two squirts was equivalent to 2 mi and slhe stated that s/he does not know if that is how much is in the two squirts, but that was the way they were taught to apply. The RN was not able to ensure that two'squirts are equivalent to 2 ml at 4:30 PM. The RN also confirmed at this time that there is no expiration date on the label and stated that the staff shoold be picking up on that. 4.) Resident #7 has an order to administer 100 mi of water every hour. dated 1/31116, obtained via a telephone order. Review of the Medical Administration Record (MAR) for February does not have signatures for the night shift administering the water ?ushes. During day one of the survey, one or more surveyors were near the entrance to Resident #7'5 room between the hours of 10 AM and 4:30 PM. The only i (X4) ID SUMMARY STATEMENT OF to PLAN OF CORRECTION (XS) PREFSX (EACH DEFICIENCY MUST BE PREC EDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE . COMPLETE mo REGULATORY or: Lee ceosseer-"sesnoeo TO THE APPROPRIATE i DATE .5 DEFICIENCY) . 1 R155 Continued From page :3 R155 Mad/Dedicated?; Wairuec?i ?mitt Manager wet revisit) ?at 527/ Cil?iC-tLr?iw i thin; wield. 3 tool 319-: Conduct-{ct For I?Ettnciom Committees; - rte-to its MU lee restart-Lied 351/; (e with manager Chart/an} west for: Mei In?imaoitade tar.? RM and tit/Lehman?- mutt Thor} 5M8 and Waihiri?y' Division of Licensing and Protection STATE FDRM EBDS it continuation sheet at of 26 833144528115 11:25 saeffatfaa Division of Licensing and Protection CIUR HOUSE Hi3! PAGE 1 3 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) FR OVIDERISUPPLIERICLIA rxai MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 037? WING ozroarzois NAME OF OUR HOUSE TOO RESIDENTIAL CARE HOME PROVIDER OR SUPPLIER RUTLAND, VT 05701 STREET appease. CITY. STATE. ZIP cops 69 1i2 ALLEN STREET administration of water for the resident was during medication administration and to ?ush the feeding tube after Jevity feeding. The staff member that was responsible for administering the'flushes 0n the day shift had signed the MAR to indicate the flushes were done. The RN stated that they were ordered every from because the resident had a temperature. 5.) During the observed tube feedings for Resident #7 on 32/16 at 11:00 AM, the staff member did not check for placement of the feeding tube per training and policy, Slhe did not aspirate for residual prior to administration of feeding. Con?rmation made by the staff member at 11:47 AM that placement had not been checked. Again on 2/21/16 at 4:25 PM. the evening staff member responsible for the tube feeding was observed not to check tube for placement and did not check residual prior to administration of feeding. Con?rmation made by staff at this time. 6.) On 2f2i16 at 2:00 PM the medication delegated staff member prepared RiSperidone 0.125 milligrams for Resident #11. The resident was not alert and did not accept the medication when it was offered. The medication delegate then placed the medicine Cup with the medication in it into the medicine closet in the residents designated box. At the change ofshift the on coming staff responsible for medication administration was alerted that Resident #11 had refused the medication and staff member placed a call to the Registered Nurse to let himiher know that it had not been time. When s/he received the approval to give that it was in the medicine closet. At 3:given at 2:00 and asked if it could be given at this the medicine, sine retrieved the Risperidone that . (x4) ID SUMMARY STATEMENT oF DEFICIENCIES .D PLAN OF CORRECTION i (x5) PREFIX DEFICIENCY MUST es Pseceoso BY FULL PREFIX (EACH ooneeonve ACTION SHOULD as. COMPLETE TAG REGULATORY DR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) R155 Continued From page 4 l? R155 Division of Licensing and Protection STATE If continnatlon sheet 5 of 23 EBr?ld/EEilEi 11:25 882??2??33 Division of Licensingand Protection EILIR HCILISE 1 3 PRINTED. FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA AND PIAN OF CORRECTION NUMBER: 0377 MULTIPLE CONSTRUCTION A, BUILDING: B. WING (an om'e SURVEY COMPLETED . 02I03f2015 NAME or PROVIDER on SUPPLIER STREET AD DRESS, CITY, STATE. ZIP CODE 69 1.3.2 ALLEN STREET RUTLAND, VT OUR HOUSE TOO RESIDENTIAL CARE HOME {x4} ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID I PROVIDERS PLAN or coneecnon 9(5) DEFICIENCY) PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE COMPLETE R155 R161 Continued From page 5 was prepared by the day shift caregiver from the closet and then Crushed it and administered it to Resident #11. At 3:20 PM sihe con?rmed that slhe had given the medication prepared by the other caregiver. Per interview with the RN at 4:30' PM, sihe stated that the staff are not to give anything that was prepared by anyone else and elite was not made aware at the time of the call that the medicatinn had been prepared by the day shift. 7.) On 28/16 at 8:00 AM, the medication delegated staff member administered Lasix 40 mg by mauth to Resident Review of the medical record presents that the physician orders, dated 11?5/18 states that resident is to have Lasix 40 mg one tablet oral daily in PM (morning) as needed for swelling. Orders and MAR reviewed with the house manager at 3:10 PM and sfhe confirmed that the orders in the chart and the MAR do not match and that the order is to give as needed and the MAR is to give every day. Sine said that they would have the RN check the orders. The RN stated that the resident has been receiving Lasix every day for a long time, but con?rmed that the orders are to be given only as needed. the stated that they are responsible for checking the MAR and physician orders. V. RESIDENT CARE AND HOME SERVICES 5.10 Medication Management 5.1m: The manager of the home is responsible for ensuring that all medications are handled according to the home's policies and that designated staff are fully trained in the policies i: i i R155 R181 '1 Division of Licensing and Protection STATE FORM Wt Pawn Il continuation sheet 6 of 26 Bails/281E? 11:25 DLIR HDLISE FREE 1Eir?13 PRINTED: .. . FORM APPROVED of Licensing and Protection . STATEMENT or: DEFICIENCIES {Xi} so) MULTIPLE CONSTRUCTION (st DATE suavsv AND PLAN OF CORRECTION NUMBER: 9.. BUILDING: COMPLETED 0377 - "40 02/03/2016 NAME OF PROVIDER OR SUPP STREET ADDRESS. CITY, STATE, ZIP CODE 89 1/2 ALLEN STREET OUR HOUSE TOO RESIDENT CARE HOME RUTLAND, VT 05701 Io SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5; PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL i (EACH CORRECTIVE ACTION SHOULD ESE I COMPLETE TAG REGUIATORY OR IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE I DATE i DEFICIENCY) R161 Continued From page 6 1 R161 i. and procedures, 1 i This REQUIREMENT is not met as evidenced I by: kite, Us Based on observation, staff interview and record 5 review, the manager oithe facility failed to ensure DJ pg, Staff-i2 who that all medications are handied according to the . home's policies for :2 of residents, Resident a 7 are We $0 ileum ?it and It. Findings include: - . 