N.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 Voice/TTY (802) 241-0480 Survey and Certification Fax (802) 241?0343 Survey and Certification Reporting Line: (888) 700-5330 To Report Adult Abuse: (800) 564?1612 February 6, 2018 Mr. Adam Lawrence, Manager The Residence At Quarry Hill 465 Quarry Hill Road South Burlington, VT 05403 Dear Mr. Lawrence: Enclosed is a copy of your acceptable plans of correction for the survey conducted on January 3, 2018. 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, WM Pamela M. Cota, RN Licensing Chief Developmental Disabilities Services Blind and Visually Imparied Licensing and Protection Vocational Rehabilitation PRINTED: 01I?18r'2018 FORM APPROVED Division of Licensing and Protection STATEMENT or DEFICIENGIES (x1) PRovIoEmsuppLIEchUA (x2) MULTIPLE {x3} DATE SURVEY AND PLAN or IDENTIFICATION NUMBER: COMPLETED A 1012 8- MNG 0130310018 NAME OF PROVIDER OR SUPPLTER STREET ADDRESS. STATE. CODE 465 QUARRY HILL ROAD SOUTH VT 05403 THE RESIDENCE QUARRY HILL {x4} [0 SUMMARY STATEMENT OF DEFICIENGIES ?3 Tex estrargssesrestraints; i, R100 i i al Comments: R100 R100 Initial comments: The . submission of this plan does not An unannounced on-site re?lIcensIng survey was constitute any admission of any wrong completed on 113118 by the Vermont Division of doing. Rather, this plan Of correction is Licensing and Protection to determine submitted in the spin?t and in the letter of compliance with Vermont Assisted Living cooperation to demonstrate The Residence Licensing Regulations. The following Residence at Quarry Hill?s commitment to regulatory violations were identified. continued quality. R123 V. RESIDENT CARE AND HOME SERVICES R123 R123 Action to correct Deficiency: Current residents will be provided with an 54 Refunds addendum to their current residency 3-1-18 by agreement to reflect all refunds to be ED 5.4. a When a resident is discharged, the given Withm 15 days Of discharge. resident shall receive a refund. within 15 days of Steps to prevent recurrence The discharge. for any funds paid in advance for each Quarry Hill residency agreement will be day care was not provided. In the case of a reviewed and revised to reflect discharge to a hospital or other temporary requirements listed in 5.4.a. Any new placement, the effective date for this provision residents moving into the community shall shall be the day the home is notified the resident receive the revised residency agreement. will not be returning. For the purposes of providing refunds, "day of discharge" shall be considered the day the resident's room is empty of the resident's belongings, if those belongings are too large or dif?cult for the home to store temporarily. The facility shall temporarily store small items such as clothing and other personal items if necessary- This is not met as evidenced by; Based on staff interview and record review_ the facility failed to assure that resident admission agreement language was in accordance with Vermont State Assisted Living Regulations for 3 of 3 applicable residents sampted? (Residents it 2, 5 and 6). Findings include: Per review of the admission agreement form used by the facility on 113118, the language we? an AS I ital-gem: LABORATORY CTORSO SIGNATURE Il'i'tEE (X5) Exem?ve STATE. FORM M3WT1 1 ilcontinualion sheet 10f28 l?Ots (implicit 645M Kichs?nli?nw PRINTED: 01l18r?2018 FORM APPROVED Division of Licensing and Protection STATEMENT oF DEFICIENCIEs (x1) PROVIDERISUFPLIERICUA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. 1 LD I (31 COMPLETED 10 I 2 a 0NQ3I2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 465 QUARRY HILL RDAD THE RESIDENCE AT QUARRY HILL SOUTH BURLINGTON, VT 05403 (x4) ?3 SUMMARY STATEMENT OF PLAN OF CORRECTION {st PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH ACTION SHOULD BE coerJLErE TAO REGULATORY OR INFORMATION) TAG WE R12300ntinued From page 1 R123 related to resident refundS was not in agreement 3-148 by with the stated Vermont regulations for time Executive requirements for refunds after discharge. The facility's admission agreement stated that refunds D'redor- will be made within 30 days Of discharge: the required regulatory time period for refunds is within 15 days of discharge. Per review Of a sample of 3 signed and dated admissiOn agreements, all of the agreements included the incorrect time period for return of unused funds after discharge from the facility. The error regarding the required time period for refunds after discharge was confirmed during interview with the Executive Director on the afternoon Of 1/3118. R128 V. RESIDENT CARE AND HOME SERVICES R128 R128: Action to correct deficiency: Signed Physician orders for all 345-18 by medications for residents #1 and 5 will RCD 5.5 GeneralCare be obtained. Steps to prevent recurrence: All 5.5. c. Each resident's medication, treatment. nurses will be provided with re- and dietary services shall be consistent with the education on policieS. procedures and physician's orders. requirements listed in 5.5.c pertaining to obtaining physician orders. The RCD or designated nurse will be reSponsible for This REQUIREMENT is not met as evidenced ensun'ng 8" physician orders are signed by: appropriately for new and current Based on staff interview and record review. the residents. The ROD or designated?nurse facility failed tO assure that each resident's monitor th's w'th each new reSIdent medication, treatments and dietary services were adm:ssron. consistent with physician orders for 2 of 6 residents in the sample. (Residents #1 and Findings include: 1. Per review of the medical record for Resident there was no provider order. including 8 dated signature on the initial visit summary to establish care dated 11!8f1?, which included a list of the STATE FORM M3WT11 ?continuation sheet 20f28 PRINTED: 01f18f2018 . FORM APPROVED Divismn ofL1ce1?smg and Protection STATE FORM M3WT11 "continuation sheet 3 of 28 Division of Licensing and Protection PRINTED: D1I18I2018 FORM APPROVED STATEM ENT OF DEFICIENCIES (X1) AND PLAN OF CORRECTION IDENTIFICATION NUMBER: IUIZ (x2) MULTIPLE CONSTRUCTION BUILDING: BWINGHH (X3) DATE SURVEY COMPLETED 0U03I2018 NAME OF PROVIDER OR SUPPLIER STREET ADD RESS.CITY, STAT E, ZIP CODE 465 QUARRYHILL ROAD SOUTH BURLINGTON, VT 05403 THE RESIDENCE AT QUARRY HILL (x4) Io PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) iD PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REF ERENCEDTD THFAPPROPRIATE CATF- DEFICIENCY) R128 R134: Continued From page 2 resident's Current medications. (Resident #5 was admitted to the facility on During interview with the RN on ?2117 at 2 PM. the nurse indicated that this visit summary was considered to be the initial order set of the provider after admission to the facility from another state. The RN had not realized that the orders were not properly executed, including the provider signature and date signed. As of the date of survey. (112118}, there were signed, dated orders for only 2 of 11 current medications, (telephone orders of 11I20I17 and 2. Per record review, Resident #1 was admitted in November 201?, and is administered medications by staff, including two types of insulin. There were MD.signed orders for the insulin regime as provided by an endocrinologist. The other medications listed by the primary care physician for this resident were not signed as part of the admission orders. The physician signed the ?rst page of the resident?s medical information. however the medication list was not signed and dated. The signed page stated to "see attached" under medications sectiOn, however there was no indication of which documents were "attached" to the signed orders. There was also no evidenCe Of an electronic signature on the medication list page. Per interview on 1I3I17 at 10:45 AM, the Registered Nurse con?rmed that the medication list was not signed as part of the admission orders. V. RESIDENT CARE AND HOME SERVICES Assessment 5.7.3 An assessment shall be completed for R128 R134 R134: 1 Action to correct deficiency: All medication assessments will be brought current. ROD 3-15-18by STATE FORM IJiTrTs'an?iLIcensmg and Promotion. M3WT11 1f continuation sheet 3 at 28 Division of Licensing and Protection PRINTED: 01i18t'2018 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 1012 (X1) NUMBER: A. BUILDING: MULTIPLE CONSTRUCTION . (X3) DATE SURVEY COMPLETED 01f03f2018 NAME OF PROVIDER OR THE RESIDENCE AT QUARRY HILL STREET ADDRESS. CITY. STATE, ZIP CODE 465 QUARRY HILL ROAD SOUTH BURLINGTON, VT 05403 rum: ll??nn?. A. A . l' lulu.? Ul? I tum (X4) 10 SUMNARY STATEMENT OF (D (EACH CORRECTNE Acne? BE A PREFEX (EACH MUST BE PRECEDED BY FULL pREm To THE APPROPRWE =e-Clltir'L-1-EE TAG REGULATORY OR LSC IDENTIFYING TAG DATE R134 Continued From page 3 R134 . Steps to prevent recurrence: 345,18 each? resident Within 14 days. of admission. Quarry Hill policy and procedure by RCD the physiCian