3 ln?rlrfut+ym15 :3 4' 1.) Resident #7 has an Order to administer 100 . 11R Lt.) mi of water every hour. dated 1/31/18 and Md" . I obtained via a telephone order? Review of the oi stair-on wineri- ?ir?m ?le-:3 Medical Administration Record (MAR) for {melt- 4 I . . +9 {in note or February does not have signatures for the night i ?5 - shift administering the water flushes. During clay (so: ecu-Span clad 90?? one of the survey, one or more surveyors were I 5.1? near the entrance to Resident#7?s room between med ML the hours oi1U AM and 4:30 PM. The only ., :3 administration of water iorthe resident was I Po . 0 during medicatiOn administration and to flush the a ram u?feeding tube after Jewry feeding. ma??i? I 4? in; [him L'i'br Cid/i"? 2.) During the observed tube feedings for Greats. add? as {plan Residenti? on 2/2/16 at 11:00 AM. the staff and 13150. (a 5 ?q member did not check for placement of the on Ci b?i I: feeding tube per training and policy. S/he did not aspirate for residual. Con?rmation made by the staff member at 11:47 AM. On 2/2/16 at 4:25 I PM. the staff member reaponsible for the tube 1. feeding was observed not to check tube for placement and did not check residual. Confirmation made by staff at this time. Interview 1 with the house manager at 4:30 PM after s/he was noti?ed of the ?nding, stated that the staff knows they are suppose to check the placement of the feeding tube before they administer anything via the tube. S/he further stated that i they have all been taught. Division of Licensing and Protection STATE FORM um Pain/1i If continuation sheet 7 of 26: 111?13 PRIN I FORM APPROVED 11:25 DUE HOUSE Division of Licensingand Protection STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A CCIMPLETED 0377 e. WING 02I03f2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE I39 ALLEN STREET on use ESID (X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1 ID i PLAN OF CORRECTION PREFIX DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACI-I CORRECTIVE ACTIDN SHOULD BE .- comers TAG REGULATORY DR LSC IDENTIFYING INFORMATION) . TAG CROSS-REFERENCE) TO THE APPROPRIATE I DATE I DEFICIENCY) R161 Continued From page 7 R161 I 3.) On 2/2i16 at 2: 00 PM the medication delegated staff member prepared Risperidohe I 0 125 milligrams for Resident#11. The resident I was not alert and did not accept the medication I when It was offered The medication delegate then placed the medicine cup with the medication I in it into the medicine closet At the change of . shift the on coming staff responsible for I medication administration was alerted that - Resident #11 had refused the medication and that it was in the medicine cioset. At 3:10 PM the staff member placed a cali to the Registered Nurse to let himlher know that it had not been given at 2:00 and asked if It CDuld be given at this time. When slhe received the approval to give the medicine. slhe retrieved the Risperidone that was prepared by the day shift caregiver from the closet and then crushed it and administered It to Resident #11. Policy review presents that medications are not to be administered by anyone but the person that prepares them. At 3:20 PM slhe confirmed that slhe had given the medication prepared by the other caregiver. Per Interview with the RN at 4:30 PM slhe stated that the staff are not to give anything that was prepared by anyone else. I R163 v. RESIDENT CARE AND HOME SERVICES rues 5.5 Medication Management I 5.10.d lfa resident requires medication administration, unlicensed staff may administer medications under the following conditions: (1) A registered nurse must Denduct an 5 assessment consistent with the physician's Division of Licensing and Protection . STATE FORM ??99 PQJVII If continuation sheet 3 area @3314 11:25 Division of'Licensing and Protection OUR HOUSE 12.313 PRINTED: 5 FORM APPROVED STATEMENT OF AND PLAN DF CORRECTION PROVIDERISUPPLIERICLIA NUMBER: 0377 (x52) MULTIPLE CONSTRUCTION A. BUILDING: B. WING (x3) DATE SURVEY COMPLETED C2 02I03i2016 NAME or RDVIDER OR 3 UPPLIER STREETADDRESS. CITY) STATE, CODE 691R ALLEN STREET RUTLAND, VT 05701 OUR HOUSE TOO RESIDENTIAL CARE HOME This is not met as evidenced by: Based on staff interview and record review, the facility failed to ensure that the registered nurse conducts an assessment censistent with the physician's orders for 2 of 9 residents reviewed. Resident #5 and 3. Findings include: 1.) On 2/215 at 5:25 PM, during medication administration, the delegated staff asked which dose of Warfan'n should Resident 8 be getting because there were two of them. One order on . the Medication Administration Record (MAR) read to give Warfarin 2.5 milligrams (mg) daily at 5:00 PM and the One listed right above that said to give Warfarin 2_ mg. The physician order in the medical record stated to give the Warfarin 2 mg daily. At 4:55 PM the Registered Nurse (RN) stated that s/he does the medication training and she reviews the MAR each month. She stated that s/he checks the MAR against the one from the month before doesn't check them against the medical record. S/he said that s/he reviews all the orders so knows if there is anything new and must have missed this one, but con?rms that the house manager will sometimes take orders. 2.) On 2/3/15 at 8:00 AM, the medication delegated staff member administered Lasix 40 mg by mouth to Resident Review of the medical record presents that the physician orders. dated 1/5/16 states that resident is to have Lasix 40 mg one tablet oral daily in AM (morning) as needed for swelling. Orders and MAR reviewed with the house manager at 3:10 PM and s/he confirmed that the orders in the chart and the MAR do not match and that the tilt! Syd-Items 049.04. ?ats ?if d/icz/L?id 5,9100 made ,C?r HM mamas/y Aldo/'7" Preceded: chaff?? Mu 5355/55.? {dd/Th y/ ?3871? Rio deli (1 rat/teal? at: #473351? Mare/jar wetti- mas/?r. 2666!? mare?eai me are, Met/142842;? 52/3 01 (Zia dh?fif as bed-did sky-35110) (xii; if) i SUMMARY STATEMENT or DEFICIENCIES lD PROVIDERS PLAN or CORRECTION 5 [x53 PREFIX (EACH MUST BE PRECED Ec BY FULL PREHX (EACH conescnve ACTION SHOULD BE COMPLETE TAG REGULATORY on Lee TAG CROSS-REFERENCED To THE APPROPRIATE DATE R163 Continued From page 8 R163 diagnosis and orders of the resident's care needs as re uired in section 5.7.c i a up 3 {gym/)4, STATE FORM Division of Licensing and Protection '31! If continuation sheet of 26 11 ?5 862??2??33 EILIR HOUSE PAGE 13II13 a3/14r2a15 .z PRINTED: 02/18/2015 . . . . . FORM APPROVED ol- LIcensInq and Protection I STATEMENT OF DEFICIENCIEB on} (X21 MULTIPLE DATE susvsv I AND PLAN OF CORRECTION IDENTIFICATION A BUILDING. COMPLETED I a 0377 WING 02/03/2016 NAME OF PROVIDER CIR SUPPLIER STREET ADERESS, CITY, STATE, ZIP CODE 69 1/2 ALLEN STREET OUR HOUSE TOO RESIDENTIAL CARE HOME RUTLAND, VT 05701 (M) SUMMARY STATEMENT OF DEFICIENCIES lo I PLAN oF CORRECTION i Ist PREFIX (EACH DEFICIENCY mus?r sE paecsoeo ev FULL I (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY DR LSC IDENTIFYING INFORMATION) TAG I CROSS-REFERENCED TO THE APPROPRIATE 5 DATE I I DEFICIENCY) I order is to give as needed and the MAR is to give I R163 Continued From page 9 I R163 check the Orders. During interview at 4:10 PM, the RN stated that the resident has been receiving Lasix every day for a long time, but Confirmed that the orders are to be given only as needed. S/he stated that s/he is responsible for Checking the MAR and physician Orders. every day. Sine said that they Would have the RNI During medical review on 2/3/26, Resident #8 has an Order for Colchicine 0.6 mg by mouth daily as needed for gout flare?ups. listed on the MAR and medication list. Review of the last Signed physician orders dated 1/15/16, there is no order for Coichicine. Per interview with the manager at 3:10 PM, the resident was taken to the doctor and a list of the medications was ta ken with him/her. S/he said that the RN reviews the medications after a dOctor visit. At 4:10 PM, the RN Confirmed that she reviews the medications and did not reaiize the medication was not on the recent signed orders. 4.) On 2/3/16 medical review for Resident #5 presents that s/he was admitted to the facility 11/7/15 with diagnosis that includes Coronary Artery Disease, Arterioscierotic Coronary Vascular Disease and Pammaker placement. His/her physician orders represent that s/he is to have TOproI XL 100 mg tablet (1/2 tablet) to equal I 50 mg by mouth daily. Review of the MAR does not represent that the resident is to take the I TOprol XL. Reviewed with the house manager at I 3:10 PM and s/he COn?rmed that the admission I orders included that the Toprol XL was part of the I orders. Per interview With the RN at 4:10 PM, confirmed that s/he had spoke with the Physician i Assistant upon admission to review the I mediCations and was told that the resident needed to be on the Toprol because of his I DivisiOn of Licensing and Protection STATE FORM . if continuation onset to of 26 33.314 K2816 11:29 8827727733 Division ot?Lioensino and Protection DLIR HDLISE FORM APPROVED 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 responsibility for 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: Based on staff interview and record review, the facility failed to ensure that the Registered Nurse (RN) is responsible for teaching, monitoring and fitted too; (in (you. be wees ?11 Mat ridge 1" STATEMENT OF DEFICIENCIES [x1] LIA (my MULTIPLE CONSTRUCTION (x3) DATE suevev AND PLAN CJF CDRRECTIDN IDENTIFICATION A, BUILDING COMPLETED 0377 3' 021031201 5 NAME OF PROVIDER DR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE es 1I2 ALLEN STREET OUR CARE HOME HOUSE 0 ENTIAL RUTLAND, VT 05701 (5m) to SUMMARY STATEMENT or2 DEFICIENCIES i to PeoonR-s PLAN or conescnon (x5; PREFIX (EACH DEFICIENCY MUST BE PRECEDED av FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY on Lee INFORMATION) TAG CROSS-REFERENCED To THE AP I DATE i DEFICIENCY) i . I R153 Continued From page 10 i R163 . coronary diseases. S/he confirmed that sine did i not question the Tcprol not being carried over i from November to December. Sihe stated that i s/he reviews and prepares the MARs each i month, but sine will often take them home and goes from MAR and does not review the orders with the medical record. R165 V. RESIDENT CARE AND HOME SERVICES R165 [made SistlS/m?i??% "gr/m4 re (tsetse staff we? 53? PM mutant? rte oi- (you Divlsion of Licensing and Protection STATE FORM ?m Pawn If continuation sheet it 0126 121371472815 11: 2?3 8327727733 Divrsicn Eli and EILIR HOUSE HQ ?12717 PRINTED: ozziszems FORM APPROVED ixa . does the training for staff that will tie-doing tube Continued From page 11 i evaluating designated staff performance in 3 carrying out the nurse's instructions fro medication administratiOH. Findings include: F?er interview with house manager on at 10:00 AM, sihe stated that sine trains the caregivers thatwill be delegated to pass medications. Slhe said that slhe ?rst gives them a' test to take, she has them review the to loot: up answers for the test and then the that is corrected by the RN, folloWed by a medication pass while the caregiver shadowing another delegated medication staff member. Sihs further stated that the RN does not do much of the training until it is time for them to be certified. When the manager feels the staff member is Competent. sine sets up the time for the staff member to shadow and then sets up a time for the RN to come in to watch a medication pass and then the RN will deem them as certified. the further stated that the RN doesn't re-evaluate or monitor the day shift because slhe is there to answer questions and the RN evaluates and monitors the evening shift. The house manager also stated at this time that sihe feedings. She said that she will show them the Medication Administration Record, where the equipment and Jevity is kept how to clean and check for residual by aspirating before giving medications or the Jevity. The RN will then checklI for competency during medication certification i At 12 noon per RN interview. s?he says that the medication training consists or giving the i handbook to study the house manager goes throIIgh the book with them Slhe said that she . will correct the test after they take it and then they shadow the house manager or whoever sihe STATEMENT OF DEFICIENCIES (X1) MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: A. BUILDING COMPLETED 0377 s. WING 02(03r2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 69 ALLEN STREET House Too RESIDENTIAL CARE HOME RUTLAND. VT 05701 (x4; in summer STATEMENT OF DEFICIENCIES i ib paovmsas PLAN or cosasonon {st PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING TAG TO THE APPROPRIATE DATE Rise R165 Division of Licensing and Protection STATE FORM BEND Ii continuation sheet 12 of 26 11: 2?3 Division of Licensing and Protection DUR HDUSE 83;?1? PRINTED: FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PRDVIDERISUPPLIERICLIA IDENTIFICATION NUM BER: 0377 (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING (X3) DATE sunvsv COMPLETED 02(0312016 NAME OF PROVIDER CIR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE OUR HOUSE TOO RESIDENTIAL CARE HOME 69 1i'2 ALLEN STREET VT 05701 SUMMARY STATEMENT OF DEFICIENCIES PLAN OF CORRECTION 5.10 Medication Management 5.10.d If a resident requires medication administration, unlicensed staff may administer medications under the foiiowing conditions: (4) Ali medications must be administered by the person who prepared the