s. diagl?IOSlS and . regarding assessing the residentis orders. using an aSsessment instrument provuded ability tO self-manage medications will by the licensing agency. The resident's abilities be reviewed and revised to meet regarding medication management shall be requirements listed in 5.7a. All nurses assessed within 24 hours and nursing delegation will be re-educated in regards to implemented. if necessary. pOlicy changes and recluirements listed in 5.7a Medication assessments This REQUIREMENT i not met as evidenced will be tracked through the Yardi bill Dashboard. The dashboard will be Based on staff interview and record review, the monitored daily by the RCD or Registered Nurse (RN) failed to complete an designated nurse. admission assessment within 14 days of admission to the facility, andlor failed to assess the resident's abilities related to medication management within 24 hours if necessary, for 3 of 6 residents in the total sample. (Residents 4 and 6). Findings include: 1. During interview (113MB at 10:30 AM) regarding the regulatory requirements for assessments upon admission. the RN (registered - nurse) RCD (Resident Care Director) confirmed that slhe had not assessed residents currently residing in the facility regarding their medication management abilities (if appropriate) within 24 hours of admission. as required. R134 2 a, b: and 0 Steps to prevent recurrence: Quarry Hill 2. Per record review, the following resident policy and procedures regarding new admission assessments were not completed resident admission assessments will 34543 within 14 days of admission to the facility: be reviewed and revised to reflect By RCD requirements listed in 5.7 a to include a. Resident admitted 10127716 and speci?c assessment timeframe of admission assessment completed 12i9l16; within 14 days Of admission. b. Resident #2 was admitted On mans. and nurses will be re-educated in regards the initial admission assessment was dated as t? change and requirements completed before the move-in date of admission I'Sted ?1 5-73 on 6i28l16. There was no assessment Assessments be tracked through completed after admission within 14 days of the the Yard! dash board- move-in date. C. division of Licensing and Protection STATE FORM M3WT11 ifconlinuation sheet 40f 28 Division of Licensing and Protection PRINTED: 01(18!2018 FORM APPROVED STATEMENT OF DEFICIENCIES (x1) PROVIDERJSUPPLIERICUA (x2) DATE SURVEY AND PLAN OF CORRECTION NUMBER: COMPLETED A 1012 ELWING 01f03f2018 NAME OF PROVIDER OR SUPPLIER STREET CITY. STATE. CODE 465 QUARRY HILL ROAD THE RESIDENCE AT QUARRY HILL SOUTH BURLINGTON. VT 05403 001) ID SUMMARY STATEMENT OF OEFICIENCIES PLAN OF ixs; PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY {mpg-ix (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR TAG CROSS-REFERENCED TO THE APPROPRFATE DEFICIENCY) WE R134Continued From page4 R134 d. Resident #4 was admitted on 3i22i17. and the resident?s assessment signed as completed before the move-in date on 3f16l17. There was no assessment completed after admission within 14 days of the move-in date. During interview (123218 at 10:30 AM) the RCD also confirmed at this time that the resident assessments were sometimes completed before the actual move in (admit) date and not within 14 days Of admission as required. R136 V. RESIDENT CARE AND HOME SERVICES R136 R136 Action taken to correct the Egg??3 5.7. Assessment 5.7.c Each resident shall also be reassessed annually and at any point in which there is a change in the resident's physical or mental condition. This REQUIREMENT is not metas evidenced by: Based on staff interview and record review. the Registered Nurse (RN) failed to complete an annual reassessment within a year Of their last assessment, for 2 of.6 residents in the total sample. (Residents #2 and #3).Findings include: 1, Per record review, Resident #2 was admitted 7116216. The annual reassessment of this resident was signed as completed and dated 8123(17. 2, Per record review. Resident #3 was admitted 4 10131i16, and the admission assessment deficiency: Annual reassessments for residents #2 and 3 will be updated. Steps to prevent recurrence: nurses will be reeducated on requirement listed in 5.70. to include annual re- assessment and change of condition policies. Assessments are tracked through the Yardi dashboard. The RCD or designated nurse will be responsible for checking this dashboard daily. Additionally the RCD or designated nurse will randOmly audit a sample of charts at minimum twice yearly to ensure poticies are upheld by staff. The audit will include a review of completed assessments and service plans. STATE FD RM M3WT1 ?i if continuation sheet 5 of 23 PRINTED: 01f18l2018 I I I FORM APPROVED Licensmgand Protechon STATE FORM M3WT11 ifcontinualion sheet 6 of 28 PRINTED: 011182018 FORM APPROVED Division of Licensing and Pr [action STATEMENT OF OEFICIENCEES (x1) PROVIDERISUPPLIEHICUA {x2} MULTIPLE CONSTRUCTION iX3i DATE SURVEY AND PLAN cF NUMBER: COMPLETED 9. BUILDING 1012 . 01.533123] 8 NAME OF OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 465 QUARRY ROAD THE RESIDENCE AT QUARRY HILL SOUTH BURLINGTON. VT 05403 (X41 ID SUMMARY STATEMENT OF OEFICIENCIES PROVIDERS PLAN Oi"- CORRECTION DEFICIENCY uusr PREC EDED sv FULL CORRECTIVE ACTION SHOULD as COMPLETE TAG REGULATORY on LSC TAG To THE DATE R136 Continued From pages R136 completed on 10i31i?16. The annual reassessment has not yet been completed for this resident. Per staff interview on IBMS at 10:30 AM. the Resident Care Director confirmed that the above annual reassessments were not completed within the required timeframe. within 365 days of the previous assessment. R145 CARE AND HOME SERVICES 852E R145 Action taken to correct de?ciency: Service Plans for Oversee development of a when plan of care for residents #125! and 6 will be brought each resident that Is based on abilities and needs up to date to refleCt the residents as identified in the resident assessment. A plan current needs and to meet of Care must describe the care and services requirements listed in 5.90 (2) 3115518 necessary to assist the resident to maintain R145 #RCD independence and well-being; reassessment will be completed for resident 5 and the service plan will be updated to reflect current level of care needed to include specific interventions This REQUIREMENT i -not met as evidenced for bowel and bladder incontinence. by: nutritional needs .and non- Based on staff interview and record review. the pharmacological approaches for Registered Nurse (RN) failed to devel0p a care depression. Language that incorrectly . plan to address the all of the identified needs for states the resident receives anti- 4 of 6 residents in the total sample. The care anxiety medication be removed. plans also failed to include measurable goals and specific interventions to achieve those goals. (Residents 2. 5 and 6). Findings include: 1.) The care plan for Resident who was admitted to the facility approximately 2 months ago. failed to address the following resident needs: a. Failed to accurately reflect the resident's Ivision of Licensing and Protection STAIE FORM WW ?3?:qu sheet ?of28 Division of Licensing and Protection PRINTED: 01(1812018 FORM APPROVED Cl? (X1) UA CONSTRUCTION I DATE suava AND PLAN OF CORRECTION ID ENTEFICATION A BUEL DING COMPLETED 1012 01f03i?2018 NAME or on SUPPLEER smEsi ADDRESS. CHY. sure ZIP cops 465 QUARRY HILL ROAD THE RESIDENCE AT QUARRY HILL SOUTH BURLINGTON, VT 05403 ID SUMMARY STATEMENT or PLAN OF CORRECTEON (x5) PREFJX DEFICIENCY MUST BE PRECEDED EIY PU L1. 10 PREFIX CORRECTNE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC TAG TO THE DATE R145 Continued From page 6 R145 needs related to the level of staff participationi?assistance required for completion of AOL (activities of daily living). During interview on 1i2i?18. the RN staff nurse confirmed that this resident did not reguire extensive physical assist for dressing and bathing. as stated in the care plan. . 8 b. Failed to state the resident's potential for R145 #11) A reweight of resident #5 3'2? weight loss andior actual weight loss. based on a has been obtained, the resident has review of recorded weights since admission. The since gained weight and the physician By RCD first recorded weight in the record was on 118117 is aware. Nurses will received re? during a visit to the provider. and was 130 education on the requirements listed in pounds. The next weight was dated 11i1 5K1 7 and 5.7 9 The community weight sheets recorded as 112.2 pounds: a December, 2017 will be updated with instructions to re- weight was 115.2 pounds. There was no evidence weight any resident with a weight lost 3 of an immediate re?weigh after the weight of lbs. or greater within 24 hours. The 112.2 pounds. Per interview on 1i?2i?18 at 2 PM. RCD or designated nurse will be the RN staff nurse acknowledged the weight responsible for monitoring the weight discrepancy should have been veri?ed by a sheets communicating with re~weigh and potential weight loss was a concern the resident?s. Family or legal for this resident due to isolating behaviors. The representative. physician and dietician. care plan also failed to include the intervention The RCD or designated nurse will also (per MAR) that the resident was offered a be responsible for ensuring dietary nutritional supplement, Rescurce. 