doses unless the nurse responsible for delegation approves of an alternative method of preparation and administration of the medications. This REQUIREMENT is not met as evidenced by: Based on observation and staff interview, the facility failed to insure that all medications administered by the person who prepared the doses unless the nurse responsible for delegation approves of an alternative method of preparation and administration of the medications On 2/2/16 at 2:00 PM the medication delegated staff member prepared Risperidone 0.125 milligrams for Resident #11. The resident was it was offered The medication delegate then into the medicine cioset. At the change of shift the on coming staff responsible for medication not alert and did not accept the medication when mo I I i placed the medicine cup with the medication in It 1 administration was alerted that Resident #11 had I Communim?dn after? Knew +616 tune on - SAAU?s/??d/m/?a mad bane of 6:451!ng 2,23, 7?73 h: dams/or: met/urge: EM and Harrow meme; a" wad man X4 015) (EACH DEFICIENCY MUST BE PRECEDED BY FULL I (EACH CORRECTIVE ACTION SHOULD BE 5 COMPLETE TAG REGULATORY OR LSG IDENTIFYING INFORMATION) 2 TAG CROSS-REFERENCED TO THE APPROPRIATE I DATE i I I R165 Continued From page 12 I Rios I delegates and then the RN will do a medication i 1 pass with them. Sine said that the tube feedings I i are done by other than himiher and before they i_ 5 do it alone? sine will be with them and then sign I off to certify. ?5 1? R166 V. RESIDENT CARE AND HOME SERVICES R166 35:0 a/a?e Division of Licensing and Protection STATE FORM noon PQJVII If continuation sheet 13 of 26 33.14;? 281E: 11:29 Division of?Licensino and Protection IZILIR HCILISE Eldr?l? PRINTED: 02H FORM APPROVED techniques they are expected to perform before proViding any direct care to residents. There shall be at ieast twelve (12) hours of training each year for each staff person providing direct care to residents. The training must include, but is not limited to, the following: (1) Resident rights; (2) Fire safety and emergency evacuation; (3) Resident emergency response propeduree such as the Heimlich maneuver accidents. police. or ambulance contact and first aid; (4 Policies and procedures regarding mandatory reports of abuse neglect and exploitation; (5) Respectful and effective interaction with residents; 5' (6) Infection control measures, including but not 9 limited to, handwashing, handling of linens, maintaining Clean environments, blood home STATEMENT or: DEFICIENCIES {Xi} {mi MULTIPLE consmucnow no} DATE SURVEY AND PLAN or: now-zen: A. BUILDING: COMPLETED 037? ozroarzmc NAME or: Pnowosa oa SUPPLIER smear appease. CITY. STATE. ZIP cooe as ALLEN STREET OUR HOUSE TO RESIDENTIAL CA HOME 0 RE RUTLAND, VT 05701 not} ID I SUMMARY STATEMENT or: DEFICIENCIES PLAN cs CORRECTION (x5; pncpix (EACH osnmencv MUST ea PRECEDED av FULL i page); (EACH connecnve ACTION SHOULD BE COMPLETE TAG REGULATORY DR LSC TAG TO THE APPROPRIATE DATE DEFICIENCY) 5 I R166 Continued From page 13 was i refused the madicatidn and that it was in the medicine closet. At 3:10 PM the staff member . placed a call to the Registered Nurse to let him/her know that it had not been given at 2:00 and asked if it could be given at this time. When i . s/he received the approval to give the medicine, s/he retrieved the Risperidone that was prepared by the day shift caregiver from the closet and then crushed it and administered it to Resident i #11. At 3:20 PM s/he confirmed that s/he had . given the medication prepared by the other i Garagiven i V, CARE AND HOME SERVICES - R179 SSEE 5.11 Staff Services 5.1M) The home must ensure that staff demonstrate competency in the skiila and STAT FORM Division of Licensing and Protection 5650 P9JV1 i If continuation sheet I4 of 26 BBFl?ir?EEilEi 11: 29 DUR HEIUSE 8531? PRINTED: ozriorzoio FORM APPROVED Division of Licensing and Protection STATEMENT OF DEFICIENCIES {Xi} PROVIDERISUPPLIERICUA MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF NUMBER: 9L COMPLETED 0377 0210312016 NAME QF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. CODE 69112 ALLEN STREET OUR HOUSE TOO RESIDENTIAL CARE HOME RUTLAND, VT 05701 {mi iD SUMMARY STATEMENT OF osrioienoiss Io PRoVioEas sum or {st PREFIX (EACH DEFICIENCY MUST BE PRECEDED ev FULL pREFix (EACH CORRECTIVE SHOULD as i COMPLETE TAG REGULATORY 0R LSC IDENTIFYING INFORMATION) TAG APPROPRIATE DATE i I R179 Continued From page 14 R179 . i pathogens and Universal precautions; and R174 35/9 '567l0f655 and CV30 . i (7) General supervision and care of residents. was are images i 3/,7/w . i OUI EMEN 5 Man da7?0?f wet-C This RE is not me as evi once i . by: . i {Nor-E C/?i?jg/y Based on employee file review and staff interview 00m Militia? 5mg? 0M0 the facility failed to ensure that?2 of 8 employees '09 receive twelve (12) hours of training each year for fin/SS (1an andr?'or?f ?193' a each staff person providing direelcare to mm be af?rm an residents. The findings include the following: [?6'be mu? Cme/gfe (it I . a Review files on $316 presents that Edelys Dinah? 6 ?7 Mo caregivers did not have the required twelve 01/2 Flam hours of training. Two caregivers did not have Mm training hours in Emergency response, Resident th?lf (3007197 0 FEW Rights, Abuse/Neglect and Exploitation and one Hg 6? ?7 did not have training hoors for infection Control. waif/7,33% This was con?rmed by the Human Resource Registered Nurse on 2/3l16 at 1:05 PM. R187 V. RESIDENT CARE AND HOME R187 . . . 2? ?77 .711"? engined (e5. Jen?? Ail" 5.12.b. (1) M5 d?5+mlf?d dorm? A resident register including all discharges, @nsfru?jwri s? 15mm? ?(Ii/reg I transfers outof the home and admissions. ha& been moreofed (Md wed This REQUIREMENT is not met as evidenced be m; ?fe/fled 6.1., We. house by: .- {as reviewed Based on staff interview and record review. the ef? ?mm i facility failed to have a resident registerthat 011055 mow/{ply (if includesall discharges, transfers out of the home 5 mac 79,46 Wp?h and admissions Findings include: i homage?: M- i th 'd th :4ng UpDn request or real en regis or, ouse . I 41/in (Maggy, manager presented a current list of the census. (fir-66' . Further review of previdu's logs presented as Division of Licensing and Protection STATE FORM ll continuation sheet 15 of 26 dsflafzels 11:29 BUR HOUSE Ha PeeE earl? PRINTED: Generaoie FORM APPROVED Division of Licensing and Protection STATEMENT OF (x1) pie) MULTIPLE CONSTRUCTION (st mire SURVEY AND PLAN OF CORRECTION NUMBER: A. COMPLETED 0377 8- WING 0210312016 NAME OF PROVIDER DR SUPPLIER - STREET ADDRESS. CITY, STATE, ZIP CDDE as ALLEN STREET SID . OUR HOUSE TOO RE ENTIAL CARE HOME RUTLAND, VT 05701 (M) ID SUMMARY STATEMENT OF ID 3 PROVIDERS PLAN or: CORRECTION 5 1x5) PREFIX DEFICIENCY MUST BE PRECEDED ey FULL I [31:25le CORRECTIVE ACTION SHOULD BE 1 COMPLETE TAG REGULATORY De Leo IDENTIFYING TAG I TO THE APPROPRIATE DATE . i i I Continued From page 15 i i incomplete. Con?rmation by the house manager I on 2/3163 at 11:35 AM that the register does not i include discharges of residents and that there are residents listed that no longer resident at the i R213 VI. R213 5 ss=e 6.1 Every resident shalt be treated with 2, 5 consideration, respect and foil recognition of the resident's dignity, individLIaiity, and privacy. A home may not ask a resident to waive the i resident's rights. 