2 daily. recommendations are followed through c. Failed to address bowel and bladder Der physicians order. occasional incontinence; there were no specific interventions to help maintain continence; d. Failed to provide any non~medication related R145 #1 D- Nursing and Care staff interventions to address the resident?s will be provided with re~education of 3?15'18 regarding depressron; the carexplan also stated non-pharmacological interventions for By RCD that the resident was receiving an anti?anxiety depression and anxiety through the medication and there was no medication ordered community Brass Ring Wellness in - to treat anxiety per review of the summary service. Brass Ring Wellness training provided by the R00. is a nationally certified training through the National Institute of 2.) The care plan for Resident #6 failed to Dementia Education address the resident's current needs regarding a history of falls with recent injuryi?fracture, ongoing pain assessment and management after injury.current mobilityi?transfer needs post rehab Division of Licensing and Protection STATE FORM 6?33? M3WT11 if continuation sheet If of 28 Division of Licensing and Protection PRINTED: 01f18f2018 FORM APPROVED physically combative with them. and somewhat unpredictableThe resident Was also prescribed medication, including a dosage which were also not addressed in the plan of care. Per review of the resident's plan of care, there was nothing to address the behavior or any interventions to assist in caring for the resident. Per interview on 1i3i18 at 10:05 AM, the needs to include specific behavioral interventions and PRN medication usage. STATEMENT OF (Xi; i>Rowomrsueeu?eicun MULTIPLE iXi'il DATE SURVEY AND PLAN or COMPLETED A 1012 01?103/20 I 8 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. STATE. CODE 465 QUARRY HILL ROAD RESIDENCE RRY HILL HE A A SOUTH BURLINGTON, VT 05403 ID SUMMARY STATEMENT OF ID PROVIDERS PLAN OF (X5) PREFIX MUST BE PRECEDED av FULL pggpix (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY on LSC ms TO THE APPROPREATE DATE R145 R145 cont'nUEd page 7 145 2 Action taken to 3-15-13 services, and resident use of over the counter Fregentddefi?lgnc?: A reassessment medication without knowledge (per iorl 35' ?3an be compteteed to incident report of 122.21% During interview on :if: and 1i2i18, the RN confirmed that the resident's Servige planowill be complseted reflect spouse had given the resident a bottle or the resident?s Current needs and will medication and it was not reported to facility staff include specific interventions for fall nor approved by the provider. posing a safety risk reduction and pain management to the resident and any other residents on the Refer to tag 150 for unauthorized dementia unit who might gain access to the medication found unsecured medication. Refer also to 150_ 145 3 Action taken to correct Deficiency: The service plan for resident 3.) The care plan for Resident #1 failed to I be updated to VBIIECI the items address all aspects of care for Diabetes such as '3th in RI45 3- Ahypogiycemia 3.1543; the Insulin regime which includes a sliding scale protocol be obtained from the By RCD administration and blood glucose checks. The physiolan and Wf?_be on the care plan also did not contain interventions medication administration record. regarding the response to abnormal glucose Ste 5 to revent ecurren e' The readings, including a prescribed glucose tablet for compmunitI; insulin rolic ??1'be reviewed hypoglycemic episodes. Per intervrew on 1i3i18 and revised to uirements listed at 10:00 AM, the Resident Care Director 'n R145 3 and II edt confirmed that there was nothing in the plan of Iwill be provided r1: diIcg?oannin Tagargg ?50 care to address these concerns. new or revised policies. The RCD or . . desi nated nur3e will be res onsible for 4.) The care plan for Resrdent'#2 failed to mon?oring through random gudit to address the behemor Concerns of theresident. ensure staff are Quarry Hill policies and The resrdent was documented as having very procedures combative behaviors with staff during the provision of care. Per interview with two of the R145 4 Action taken to correct Resident Care Aides familiar with the resident, deficiency Resident 2 will be ?hey-Stated that they aIV'Vays use two people to reassesSed and the Service plan be 3-15-18 prowde care as the resident was sometimes updated to reflect the residents current By ROD Halls?)?! of L1 censt?ltg and Protedton STATE FORM M3WT1 1 if continuation sheet 8 of 26 Division of Licensing and Protection PRINTED: 0111812018 FORM APPROVED STATEMENT OF DEFICIENCIES (XI) AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 1012 A I LDI NG (x3) DATE sunvsv COMPLETED 0 If03f2013 NAME OF PROVIDER OR SUPPLIER THE RESIDENCE AT QUARRY HILL STREET ADDRESS. CITY. STATE. ZIP CODE 465 QUARRY HILL ROAD SOUTH BURLINGTON, VT 05403 5.9. (7) Assure that or signs of illness or accident are recorded at the time of oCcurrence, along with action taken; This not met as evidenced by: Based on staff interview and record review, the RN failed to assure that or signs of illness or accident were recorded in the record. .- along with actions taken at the time of occurrence for 1 of 6 residents in the sample. (Resident Findingsinclude: Per review of an incident report regarding an unsafe resident situation that occurred during December. 2017, staff failed to notify the Resident #6's physician when a bottle of medication was found in the resident's belongings and the resident stated that they had just taken 2 pills. The resident resided on the Reflections Memory Care unit and was not deemed safe to self-administer their own medications.8taff were unaware that the resident had obtained this medication from some outside source. Although staff notified the family of the concern, they failed to notify the physician. The lack of physician notification was confirmed during interview with the RN Resident Care Director on 18118 at 5:10 PM. Refer also to 145. Oivisisn of Licensing and Protection STATE FORM M3WT1 not; ID summer STATEMENT or DEFICIENCIES n3 PLAN or CORRECTION PREFIX (axon MUST BE PRECEDEO av FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING IN FORMATION) TAG TO THE APPROPRIATE R145?fontinued From page8 R145 . . Ste to revent recurrence: . Resident Care Director con?rmed that there was . nothin in the lan of care to address these Nursmg and care Staff be re" conceEns educated on the Quarry Hill PRN medication policy and the requirements listed in 5.90 (2). And R150 V. RESIDENT CARE AND HOME SERVICES R150 receive in servicing on non- pharmacological behavior interventions through Quarry Hill Brass Ring Wellness training and behavior intervention map .A behavior log for all residents with PRN medication orders will be implemented to include behavi0r tracking and specific non pharmacoiogical interventions tried prior to PRN medication administration. The RCD or RD will be responsible for monitoring behavior tracking and interventions through random chart audits which will include review of behavior logs and PRN medication usage. R150 Action taken to correct deficiency: The bottle of medication has been removed and the RD and R00 have reviewed policies and requirements listed in 5.9 (7) with the family that provided the unauthorized medication. Steps to prevent recurrence Nursing and care staff will be re-educated in regards to requirements listed in 5.9.c (7) as well as in serviced on Quarry Hili policies and procedures to include incident reporting, physician and family notification. and safety programs. Quarry Hill has a detailed Safe Haven program that ensures for the safety of all residents residing on the Reflection memory care neighborhood. The safe Haven program included procedures for locking personal items. and completing environmental safetv rounds. The RD 3-1548 By RCD 3-1548 By RCD Ifconlinuation sheel 90t28 ONTBIZOTB . . . FORM APPROVED of Licensing and Protection STATEMENT OF DEFICIENCIES (x1) MU LTIPLE CONSTRUCTION SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETED A BUILDING 1012 WING .s 0U03l2018 NAME OF PROVIDER OR SUPPLIER STREET CITY. STATE. ZIP CODE 465 QUARRY HILL ROAD HE RESIDENCE AT UA RY HILL SOUTH BURLINGTON. VT 05403 (id) to STATEMENT OF DEFICIENCIES lg PLAN or CORRECTION (x3) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (Eimcn CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR IDENTIFYING CROSS-REFERENCED TOTHE APPROPRIATE DATE TAG DEFICIENCY . i R151 V. RESIDENT CARE AND HOME SERVICES R151 ss=D Will be respon31b1e for retraining all staff on these procedures and 5.9. (8) ensuring follow through. Environmental rounds tracking sheets will be utilized and audited by the RD. The RCD or designated - nurse will be responsible for This REQUIREMENT i not met as evidenced insuring incident reports are Ensure that the resident's record documents any changes in a resident's condition; by: - Based on staff interview and record review, the completed appropriately. These RN failed to assure that staff documented all be monllored through the Changes in condition in the medical record for 1 Yardi dashboard daily by the RCD of 6 residents in the total sample. (Resident 5). or designated nurse. Findings Include: 151 Action to correct deficiency: 1. Per record review, during an Of?ce visit Physician Orders for resident #5 will be summary of 1 1(8r17, the provider wrote orders reviewed with all med techs to include that stated; special instructions, parameters, and "Do vital signs 3 weekly at different times, notify nurse reporting. provider if blood pressure 90l60.? Per review of ?5?18 the documented vital signs in the resident?s Steps to prevent recurrence: The By RCD record, on 12I17I17, the blood pressure was RCD or designated nurse will be documented as 8054 and there was no written reSPonsibIe for reviewing all physician evidence in the medical record (MR) that the orders With instructions and provider was noti?ed. Per interview with the RN Parameters with med techs? On 1i2l17 at 2 PM. slhe confirmed that there was no progress note or assessment in the record related to the low blood pressure reading and that the provider had not been notified, per order instructions. 821503? v. RESIDENT CARE AND HOME SERVICES R153 5 9. (10) R153: Action to correct deficiency: 3?15-18 Monitor stability of each resident's weight; The scate used for weights will By RC9 be calibrated. The current weight sheets {vision oil?i cens1ng and Protection STATE FORM ifcontinuation sheet 10 of 28 Division of Licensing and Protection PRINTED: 01/18/2018 FORM APPROVED STATEMENT OF DEFECTENCIES (X1) PROVIDEWSUPPLIERICUA (X2) CONSTRUCTION '(xai DATE AND PLAN or NUMBER: A I DI c; COMPLETED ?312 B. WENG 01,103,061?; NAME or pRoviDER on SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 4l85 QUARRY HILL ROAD THE RESIDENCE AT QUARRY HILL SOUTH BURLINGTON, VT 05403 (x4) iD SUMMARY STATEMENT or ED PLAN oF CORRECTION (XS) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREHX (EACH CORRECTIVE SHOULD SE COMPLETE TAG REGULATORY DR LSC EDENTIFYING TAG c: OSS-REFERENCED To THE APPROPR DEFICIENCY) R153 Continued From page 10 R153 . Steps to prevent recurrence: This REQUIREMENT not met as evidenced by: Nursing and care staff will be re- Based on staff intervzew and record review. the educated in the requirements listed in RN failed to assure ongoing monitoring of the 590 The community weight stability of each resident's weight for 1 appiicable sheets will be Updated with resident in the targeted sample. (Resident instructions to re?weigh any resident 3'154?3 Findings include: with a weight lost 3 lbs. or greater By RLD within 24 hours. The RCD or Per record review of recorded weights since designated nurse will be responsible admission on 1Di?31i?17. Resident #S's weights for monitoring the weight sheets showed evidence of potential or actual weight communicating with the losS and the nurse faited to document action resident?s physician and dietician. The taken to indicate ongoing monitoring of the RCD or designated nurse will also be stability of the resident?s weight reSponsible for ensuring dietary The resident's first recorded weight in the record recommendations are fOiiOWF-?d was on 11/8117 during a visit to the provider. and through per physicians order. was 130 pounds. The next weight was dated 11i?15i?17 and recorded as 112.2 pounds: a December, 201?. weight was 115.2 pounds. There was no evidence of an immediate re-weigh after the weight of 112.2 pounds. Per interview on 1/22'18 at 2 PM. the RN staff nurse acknowledged the weight discrepancy should have been veri?ed by a re-weigh and that potential weight loss was a concern for this resident due to isolating behaviors. The RN also stated that they have had problems with obtaining accurate weights with the scale available for resident use. The nurse stated that the chair-type scale was very sensitive and would change with any slight movements by the resident being weighed. The nurse did not identify any pians to attempt to assure that resident weights were accurate. R1601 V. RESIDENT CARE AND HOME SERVICES R160 R160 Action to correct defucnency: A procedure Will be put into place and 3 15 '3 . . com ieted to monitor residents #5 and 5?1 0 edication Management #6 fopr potential side effects of BY RCD medication IWSIOH 0i Licensmg ano Erotection STATE FORM ifconlinuation sheet 1 of 28 PRINTED: 01i?18i?2018 . FORM APPROVED Divsion of Licens1ng and Protectmn STATEMENT OF [Xi] CONSTRUCTION EMTE SURVEY AND PLAN OF CORRECTION IDENTIFICATION COMPLETED - A 1012 ?3 01i03i2018 NAME OF pnovmsn on SUPPLIER STREET cnv. STATE, ZIP CODE 465 UARRY HILL ROAD THE RESIDENCE AT QUARRY HILL 0 SOUTH BURLINGTON, VT 05403 SUMMARY STATEMENT OF ossicissciss (XS) PREFIX DEFICIENCY MUST 8E FULL PREHX (EACH CORRECTIVE ACTFON es COMPLEIE TAG REGULATORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE AFPROPREATE R160 Continued From page 11 R160 5.10.a Each residential care home must have written policies and procedures describing the home's medication management practices. The policies must cover at least the following: (1) Level homes must provide medication management under the supervision of a licensed nurse. Level IV homes must determine whether the home is capable of and wilting to provide assistance with medications andior 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) Qualifications of the staff who will be managing medications or administering medications and the home's process for nursing supervision of the staff. (4) How medications shail be obtained for residents including choices of pharmacies. (5) Procedures for documentation of medication administration. (6) Procedures for diSposing of outdated or unused medication, including designation of a person or persons with responsibility for disposai. (7) Procedures for monitoring side effects of medications. This not met as evidenced by: Based on staff interview and record review] the facility failed to develop a policyiprocedure for monitoring side effects of I medications. This practice had the potential to affect all residents of the facility receiving medications; 2 of 6 residents in the Steps to prevent recurrence: The current medication policy will be reviewed and revised to include ali requirements listed in 5.10 a 1-7. Revised policy and procedure will be reviewed with nursing staff. The 3-15-18 RCD or designated nurse will be By RCD responsible for monitoring and ensuring staff follow through. AIMS assessments for residents receiving medications will be monitored and tracked through the Yardi dash board daily. Documentation of assessment of potential side effects of other medications will be documented in a resident progress note. Vl?t?? 0i a ?16 HIOIJBCUOW STATE FORM (if: M3WT1 1 If cenlinuation sheet 12 of 28 PRINTED: D1f18i'2018 FORM APPROVED of Licensing and Protection STATEMENT OF (Xi) pnevioanisunmenicun {x2} MULTIPLE DME AND or: CORRECTION NUMBER: A BUILDENG WING NAME OF PROVIDER on SUPPLEER STREET ADDRESS. CITY, STATE, CODE 465 QUARRY HILL ROAD THE RESIDENCE AT QUARRY HILL SOUTH VT 05403 iD SUMMARY STATEMENT OF DEFICIENCIES 10 PnoviDER's PLAN orT CORRECTION {x5} PREFEX DEFICIENCY MUST BE PRECEDED BY FULL pREqu CORRECTIVE ACTION SHOULD TAG REGULATORY 0R LSC TAG CROSS-REFERENCED To THE APPROPR IATE DATE R160 Continued From page 12 total sample were receiving medications. (Residents 5 and Findings include: Per interview with the RCD on the afternoon of ?lms, regarding policies/procedures for monitoring side effects of medications for residents receiving this classification of medication, the RCD confirmed that he was not aware of any policyi?procedure for this type of monitoring for evidence of side effects. They do AIMS testing for residents receiving an classi?cation of medication. However, Resident's #5 and if 6 were receiving antidepressant medications, which are medications; the RCD stated that they had no policyi?process for ongoing monitoring for side effects for these residents. V. RESIDENT CARE AND HOME SERVICES 333D 5.10 Medication Management 5.10.d Ifa 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 reSponsibie 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, R160 R165 1 Action to correct de?ciency All staff that administers medication to resident 1 wiil be re- educated on the residents service plan physician orders to include special instructions and parameters and needs related to the diabetes diagnosis. 