1 This REQUIREMENT is not met as evidenced by: Based on observation and staff interview, the facility failed to treat each resident with respect and dignity, ReSidehts 6, 7, 9 and 10. Findings include: 1.) Resident 9 was administered Acetaminophen topically en 32116 at 12:15 PM, the medication delegated staff member applied 3 two squirts from the pump bottle into his/her i gioved hands and applied it to the chest of the resident while the resident was seated at the dining room tabie waiting for iunch. The resident had a visitor and there were other residents in the dining room. After the administration the staff member confirmed that the resident was in a public area at the time of administration and it probably should have been dene somewhere else. 2.) On 2/2l16 at 4:45 PM. Resident #10 was wandering in the facility with pajamas on and then was later seen sitting at the dining room table. At Trainer had) been (sectors-eat a? 90m Stat-Ba Ehdih?se??a tired Mg; We WA met ?are.? i?Lem (far-agate: ihpct-i?lislmm? +0 rained) dict-r 0171f, each thunder/?ti? L5 i5 S?peuati unit peqple MM: cijemen (vanities have heirs bf leaf/mi? Qdu?q?-iah On Our? Indl?tcttud {of ?Stead Leashupe mater 3;.er Rn? 09:10 ?r Certain I'nd?mduaci? (we! Rim tired are mavens and Suppam' ?i?idld?: daemons - o'neL) eating $50 "t mitcommon- (bugi'ati 5mm id be done. ?ight-{7 .. he, .. F?Tis Covered moth area: ef?Seic?L?. biuiri? has been advised We? Division of and Protection STATE FORM if continuation sheet 13 of 26 asflafaete 11:29 Division of Licensinq and Protection BEIQTTETTGE EILIR HCILISE HG eifl? PRINTED: oznarzo It?j STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDERISUPPLIERICUA IDENTIFICATION NUMBER: 0377 FORM APPROVED MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING: COMPLETED 0210312016 NAME OF PROVIDER OR SUPPLIER OUR HOUSE T00 RESIDENTIAL CARE HOME STREET ADDRESS. CITY. STATE. ZIP CODE 69 112 ALLEN STREET RUTLAND, VT 05701 PROVIDERS PLAN OF CORRECTION ?facility uses large cloth incontinent pads on the I 5:05 PM Resident 6 was also seen sitting at the i dining room table in pajamas. Interview with staff at this time presented that the One resident had been incontinent and the other had a shower and e/he is sometimes resistive after dinner. so it was not unu5ual to put them in pajamas because it is easier. 3.) On 212/16. during a tube feeding observation i offer Resident# 7 at 4:00 PM, the resident began to cough and had museus in his/her mouth. The caregiver used the hem of the i resident's shirt to scoop the mucous out of Resident #7?s mouth. When the tube feeding was completed, the caregiver left the room. S/he confirmed at 4:10 PM that she had used the shirt to wipe the mucOus Out of the mouth. rt) On 2/2216. during the evening meal observation at 5:45 PM. Resident#10 had been eating a sandwich and haif of the sandwich had fallen on the ?oor and half ef'the other half was on her chair, she had also spilled some of hisrher-s drink and had clumped some of hisrher pears onto the plate and was trying to bite the bowl. The caregiver stated that they don?t assist him/her because they get angry and then won't eat, but did confirm that his/her appearance at this meal was not digni?ed. 5.) Par observation on 2i2i1i5 and 25/16. the couches and chairs. Per house manager. they are used to protect the furniture when the residents are incontinent. On 2/3/16 at 5:45 PM sihe confirmed that it could be a dignity issue for the residents. i I i i (int-i aL {x4310 SUMMARY STATEMENT OF DEFICIENCIEB ID (x5) PREFIX DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE . COMPLETE TAG REGULATORY oFt L30 IDENTIFYING 1A5. CROSS-REFERENGED To THE APPROPRIATE DATE 1 R213 Continued From a 16 R213 . - I E?s-idend' writ 00hr tandem/91? Ether.) bE?. Served Smell-i] timed/it?d one demo men/Er?eri?j- away}; +0 k?fep mower/?am 6"?ng an ihdrv?ldmei baa/5e Trains? and House ?1&2?qu waif r751" Pg] resident? Mead are expected *0 ?fe-077 ?Hie and Site/?7? War/red discard/?ag hi? It, fan?s Leg/dent?" 43C Whrx?er ram-?1- MM 5 was ??ppy Wain/Ila if?" 69'5? Chews; Add ?eevz ?mmc?td 0:5 His repentance dp?e?j?o? rind eels/en [Habit/3g . .t xii/Irv 3.5 .. ?nd MW. Division of Licensing and Protection STATE FORM- ?t'if-Ii? continuation shoot 17 Of ZE- 11:29 882TT2TT33 Ditrision of Licensing and Protection OUR HCILISE FREE 882' 1 PRINTED: I5 STATEME AND PLAN OF CORRECTION (x1) PROVIDERISLIPPIJERICIJA IDENTIFICATION NUMBE R1 NT OF DEFICIENCIES 0377 FORM APPROVED (X2) CONSTRUCTION (X3) DATE SURVEY A. BUILDING: COMPLETED 0210312016 NAME OF OUR HOUSE T00 RESIDENTIAL CARE HOME PROVIDER DR SUPPLIER STREET ADDRESS. CITY. STATE, CODE 691i? ALLEN STREET RUTLANO, VT 05701 Residents shall be free from mental, verbal or physical abuse, neglect, and exploitation. Residents shall also be free from restraints as described in Section 5.14. This REQUIREMENT is not met as evidenced by: Based on observation. staff interview and record review, the facility failed to ensure that 2 of 8 residents sampled, Resident #3 and #5 were free ?ndings include the following: - 1.) Per observation on 2/3/16, at 10:28 AM, Resident 6 had wandered into the bedroom of Resident Resident #2 was kissing Resident #5 and they were both touching each other inappropriately. The house manager was notified at the time of observation and s/he redirected Resident #6 from the bedroom. Per interview with the manager at this time. the residents have dementia and the families have not consented to the behavior. At 10:45 AM per interview with a caregiver that was in the vicinity at the time that Resident #5 had wandered into the room stated that slhe didn't think anything about where the resident wandered to because a lot ofthe residents wander into Resident #2's room. She said that the two will hug and hold hands. but nothing has ever happened before. Resident #2 had been observed at different times. during the incident that involved pushing another resident resident of the opposite sex. Per interview with the house manager at 2:15 PM, she confirmed from sexual and physical abuse and neglect. The survey, directing his/her attention toward another resident. Resident #2 was also involved in a prior I because both of them were interested in another sari" ('55 ?Hem-eel J1) mariner? ear-m3 emits as. new?? on going gs 5Com ref-Ions