3~15?18 By RCD R165 Steps to prevent recurrence All Med techs and nursing staff be provided with re~education on medication documentation, including what is documented in the communication log versus progress notes documentation, and nurse notification, translating physician orders, and execution of parameters and what and when to notify the nurse. The Med tech training will be reviewed and revised to include insulin training. medication policy and nurse delegation. All nurse will be in-service on Regulatory requirement for nurse delegation. The RCD, designated nurse, or pharmacy consultant will complete random chart audits for reviewing medication management practices at minimum tvvice yearly. Div Bier: of Licensing a no Protection STATE FORM M: ion sheet 130(28 PRINTED: 013180018 FORM APPROVED Division of Licensing and Protection STATEMENT OF {x1} (x2) ll??le' CONSTRUCTION (x3) DATE AND PLAN OF RR TION co EC NUMBER A BUKLDING . .WIN 1012 - 0110312013 NAME OF PROVIDER DR STREET ADDRESS, STATE. ZIP CODE 465 QUARRY HILL ROAD THE RESIDENCE AT QUARRY HILL SOUTH BURLINGTON, VT 05403 lD SUMMARY STATEMENT Dr lD PLAN OF CORRECTION {x5} PREFIX (EACH MUST BE PRECEOED BY FULL PREFEX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR mg ENCED To THE APPROPRIATE DATE . NCY) R165 Continued From page 13 R165 . All nurse W111 be m?sennce on Regulatory requirement for nurse 3?12-33?) delegation. The RCD, designated By 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 nurse, or pharmacy Consultant will Performance in carrying the nurse's complete random Chart audits for '"Stwm?ons' reviewing medication management This REQUIREMENT is not met as evidenced Pram?es at mmlmum ??106 yearly by: Based on record review and staff interview, the Registered Nurse failed to mOnitor the designated unlicensed Staff performance regarding medication administration for 1 of 6 residents reviewed (Resident# 1). Findings include: 1. Per record review, Resident #1 has diagnoses that include insulin-dependent Diabetes. The physician orders include a daily scheduled long acting insulin dose. aS well as a sliding scale Novolog Insulin regime that is adjusted based on blood glucose readings by fingerstick, and given at mealtimes. The resident also has blood glucose ?ngersticks ordered to be done ?ve times daily at 6:30 AM. mealtimes, and at bedtime. Per review of the Medication Administration Record (MAR) for the month of December 201?, there were multiple missing staff initials to indicate the Novolog Insulin had been administered as ordered. On December 10th there were blank spaces with no initials for the signing of administration of the breakfast and Iu no dosages of the Novolog. On 12f15f17, the breakfast dose was not Signed 12l25l17, all three mealtime dosages were notsigned as given. Besides these dates listed. there were multiple blank spaces on the MAR for the dinnertime administration of the Novolog. There was no staff initials on the MAR for Dec. 7 ~15. 18, 21, 22, 25. and 27th for the dinnertirne dose of Novolog. Also a concern in this resident ivisionofLicensing and Prolectl on FORM mm? - licontinuation sheet 140i26 Division of Licens1na and Prctection PRINTED: 01i13i?2018 FORMAPPROVED record was the missing signage in the MAR of the 6:30 AM fingerstick readings- Per interview on 1l3l18 at 2:45 PM, the Registered Nurse confirmed that there were missing staff initials in the December MAR for the administration of the Novoiog and that the nurse was not aware of the missing The nurse also con?rmed that the night staff responsible for taking the 6:30 AM glucose reading had been documenting the readings in a notebook that contains staff notes regarding residentswas the eXpectatEOn and the way all other staff were documenting this. The Resident Care Director confirmed that they were not aware that the staff had not been properly signing off the administration in the MAR, and that they had not audited staff performance documenting administration of insulin for this resident. During the review of the notebook readings recorded. the nurse confirmed a log entry that morning on 1f3f18 that the resident had a ?ngerstick reading of 60. Per review of the physician?s orders, the residentwas to receive a glucose tablet if the blood glucose reading was under 80. The administration of the glucose tablet was not documented in either the notebook or the MAR. and the RN confirmed that there was no way to know whether the staff person had recognized the need to give the glucose tablet, and did not document administration. They also did not alert the nurse regarding the low reading. The Resident Care Director (ROD) confirmed that they were not aware that the staff had. not been properly signing off the administration in the MAR, that they had not alerted nursing to the low I reading, and did not document carrying out the STATEMENT OF (x1) (x2) MULTEPLE (x3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: A. BUILDING. were 1012 01f0312018 NAME or 0R SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 4 5 RRY HILL ROAD THE RESIDENCE AT QUARRY HILL 6 A SOUTH BURLINGTON, VT 05403 (M) io SUMMARY STATEMENT OF DEFECIENCEES ID PLAN OF rxsi PREFIX (EACH MUST BE PRECEDED BY FULL PREFIX (EACH ACTION SH DU LD BE COMPLETE TAG REGULATORY OR TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) R165 Continued From page 14 R165 :51 0 not Licensmg and Protection STA TE OR 1 it continuation sheet 15 of 28 Division of Licensina and Protection PRINTED: 01f18f2018 FORM APPROVED STATEMENT OF DEFICIENCIES PROVIDERISUPPLIERICUA MULTIPL CONSTRUCTION (X3) SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER. A DING COMPLETED 1012 9- onosxzots NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 465 QUARRY HILL ROAD THE RESIDENCE AT QUARRY HILL SOUTH BURLINGTONVT 05403 (x4) SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION {x5} PREFIX DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE coasters. TAG REGULATORY DR IDENTIFYING INFORMATION) TAG To THE APPROPRIATE DATE R165Continued From page 15 R165 physician order for the glucose tablet. The ROD also confirmed that as the nurse responsible for delegating medication administration to unlicensed staff, they had not audited staff performance documenting administration of Insulin and related diabetes management closely enough to detect these discrepancies and missing documentation. R16YV. RESIDENT CARE AND HOME SERVICES R167 35:0 R167 Action to correct deficiency: Updated Physician orders for resident #2 3'15'13 5.10 i a i Management will be obtained to include Specific BY RC0 behavioral indications and time 5.10.d if a resident requires medication parameters for PRN Risperidone. A administration. unlicensed staff may administer I09 3130 be in place for medications under the following conditions: this resident. Revised orders Wi? be reviewed with all nurses and med tech, (5) Staff other than a nurse may administer. PRN and education on potential side effects medications only when the home be given. The residents plan has a written plan for the use of the PRN Will be updated If needed to include non- medication which: desoribes the specific pharmacological approaches for behaviors the medication is intended to correct or behawor. AIMS assessment be address; Specifies the Circumstances that completed for reSIdent. indicate the use of the medication; educates the 1:0 prevent recurrence. quarry staff about what desired effects or undesired side Ps?ychoactIVe medication policy effects the staff must monitor for; and documents be rev1ewed and revrsed .if needed to 5R8) the time Of, reason for and specific results of the Include all requirements I?Sted .m 5'10'd medication use (5). The?Quarry HIll medication pOIIcy Will be revnewed with Nurses and Med Techs will be responsible This REQUIREMENT IS not met as ewdenced for monitoring to ensure staff is upholding by: policies through the Yardi PRN Based on staff Interwew and record rewew, the medication report weekly. Registered Nurse failed to ensure that residents receiving 'as needed' (PRN) medications had a written plan for delegated unlicensed staff to appropriately administer them for I of 5 residents reviewed (Resident mason of'Ltcensmg and Protection STATE FORM ?continuation sheet 16 Of28 Division of Licensing and Protection PRINTED: FORM APPROVED OF DEFICIIENCEES (le MULTIPLE CONSTRUCTION Ixs) DATE SURVEY AND PLAN OF COMPLETED . I012 ?3 01i03i2018 NAME OF OR SUPPLIER CITY. STATE, ZIP CODE 465 QUARRY HILL ROAD THE RESIDENCE AT QUARRY HILL SOUTH BURLINGTON. VT 05403 not} it} SUMMARY STATEMENT OE ID PROVIDERS PLAN OF CORRECTION (x3) PREFIX DEFICIENCY MUST BE PRECEDEO BY FULL PREFEX CORRECTIVE ACTEON BE TAG REGULATORY on Let: IDENTIFYING TAG To APPROPRIATE DATE R1671 Continued From page 16 R167 Findings include: Per record review. Resident#2 has diagnoses that include dementia and sometimes exhibits aggressive behavior toward staff. Medication regime includes Risperidone. both a scheduled dosage twice daily, and a PRN dose Which reads "Risperidone 0.25 mg.. take one tab by mouth twice daily as needed.? Per interview on 1 l3l18 at 11:30 AM, the Registered Nurse con?rmed that there is no written plan in place for staff that includes the specific targeted behaviors, circumstances that indicate the use of the medication, educates staff about the desired effects and undesired side effects that staff must monitor for, and documents the tine of. reason for and specific results of the medication use. There were also no time parameters set for staff to know how Close together the scheduled and PRN doses can be administered- The nurse also confirmed at this time that there is no written behavior plan for any other residents reCeiving PRN medications in the facility that meets the reguiatory requirement. 5%168 V. CARE AND HOME SERVICES R168 R163 Action to correct de?ciency: All Med tech insulin training will be 3-15-13 brought up to date and documented to By RCD 5. 10 Medication Management include using a pen. accuracy of determining sliding scale, and return If a resident requires medication demonstraii0n_ administration. unlicensed staff may administer Steps to prevent recurrence: The medications under the following conditions: Quarry Hill insulin policy will be reviewed and revised to reflect requirements listed (6) lnsulin. Staff other than a nurse may in 5.10.d. The policy revision will be administer insulin injections only when reviewed with nurse and med tech staff by the RCD. The Quarry Hill Med Tech i. The diabetic resident's condition and trainino is beino revised to include insulin medication regimen is considered stable by the iviswn of Licensing and Protection STATE FORM M3WT11 if continuation sheet ?1 of 28 Division of Licensing and Protection PRINTED: 01I18i2018 FORM APPROVED registered nurse who is responsible for delegating the administration; and ii. The designated staff to administer insulin to the resident have received additional training in the administration of insulin, including return demonstration, and the registered nurse has deemed them competent and documented that assessment: and The registered nurse monitors the resident's condition regularly and is available when changes in condition or medication might occur. This REQUIREMENT is not met as evidenced by: - Based on staff interview and record review, the Registered Nurse failed to document that delegated unlicensed staff received additional training regarding insulin administration for 1 applicable resident. (Resident#1). Findings include: Per review of staff training for the delegation of administration of medications by unlicensed staff, 1 there was no evidence that the delegating RN documented all aspects of training regarding the administration ofinsulin for Resident The training documentation did notshow training for use of the Insulin pens, accuracy of determining a demonstration of insulin administration. Per i sliding scale dosage. or evidence of return interview on 1i3i18 at 4:55 PM, the Resident Care: Director. who is the delegating RN, confirmed that not all of the training completed with the staff regarding the administration of insulin to Resident #1 had been documented as part of the delegation process. STATEMENT OF NCIES (x1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: COMPLETED A . I i012 BWNG 01103r2018 NAME or PRovipER on SUPPLIER STREETADDRESS, STATE. cooE 465 UARRY ROAD THE RESIDENCE AT QUARRY HILL SOUTH BURLINGTON, VT 05403 x4 ID SUMMARY STATEMENT or DEFICIENCIES io PLAN OF CORRECTION (X5) rise ix (EACH MusT BE PRECEDED BY FULL pREle (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG TO THE APPR DATE DEFICIENCY) R168 Continued From page 1? R168 Division at Ltcens?l ng a nd Protection STATE FORM M3WT11 ifcominuation sheet 180f28 Division of Licens1 no and Protection PRINTED: 01(1812018 FORM APPROVED STATEMENT OF (x1) (X2) MULTIPLE CONSTRUCTION lX3i DATE SURVEY AND Run?: or CORRECTION IDENTIFICATION NUMBER: COMPLETED A I . 1012 ?3 01i03r2018 NAME OF OR SUPPLIER STREET ADDRESS. STATE, ZIP CODE THE RESIDENCE AT QUARRY HILL 465 QUARRY ROAD SOUTH BURLINGTON. VT 05403 (X4) In SUMMARY STATEMENT OF DEFICIENCIES Io PLAN OF CORRECTION [st PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL pREnx ACTION SHOULD BE TAG REGULATORY OR LSC TAG CROSS-REFERENCED TO THE IATE DATE Rm continued From page 13 R171 R171 Action to correct de?ciency: 3?15?13 Rm; v. RESIDENT CARE AND HOME SERVICES The insurin. blood oiucose monitoring. By RCD 5.10 Medication Management 5.10.g Homes must establish procedures for documentation sufficient to indicate to the physician, registered nurse, certified manager or representatives of the licensing agency that the medication regimen as ordered is appropriate and effective. At a minimum. this shall include: (1) Documentation that medications were administered as ordered; (2) All instances of refusal of medications, including the reason why and the actions taken by the home; (3) All PRN medications administered, inciuding the date, time, reason for giving the medication, and the effect; (4) A current list of who is administering medications to residents, including staff to whom a nurse has delegated administration; and (5) For residents receiving medications, a record of monitoring for side effects. (6) All incidents of medication errors. This REQUIREMENT is not met as evidenced by: Based on record review and staff interview, the Registered Nurse failed to ensure that documentation was completed to indicate that ordered medications were administered appropriateiy for 1 of 6 residents reviewed (Resident Findings inciude: 1. Per record review, Resident #1 has diagnoses that include insulin-dependent Diabetes. The . parameters and nurse reporting will be . reviewed with the med techs for resident 1. Steps to prevent recurrence: Quarry Hill insulin pOiicy, nurse delegation policy. and med tech training will be reviewed, revised, and enhanced to re?ect best practices, documentation, and execution of physician orders. as weil as the requirements listed in 5.10.g, Nurses and Med Techs wiil be re? educated on at! policy and training revisions. Ail physician orders are now in the electrOnic medical record. The RCD or designated nurse will be responsible to check the eMar at the end of the shift to ensure orders were not missed- IvIsIon of Licensing and ProtectiOn STATE FORM M3WT1 1 IF continuation Sheet 19 of 28 Division of Licensing and Protection PRINTED: O?U?l8l'2018 FORM APPROVED physician orders include a daiiy scheduied long acting Insulin dose. as well as a sliding scale Novolog lnsulin regime that is adiusted based on blood glucose readings by fingerstick, and given at mealtimes. The resident also has blood glucose fingersticks ordered to be done five _times daily at 6:30 AM. mealtimes. and at bedtime. Per review of the MedicatiOn Administration Record (MAR) for the month of December 2017. there were multiple missing staff initials to indicate the Novolog Insulin had been administered as ordered. On December 10th there were blank spaces with no initials for the signing of administration of the breakfast and lunch dosages of the Novolog. On 12F15i?17, the breakfast dose was not signed off. On 12l?25il7. all three meattime dosages were not signed as . given. Besides these dates listed. there were multiple blank spaces on the MAR for the dinnertime administration of the Novotog. There was no staff initials on the MAR for Dec. 7 -15, 17. 18. 21. 22. 