drlJ-E.? . A?xem ?1.06 Mken (.35 died/nerd. fig :3 .5 emf fee ?Katy ?f?lf?g ?Framed 1L0 CHILI PIT-dig trimmed torts Int Iii-wed pens are game/Is?ed candida-Se ital-f Cede baa/3i 2) NOT woof ao??our else SUN/stitanes ?tfsri't?m Omega {garb Who Mt:- Cieldooendo meal ?l her Clo movbem did cement-Inga r?t kt diode evidences .. Potter; were Causal, APdw St?? {Iepor't? Were it IECL - Penman?? {:35 Muss +Iw. VT Starr's? Award-ext (Ea-semi. Gill? tht?r? Maj ?3,335,726 writ-bin 50 sea sisal/19M ID SUMMARY STATEMENT DF DEFICIENCIES ID . PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST as PesoEbeo BY FULL CORRECTIVE ACTION as commit TAG REGULATORY UH LSG IDENTIFYING I TAG CROSS-REFERENCED TO THE APPROPRIATE 3 DATE - I DEFICIENCY) I . i R224 Continued From page 17' .1 R224 R224 VI. RESIDENTS RIGHTS R224 seas I 0'3 zeal n47 5?12 FILL feSloIen We sme .ct I .Z/l'i/Nw Division of Licensing and Protection STATE FORM CID If continuation sheet 13 01?26 aarldraols 11:29 OUR HouaE Ho earl? uzntiizmc? FORM APPROVED Division of Licensing and Protection . . STATEMENT oi= DEFICIENCIES on) PaoVIoERisur-vpuemcua (x2) MULTIPLE CONSTRUCTION 013) DATE suavey AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED C: 0377 3- WING 020332016 NAME on PROVIDER oe SUPPLIER STREET ADDRESS. CITY. STATE, ZIP cer 69 ALLEN STREET OUR HOUSE Too CARE HOME RUTLAND, VT 05701 9(4) Io SUMMARY STATEMENT OF In PRoutoEn's PLAN DF (x5) PREFIX DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE COMPLETE mo REGULATORY OR IDENTIFYING m3 To THE APPROPRIATE DATE i i DEFICIENCY) i R224 Continued From page 18 R224 . . It: 0 tar" TIPS ole?IF" that the residents not been monitored for Con?rm Huff; rail? behaviore of the type witnessed. but they hairs Can't? at (Stations Rid/7 and Cr? 5 hugged and held hands before-and Resident #6 . whgr??f ?ea-?156?! .. has been in the room of Resident#2 before, also Cid-w? 09 mm; ?1 confirmed that the behavior was inappropriate. Cont? mug. ?mime Stump i 2.) Per review of intake information dated 0n W?qwn??lz? (?hi 0F (2ng m? ?1516, provided by the facility administrator, I deio?U and Resident #3 was observed on a video surveillance tape dated moi/15 at 1:58:58 QM mah??a?r?, a II Step; through 2:00:10, being pushed by resident care - A. outUL attendant from behind catising the resident to (2nd (Ed at imam/def? fail to the floor. The employee walked away from For" dam f?hc? . Resident #3 who was lying on the floor. The l?br (P attendant did not offer the resident assistance her did sine report the occurrence to resident care tau m; dim)? l??ibn attendant who was on duty at the time. Per dd?: Why}, ?t Edinma?ledv" intake information the perpetrator abandoned partial: ?5 . ?y herihis position at approximately 3 AM, leaving dementio' is cl ?cussed the facility understaffed and without a medication ?1 dame/77W: #02215 technician. Rap/e tun/h ?exils?r' 2?00 (3'11; dag/?30 P3 62 Comm I i 5147/ Per observation of the video surveillance on +410? l1 Q?+f?d witty at approximately 9 AM. in the 1 (15 turf}: dis/14977413! administration offioe for the four"Our House? I. {,2ch b0? fed . with the administrative staff and the need manager of the facility, con?rmation is made that ?ance 15'? CM - the Surveillance tape evidences the physical mrd?/ 95?; {3?33 Wg?? abuse to Resident #3 by employee Compass/one I e1 . (and aged/V" . Per resident care service note dated u' . . . f) (at? Hf) 1/ ?317 r' the resident returned to the faoility after i - Gf?'f/ 7/ Emergency Room evaluation with a diagnosis of i' POT Cit? if?! 10/42/1755? ?9 right hip contusion and treatment advised. i [?nerfat. 0? 7?10 I R228 VI. RIGHTS R228 em?? - a 552A ?dM/fir??ffa? 2? 3% i - . ?5.16 Residents have the right to formulate I Division of Licensing and Protection STATE FORM 059?] P9..N1 1 if continuation shoot 19 of 26 83f14i?2818 11:29 OUR HOUSE HQ PRINTED: 021 I step I FORM APPROVED Division of Licensing and Protection STATEMENT OF DEFICIENCIES MULTIPLE CONSTRUCTION 0(3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUII COMPLETED 0377 ii- WING 02/03/2016 NAME or PROVIDER 0R SUPPLIER STREETADDRESS. CITY. STATE. ZIP CODE 69 ALLEEN STREET OUR HOUSE TOD RESIDENTIAL CARE HOME RUTLAND, VT 05701 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID i PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEOED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY 0R LSC IDENTIFYING INFORMATION) was CROSS-REFERENCED TO THE APPROPRIATE DATE R228 Continued From page 19 R223 . advance directives as provided by state law and [3.2/19 Q$;def7b {Wt/it {?8ch (2?35 1 to have the heme follow the residents Wishes Some ?are Pam: 11% man u; 9 Wm bar's ?4 Mar tit-l will lists REQUIREMENT is not met as evidenced (1'8 see on a Um direct-IV? Based on record review and staff interview the %Du6h Lift? Con-Ii-Inue 4?5 facility failed to assure that 1 of 10 residents - 5-57? sampled, formulated advanced directives as We (2&an I provided by state law and to have the home H0 as man a; i follow the residents? wishes. The ?ndings include doctum era?{- the following: Ponce.) tip and gr??tion? Per record review on 2/2/16 Resident #2 was ayng?S/Cth admitted to Our House Too, on 117/15. IO pg 5 I deh?b Document titled ?Telephone Order Form" signed 01 be: 03de by the physician on 6/15/15, identifies orders as Phi-staid?) [vi-3L Ch foilows: Do Not Resuscitate (ONR) unless and or changed by me. Clinician Orders for Life OF {r610 Sustaining Treatment(COLST) form in progress. than Wm Physician progress note dated 8/31/15 paragraph - titled: "Impression" (Imp) #5 evidences. COLST in NM Chap-n+5 goat/I; wig/ya. progress with family for (Do Not (31?:an Q?r Admnce l-ntubate). called family in and .. we are in Contact mailed to him"}. Per 5 dif?t? W11 3? interview with the Residential Care Home Manger . - . . 5 on 2/2/16 confirmation was made that the facility Mott mm a? e? - has not received any COLST form from the family Chi-U231} andR247 detail waft lee. mggedm #491 raided?" . 7.2 Food Safety and Sanitation mgr-I (1(9ng Matti ?75? R247 NUTRITION AND FOOD SERVICES 88:5 7.2.b All perishable food and drink shalt be labeled, dated and held at proper temperatures: . (1) At or below 40 degrees Fahrenheit. (2) At or above 140 degrees Fahrenheit when served or of Licensing and Protection STATE FORM 5m if continuation sheet 20 of 11:29 seerr2??33 OUR HOUSE HQ PAGE 11ft? PRINTED: 02H [1.12010 . FORM APPROVED Division of Licensino and. Protection STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 0377 3- 0210312016 NAME OF PRDVIDER 0R SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 69 112 ALLEN STREET OUR HOUSE TOO RESIDENTIAL CARE HOME RUTLAND. VT 05701 ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDERS PLAN OF CORRECTION . (X51 PREFIX (EACH osncrencv MUST BE PRECEDED sv FULL peEFrx (EACH CORRECTIVE ACTION SHOULD BE . COMPLETE m3 REGULATORY on Lee IDENTIFYING INFORMATION) rec cnoss-nsreesucec TO THE APPROPRIATE - DATE DEFICIENCY) R247 Continued From page 20 F2247 heated prior to service. . #1 m" see? lea bet rewriteI entire This REQUIREMENT is not met as evidenced by: head 1?0 L??b?ayd??p? CID Based on observation and staff interview. the $603 a -. facility failed to labeland date ail perishabiefood. 