25, and 27th for the dinnertime dose of Novolog. Also a concern in this resident record was the missing signage in the MAR of the 6:30 AM fingerstick readings. Per interview on 1(31?18 at 2:45 PM. the Registered Nurse confirmed that there were missing staff initials in the December MAR for the administration of the Novolog and that the nurse was not aware of the missing documentation. The nurse also confirmed that the night staff responsible for taking the 6:30 AM glucose reading had been documenting the readings in a notebook that contains staff notes regarding residentswas the expectation and the way . all other staff were documenting this. The Resident Care Director con?rmed that they were not aware that the staff had not been properly signing off the administration in the MAR, and that they had not audited staff performance STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICUA (x2) MULTIPLE (x3) DATESURVEY AND PLAN or CORRECTION NUMBER: COMPLETED A BUILDING mum?w 1012 a i? 01x03x2018 NAME DF PRDVIDER 0R SUPPLIER STREET ADDRESS. crrv. STATE. ZIP cooE I THE RESIDENCE AT QUARRY HILL 455 QUARRY ROAD SOUTH BURLINGTON, VT 05403 (xii) ED STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION {x5} . (EACH MUST BE PRECEDED BY FULL pREFix ACTION SHOULD BE COMPLETE TAG REGULAEORY OR TAG TO THE APPROPRIATE DATE DEFICIENCY) R171 Continued From page 19 R171 Division at Licensing and Protecti0n STATE FORM 1 lfcon?nuation sheet 20 onB Division of Licens?l no and Protection PRINTED: 01i?18i?2018 FORM APPROVED STATEMENT OF AND PLAN OF CORRECTEON NTEFECATION NUMBER: (Xi) 1012 (X2) MIJLTEPL.E A EWING -f DATE SURVEY COMPLETED i i clmsaOIS NAME OF PROVEDER DR SUPPLIER THE RESIDENCE AT QUARRY HILL ADDRESS. CITY. STATE, ZIP CODE 455 QUARRY ROAD SOUTH BURLINGTON, VT 05403 10 TAG SUMMARY STATEMENT OF (EACH DEFICEENCY MUST BE PRECEDED BY FULL REGULATORY DR LSC ENFORMATION) ID PREFEX TAG CROSS-REFERENCED TO Tl ll: AP PROPR PLAN OF (EACHCORRECTIVE ACTIONSHOULDBE cor-ma: R171 853E Continued From page 20 documenting administration of Insulin for this resident. During the review of the notebook readings recorded. the nurse confirmed a log entry that morning on lf3ft8 that the resident had a ?ngerstick reading of 60. Per review of the physician?s orders, the resident was to receive a glucose tablet if the blood glucose reading was under 80. The administration of the glucose tablet was not documented in either the notebook or the MAR. and the RN confirmed that there was no way to know whether the staff person had . recognized the need to give the glucose tablet. and did not document administration. They also did not alert the nurse regarding the low reading. The Resident Care Director (RCO) confirmed that they were not aware that the staff had not been properly signing off the administration in the MAR. that they had not alerted nursing to the low reading, and did not document carrying out the physician order for the glucose tablet. The RCD also continued that as the nurse responsible for delegating medication administration to unlicensed staff . they had not audited staff performance documenting administration of Insulin and related diabetes management closely enough to detect these discrepancies and missing documentation. R175. V. RESIDENT CAREAND HOME 5.10 Medication Management 5.10.h (3) Residents who are capable of self-administration may choose to store their own medications provided that the home is able to provide the resident with a secure storage space to prevent R171 R175 will R175 Action to correct de?ciency: All residents that currently self-administer medications wiil be provided with a locked space for medications. The policy for locking medication in the apartment 3-15?18 By RCD be reviewed with the residents. Division of Licensing and Protection STATE FORM M3WT11 ifcontinuation sheet 21 of28 Division of Licensing and ProtectEOn PRINTED: 01f18f2018 FORM APPROVED 5.12.b. (3) For residents requiring nursing care, including nursing overview or medication management. the STATEMENT OF DEPICIENCIEs on) SURVEY AND PLAN OF CORRECTION NUMBER: COMPLETED A - ?mm??ww?n 1012 -- 01:03:2013 NAME OF PROVIDER OR SUPPLIER ADDRESS. CITY, STATE. CODE THE RESJDENCE AT QUARRY HILL 465 QUARRY HILL ROAD SOUTH BURLINGTON, VT 05403 iD SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION ixsi PREFIX (EACH DEFICIENCY MUST BE ev FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAO REGULATORY OR IDENTIFYING TAG TD THE APPROPRIATE DATE DEFICIENCY) ?ns ContInued From page 21 Steps to prevent recurrence: The unauthorized access tO the resident'S Quarry Hill medication storage policy for 345'? medications. Whether or not the home is able to residents that salt-medicale Will be By RC0 provide such a secured space must be explained reviewed and to reflect to the' resident on or before admission. requirements listed in 5.10.h (3) and all residents will be provided with a secure This REQUIREMENT is not met as evidenced space for medications within their . by: apartment. The RCD will be responsible Based on staff interview and record review, the for reviewing the updated With facility failed to establish a to nurses, med techs, and reSIdents that assure that residents who are capable of setf?medlcate. self?administration and wiSh to store their own medication are provided with a secure storage space to prevent unauthorized acceSs to the resident's medicationS.Findings inCIUde: During interview with the RCD on 1f3f18 at 10:45 AM, regarding how the facility aSsureS that residents who have been assessed as safe and capable of self-administering their own medications and wish to store them in their rooms are provided a secure space to store the medications. The reSidentS must be willing to assure that all medications are kept secure in their room, and that the entrance door is locked when the resident is not their room to aSSure that unauthorized access does not occur. The RCD confirmed (1f3f18) that the facility had not developed any process nor policy to assure medications stored in resident rooms were locked and secured to ensure a safe environment in all areaS of the home. R189 V. RESIDENT CARE AND HOME SERVICES R189 D1v1s1on of Licensing and Protection STATE FORM ifcontinua?on sheet 22 of 28 Division of Licensing and Protection PRINTED: 01l18l2018 STATEMENT AND PLAN OF CORRECTION (X1) PROVIDERISUPPLI ERICUA ION NUMBER: 1012 FORM APPROVED (x2) MULTIPLE CONSTRUCTION DATE sunvsv A BUILDING: COMPLETED EWING Ull03f2018 NAME OF PROVIDER OR STREET AEDRESS, CITY. STATE. ZIP CODE 465 QUARRY HILL ROAD SOUTH 05403 THE RESIDENCE AT QUARRY HILL annual reassessment;significant change 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, the facility failed to assure that required documentation for residents requiring nursing care, was documented in the medical record for 4 of 6 residents in the sample. (Residents 2, 3. 5 and 5). Findings include: 1. Per record review, Resident #5 was admitted to the facility on 10mm and from .admission to the day of survey, ?ll2l18, there was only 1 progress note dated 11r20r17. The progress note stated that UA (urinalysis) ordered due to mental status There was no documentation in the record regarding the ?mental status changes? referred to in the note of 11r20l17. The note also stated that 'atenolol dose changed from (primary care provider). There were no follow up progress notes to document the resident?s medical response to the dose change after the change was made. The lack of progress notes in the record regarding the resident's stability of condition and response to medication changes was confirmed with the RN and R00 during the 2 days of survey. 2. Per staff interview. Resident #6 had a fall on November 8, 2017, and admitted to the hospital 11r9r17 after diagnosis with pain from fractured thoracic vertebra. The resident was admitted to a entered into the records of resident 2.3.5, and 5 to reflect recent changes, current health status. and current level of care. Steps to prevent recurrence: Nursing staff will be provided in?servicing on the requirements listed in 5.12.b. A progress note will be entered at minimum 3 1 time for all residents. Progress . notes are entered into the Yardi computer system. The RCD or designated nurse will be responsible for monitoring this through the Yardi progress notes reporting system. The change of condition assessment and documentation policy will be reviewed with all nurses. (x4) ID summnv STATFMENT or: DFFICIENCIES 10 i PROVIDERS PLAN OF CORRECTION .. PREFIX (EACH MUST BE PRECEDED ev FULL (EACH CORRECTIVE ACTION SHOULD BE nostril-=11: TAG REGULATORY on LSC IDENTIFYING INFORMATION) TAG To THE APPROPRIATE Willi: DEFICIENCY) R189 -: Continued From page 22 R189 . R189 1-4 Action to correct Record shall also contain: initial assessment; . 345-18 - defiCIency . A progress note wal I be By RCD Division of Licensing and Protection STATE ?1389 Ifcon?nualion sheet 23 mm Division of Licensing and Protection PRINTED: 01I18i?2018 FORM SNF (skilled nursing facility) for rehabilitation services on resident was discharged from the SNF and returned to the facility during December. 201?.There were no progress notes in the record regarding the date the resident returned to the facility post rehabilitation. During interview on 1i2!18 at 4:40 PM. the RN confirmed that the resident had returned to the facility from the SNF stay on 12/1311 7. There was no progress note that day to record the return to the facility, con?rmation of orders with the provider upon return and no assessment of the resident?s condition at the time of the return. The first note after the re?admission to the facility was dated 18 days after returning to the facility. The failure to document the resident's condition, changes and follow up information in the progress notes was confirmed with the RN and the RCD during the afternoon of 1i3i18. 3. Resident 2 was admitted in July of 201?6 with diagnoses that include dementia and behavioral disturbancesThe resident has declined enough that they qualify to be on Hospice and was admitted to those services on 1311/17. There are no nurse progress notes for this resident written since 6i26i17 to document the status of the resident. The RN and RCD con?rmed that there were no more recent progress notes in the record for this resident. 