5 . . 3W - Findings include?11 Accompanied by a caregiver on 2/2/16 for the NIH CI limits-?5 m. Iggf initial tour, it was observed at 10:53 AM that 3 Dr? ?hd,n c1 5 :3 refrigerator #2 in the kitchen, had two jars of . 6F) . 5 3/10]! 4? grapejelly, a jar of applesauce, a container of ?fltalr??d Comma? . stuffed shells (per the caregiver), lettuce. a bottle . H15 of barbecue sauce and a package of shredded Cid-:5 cheese. None of these items were dated as to . 15"} when they were opened. The sheila and the ?07 been pm we?) shredded cheese were not labeled as to what the 4M we, en's contents were in the packages. In the freezer I) I or? there was a package of chicken nuggets that did (ELI respond! not have a label as to what the contents were and er" no date as to when opened. These were COMP hence? confirmed at the time of discovery by the caregiver. LDLUthe kitchen cupboards there were Open jars of peanut butter and a container of Fluff that were not dated as to when they were open. In a food storage base cupboard there was an Open bag of cereal and and Open macaroni. also without dates as to When opened. These diSooveries were confirmed by the caregiver at the time of discovery. R253 VII. NUTRITION AND FOOD SERVICES R253 ss=o i -. 7.3 Food Storage and Equipment i 7.3.c Ail food service equipment shall be Kept Division of Licensing and Protection STATE FORM men If continuation sheet 21 r3126 11: 2?3 Diviision of Licensindegd Protection CIUR HCILISE 12f1? PRINTED. STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION can PROVIDERISUPPLIERICLIA NUMBER: 037T FORM APPROVED MULTIPLE CONSTRUCTION DATE SURVEY A. BUILDING: COMPLETED a. WING 02f03/2016 . NAME DF PROVIDER DR SUPPLIER OUR HOUSE TDD RESIDENTIAL CARE HOME STREET ADDRESS, CITY, STATE. ZIP CODE 59112 ALLEN STREET (X4) ID PREFIX TAG SUMMARY STATEMENT oFoer-icisnciss (EACH MUST BE PRECEDED BY FULL ass or: Lee IDENTIFYING RUTLAN D, VT 05701 ID - PREFIX TAG I showcase PLAN or: ooeescnow (EACH CORRECTIVE ACTION SHOULD BE CROSSHREFERENCED TO THE APPROPRIATE I (x53 COMPLETE DATE R253 R259 Continued From page 21 Clean and maintained according to manufacturer?s guidelines This REQUIREMENT is not met as evidenced by: Based on observation and staff interview, the facility failed to ensure that sit food service equipment was kept clean. Findings include: During the initial tour ofthe facility on 1212/16 at 10:55 AM. accompanied by Caregiver, in the kitchen the microwave turntable had dried peas and matter and there was build-up on the Sides and top of the inside of the microwave. The caregiver stated at this time that it should have been cleaned and confirmed that there was food build up in the microwave. VII. NUTRITION AND FOOD SERVICES 7.3 Food Storage and Equipment 7.3.i Poisonous compounds (such as cleaning products and insecticides) shall be labeled for easy identification and shalt not be stored in the food storage area unless they are stored in a separate, locked compartment within the food storage area. This REQUIREMENT is not met as evidenced by: Based On observation and staff interview, the failed to store poisonous compounds in a locked compartment in the food storage area. Findings include; During the initlai tour on 2.12.116, accompanied by a caregiver. at 10:53 AM, in the kitchen, there R253 R255 R259 3 (2an I5403E CdmI?'J??f . Static? has been ramindi? data: at Wee Show id, Ice cleaned occurs Celtic W43 he discusses} ct)? It's?Service Wam?es" audit mood?" . Locked. box es heft been oral Great For an (I Prod more +Iuc Stag? has been mm In cited 09 regulations also Lotti be discussed art In? Semies amt/Ito Division of Licensing and Protection STATE FORM 5:11 lf continuation sheet 22 or 26 i331? 143281 E: 11:29 Division of Licensing and Protection 131?17 PRINTED: 02H STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: 0377 FORM APPROVED IxaI MULTIPLE CONSTRUCTION (xai DATE SURVEY A. BUILDING: COMPLETED 3' WING 0210312015 NAME OF PROVIDER CIR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 691i? ALLEN STREET OUR HOUSE TOO RESIDENTIAL CARE HOME on} 10 I PREFIX TAG RUTLAND, VT 05701 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX i TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (XS) COMPLETE DATE R259 R256 Continued From page 22 were eight cans of disinfectant spray, three cans Of EBTOSOI oven cleaner, CENTS Of furniture polish and 3 containers of Cascade dishwasher detergent. The manager of Our House Outback, who was at the facility to assist with the survey, con?rmed that the chemicals were inappropriately stored at the time of discovery. IX. PHYSICAL PLANT 9.1 Environment 9.1a The home must provide and maintain a safe, functional, sanitary, homelike and comfortable environment. This REQUIREMENT is not met as evidenced by: Based on observation and staff interview, the home failed to provide and maintain a safe. functional, sanitary, homelike and comfortable environment. Resident #7 regarding infection control and homelike environment for all residents. Findings include: 1.) Per observation on ZIZHS and 26116. the facility uses large cloth incontinent pads on the couches and chairs. Per house manager. they are used to protect the furniture when the residents are incontinent. .On 213MB at 5:45 PM slhe confirmed that it did not a homelike environment for the residents. R259 R266 that? I I 2.) During initial tour of facility, accompanied by I caregiver on 212MB at 10:50 AM. Resident #7 hadl a suction machine at the bedside. Resident #7 requires oral auctioning asneeded, there was Imt We are We 0P ?+6111 M55 0i: Ember pee? {Dormitory MIT ?en/if 20f In" Con?fulba?c?? [9be 61/50 For 5PM: "fact/arr: Merit? ywm?amoi 7?0 MM On restate/7% dad?s .r I?chesaziner {eater pads are in ?le house and mark: have It: den ?fc/Frldo/ 8&9? Ado [966:7 [Emma/e 0? of proper use 4'0 be done out" zn?efeiiuzm do eraser? Wrest'? re a ma 214365;! 710 2?77m7/7?0P My? 5! Erie stagger; 5 Tides-honed It?; .2) and rTeqbrirrxond?I Sail? Km?; 5 [Drape-tr" arses?? g/m/yc Ef?e/e Division of Licensing and Protection STATE FORM M113 Ii continuation sheet 23 of 26 11:29 Djtision of Licensing and Protection EILIR HEILISE 14:17" PRINTED: FORM APPROVED 9.2 Residents Rooms 9,2.e Resident bedrooms shall be used only as the personal sleeping and living quarters of the residents assigned to them. This REQUIREMENT is not met as evidenced by: Based on observation and staff interview, the facility failed to insure that resident's bedrooms be used only as the personal sleeping and living quarters of the residents assigned to them for 1 of 13 residents, Residents?c 5. Findings include: During a tour of the facility on 2/2/16 at 10:30 AM accompanied by a caregiver, it was observed that Resident #5 had two closets in their room. Upon inspection, one of the closets contained a vacuum cleaner, storage boxes for things returned to the pharmacy, some linen and blankets and other items. The caregiver stated that the closet was used for storage for the facility. Slhe confirmed at this time that staff have to go in and out of Resident #5?sbedroom in order to get things from the closet and that the resident can?t store any of their belongings in that . closet. STATEMENT or DEFICIENCIES {x1} (x2) MULTIPLE CONSTRUCTION co) DATE suevev AND PLAN or: IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 0377 3- 0303/2016 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE as we ALLEN STREET 0U Ho semen USE Too TIAL CARE HOME RUTLAND, VT 05701 (x4319 SUMMARY STATEMENT oF DEFICIENCIES ID i PLAN oF CORRECTION (x51 PREFIX DEFICIENCY MUST as PRECEDED ey FULL seem (EACH CORRECTIVE ACTION SHOULD BE 1 COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE R266 Continued From-page 23 R235 (miudmg Cleo/mtg thick yellow mucous in the tubing as well as the rag/{3Q and Yankaur Suction oral apparatuscaregiver, the resident probably needed to be I 00%? ?3 7 ?26 s-uctioned during the night and the tubing is i suppose to be cleansed with water after each i use- S/he also confirmed at this time that the tubing and oral piece had not been cleansed. R272 IX, PHYSICAL PLANT F2272 ss=o Q272- 9150 5Li'bmr?zec! Ms at {War deed S/ai/as m? which 1% was seated pkg-fiend plat/17? it?d/7min were awake; 0,15 Hates? one seat has M5 been years (150 .- 7Hi'zs {new ?ve) Very r?di??c c/Mefs Hi #76 room tit/inf Ads?, 69?5?! We emerge aF r53 use -3?;sz5 7111;?: (Wiser/- nosed can/7' be disc-misc} Wile-r? HMore remote/if MU {of ??rmed; 1/31? duf-afwirte 50m. 'Mu er asi- vii/Lay} sin/5A3 ??iandersfeoa/ at: cringe/22.5165 Jim? rd Anon/ted. Division of Licensing and Protection STATE FORM Wt PQJV11 If continuatlon sheet 24 of 832?142?2818 11: 2?3 ULIR HOUSE H13 PAGE 152?1? PRINTED: 021?191?2016 . - FORM APPROVED Dixiision of? Licensing and Protection . STATEMENT OF DEFICIENCIES no} MULTIPLE CONSTRUCTION (X3) SURVEY . AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED C: 0377 3- 0210312016 NAME OF PROVIDER oR SUPPLIER ADDRESS. CITY, STATE. ZIP CODE 69 'Il2 ALLEN STREET OUR HOUSIE TOD RESIDENTIAL CARE HOME RUTLAND, VT 05701 0(4) in SUMMARY STATEMENT or DEFICIENCIES 1 ID . i PROVIDER's PLAN OF CORRECTION (X5) pREFix (EACH DEFICIENCY MUST BE PReceoeo av FULL PREFIX CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY 0R LSC toE NTIFYING INFORMATION) 1 TAG 1 To THE APPROPRIATE DATE . DEFICIENCY) . I R302 Continued From page 24 i R302 ?aesmAy?f?q d/oJe?f fm? aag?a SR3302 IX. PHYSICAL PLANT R302 4M mam Ass ,5 egg ?Mega =3 {std c1 )3 {ta/Fe?, A5 do 9.11 Disaster and Emergency Preparedness a?g?zde .515 we? a; eta/,5? . 5/ do 9.11.c Each home shall have In effect, and 61656452?, #1 7th" OUT available to staff and residents, written copies of MCWM. a plan for the protection of all persons in the - event of ?re and for the evacuation of the building when necessary. All staff shall be instructed periodically and kept informed of their duties R302- 5mg; has a 5mm? [41 under the plan. Fire drills shall be conducted on Err? F252 dill-(5* at least a quarterly basis and shall rotate times of ?ame Limit-I? day among morning, afternoon, evening. and - . 524?. night. The date and time of each driil and the The 25 Mat?)? 4/1'6 names of participating staff members shall be Dw?rgt 1,31% F?g gm, ll . contented. medulla. (putt be (Ewan) . grant at at. mean This REQUIREMENT is not met as evidenced . ab? 1 by: Man 5 meshes; A Baeed on staff Intervtaw and record reVIew. the Mlle bite-Eh add (321 4.0+ faoiitty failed to conduct the drills on a quarterly .. . hard BBL basis. Findings include: Mn err?: Cid?$1 During revzew of facaltty conducted fire dl'tIlS on 5?35 pt r? LL: m2, 5- 212116, the last OOndUcted fire drill was $24115. gamed LLled and. mu. I interview with the house manager at 11 :35 AM, {a sine stated that she thought they had to do six be Con per year and after reviewing the State Camp ?(1nd? with Regulations for Residentiai Care Homes, sine . . may L. confirmed that sine had not completed the fire Sa?'t?t .4 drills quarterly. maha??- ucht, Mon l, or. i R999 MISCELLANEOUS ii Rees i Based on observation and staff interview, the facility failed to encourage or provide activities for the Enhanced Residential care residents. Division of Licensing and Protection STATE FORM 0599 If continuation sheet 25 of 25 11:29 Division of Licensinq and Protection OUR HOUSE 1531? PRINTED. 02f16r'2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (x1) NUMBER: (x2) CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Others were sitting at the tables in the dining room and a couple were walking about the facility. At 2:00 PM, a staff member was asked about the type of activities the residents do, slhe said that they had not been done today and there aren't very many activities for the residents. Another staff member responded that there are no activities fer the residents. Sine said that they do them if they have time, but not every day, usually they are too busy. Staff member that is responsible for education regarding care stated that they have a scheduled activity book. but slhe can not locate it. Srhe 'said that they try to do something every day, but sometimes it gets too busy. The evening medication staff stated that there are no activities because they are too busy, but the residents like to color and they will try to let them color whenever they can. Resource: Vermont Department of Disabilities, Aging-and Independent Living Choices for Care. Lon-Term Care Medicaid Program Manual. Page IV.8.-2, #4 Recreational Activities. I '7?105? 77mg; Ms defuoh?zdf) arid ~84? pact-en?xaris me! In 3:14? lerVreMd (ind be drdcagg?o? dij' s/xe 77a me? and mam (2523/ Wed e7?. r" 0377 B. WING 021032016 NAME 0F PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 691i2 ALLEN STREET OUR House T00 CARE Home RUTLAND, VT 05701 (x4) is SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) (EACH osmosncv MUST BE PRECEDED sv FULL PREFIX i (EACH CORRECTIVE ACTION SHOULD as comma-rs me REGULATORY on Lee IDENTIFYING INFORMATION) - TO THE we oesrcrencvi Rees Continued From page 25 R999 Findings include: It was Observed on 2/2l16 that most of the #61170 ?lye-J anemic-32d reSIdents were seated in chairs tn the sitting area i . and a television was turned'on to music videos. I each a 3557 g/z/ n2: Division of Licensing and Protection STATE. FORM (-099 IT continuation sheet 26 of 25