4. Per record review, Resident #3 had muttiple falls at the home. On 11I15I17. Resident #3 had a fall in the dining room that was documented in an incident report. There were no follow up nurse progress notes regarding the fall and monitoring aftenivards for potential injury or assessment of the circumstances at the time of the?fall. The incident report log also showed that Resident#3 STATEMENT OF DEFICIENCIES (x1) FUSUPPLIERICUA (X2) CONSTRUCTION DATE SURVEY AND PLAN OF IDENTIFICATION NUMBER: COMPLETED AM 1012 0 l/ng20 8 NAME OF OR SUPPLIER STREET ADDRESS. CiTv. STATE. ZIP CODE 465 QUARRY HILL ROAD THE RESIDENCE AT QUARRY HILL SDUTH BURLINGTON, VT 05403 {x41 SUMMARY STATEM OF DEFICIENCIES .D PLAN or CORRECTION :xs; DEFICIENCY MUST BL PRECEDED BY FULL SHOULD BE TAG REGULATDRY 0R TAG To THE APPROPRIATE DATE DEFICIENCY) Continued From page 23 R189 Division of Licensing and-Protection STATE FORM M3WT11 ?continuation sheet 24 of 28 swoon of Licensing and Protection PRINTED: 01(181'2018 FORM APPROVED AND PLAN STATEMENT OF (X1) OF NUMBER: 1012 (X2) MULTIPLE CONSTRUCTION A. BUILDI NG .- B. (X3) DATE SURVEY COMPLETED 01f03f2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CTTY. STATE. CDDE 465 QUARRY HILL ROAD SOUTH BURLINGTON, VT 05403 THE RESIDENCE AT QUARRY HILL shall be planned and written at least one (1) week in advance. This REQUIREMENT is not met as evidenced by: Based on observation, staff interview and record review, the-facility failed to assure that menus for regular and therapeutic diets for the Re?ections Memory Care Unitwere planned and written at least tweek in advance. This practice had the potential to impact residents of the memory care unit who may be unable to state or indicate their preference/choice of meal choice on any given '1 day. Findings include: Per interview with the chef on duty on 1QI18, the residents of the facility may pick their meals (breakfast. lunch and dinner) fro a menu of several different items offered on a daily basis. The chef stated that the rotation of the menu items offered is about every 6 months. During interview with the Reflections Unit Director on 1i2f18 regarding how they assure meals for residents who may not be cognitively able to (x4) lD SUMMARY STATEMENT OF .9 PLAN OF CORRECTION (XS) DRFFIX (EACH oercencv MIJST or: pa ECEDFD av FULL (EACH CORRECTIVE SHOULD BE COMPLETE TAG REGULATDRY on LSC TAG TO THE APPROPRIATE DAT: R189 Continued From page 24 R189 had a fall in the hallway, again without apparent injury. There were no nurse progress notes to document any follow up or even to indicate that the resident had fallen.There were no nurse progress notes in the medical record since 9!15i17.The RN and RDC confirmed that there were no more recent progress notes for this resident despite the two falls in November and December. R232 VII. NUTRITION AND FOOD SERVICES R232 R232 Steps to prevent recurrence: Dining and care staff will be inuserviced 3-15-13. on the requirements listed in 7 1 a as gay D-mmg 7.1. a. (1) Menus for regular and therapeutic diets well as Quarry Hill policies and Director procedures. All menus are planned and written at minimum 1 week in advance. The Reflections neighborhood utilizes a 2 plate method for serving. Residents that are cognitively impaired are visually presented with two plated meals to choose from. A full menu of alternate options is available above and beyond the 2 meal choices. if a resident is unable to choose due to cagnitive impairment menus will be available in advance to the resident and responsible party to assist in preplanning meals. The dining services director will be responsible for above responsibilities and ensuring follow through of staff to uphold policies. Division otL1cens'1ng and Protection STATE FORM M3WT11 if continuation sheet 25 0128 PRINTED: 01f18f2018 FORM APPROVED Division Of Licensing and Protection STATEMENT OF DEFICIENCIES (x1) (x2) ULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN or CDRRECTIDN IDENTIFICATIDN NUMBER: COMPLETED A BUILDING: mm WING 1012 Hem-m O1IO3IZO1 8 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 465 QUARRY HILL ROAD SOUTH BURLINGTON, VT 05403 THE RESIDENCE AT QUARRY HILL PLAN OF CORRECTION f? 7.2. All perishable food and drink shall 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 heated prior to service. This REQUIREMENT i not met as evidenced by: Based on observation and record review, the facility failed to assure that all perishable foods were labeled and dated and disposed of timely per facility policy regarding safe food handling practices. This practice had the potential to affect all residents who dine at the home. Findings include: Per observation of the kitchen during the initial tour Of the dietary areas on 11318. the following observations were made regarding storage of perishable foods: a. The walk-in refrigerator had multiple foods that were not labeled andlor dated in accordance with the facility's regarding safe can In SUMMARY STATEMENT OF DEFICIENCIES Io (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY oR LSC IDENTIFYING TAG FERENCED TO THE APPROPRIATE DATE DEFICIENCY) R232 Continued From page 25 R232 indicate or voice their choice of meal, the Director stated that 'we make the Choice for them if they are not able, since we know them. Resident meals must be planned in advance for residents not able to utilize the system of selecting from the menu a choice for themselves for each meal. (This does not affect the right of every resident tO have alternate choices that are nutritionally equivalent if they do not like the meal offered on the written menu.) VII. NUTRITION AND FOOD SERVICES R247 . R247 Action to correct de?ciency: 3 13 The Dining Services Director will [gaming 7.2 Food Safety and Sanitation complete an audit of current food storage Swim and ensure all Is dated and labeled Director appropriately. Steps to prevent recurrence: The Dining services Director will be responsible for in?serviCing dining staff on Quarry Hill policies regarding food storage. The Dining Services Director will be responsible for ensuring follow through, with random inspections Of food storage performed at minimum twice 1W0 Protection STATE FORM 1 lfcontinuat?on sheet 26 of 2B Division of Licensing and Protection PRINTED: 01l18l2018 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) NU MBE 1012 (X2) MULTIPLE CONSTRUCTION A. LDING: BWING (x3) DATE sunvav COMPLETED 01f03f2018 THE RESI NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 465 QUARRY HILL ROAD DENCE AT QUARRY HILL SOUTH BURLINGTON, VT 05403 not: it} 9%le TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE TD THE APPROPRIATE DEFICIENCY) R247 Continued From page 26 food handling practices: foods that were dated 12f29f17 on 1f22?18, included mashed squash and cooked spaghetti. When the chef was asked what the facility's policy was for keeping prepared fresh foods before disposing of them. they stated 4 or 5 days, but they were not certain. The reach in cooler on the cook's line had a food container that was dated 1212517. not labeled, and was identi?ed by the chef as caramelized pears) and a container that had a brown saucelgravy with that had no label and no date. Per review of the written policy regarding food dating and labeling with the ED (executive director) on 1l3f18, the policy stated to dispose of the dated food by the end of the third day. R253 VII. NUTRITION AND FOOD SERVICES Food Storage and Equipment 7.3. All food service equipment shall be kept clean and maintained according to manufacturer's guidelines This i not met as evidenced by: Based on observations and staff interview, the facility failed to assure that all kitchen areas and food service equipment was kept clean. This practice had the potential to affect residents who dine at the facility. Findings include: Per observation during tours of the kitchen on 1f2f18 at 9:45 AM and 1f3f18 at 1:15 PM, the following areas were not kept clean and had visible soiling: the magnetic wall knife storage area (for storage of clean knives) had a buildup of visible dust on the individual slats; the 2 R247 R253 R253 Action to correct de?ciency: The kitchen will be thoroughly cleaned to include dry spice storage, lower shelf of the prep table. back panel of stove, and all appliances. Steps to prevent recurrence: All above areas will be added to the posted cleaning list. The dining services director will be responsible to in service staff on Quarry Hill policies and procedures, and the revised cleaning schedule. and to monitor and ensure staff is adhering to the cleaning schedule. The Dining service director or designated staff will be responsible for doing weekly inspections of the kitchen and cleaning schedule. 3-1 5~l 8 By Dining Services Director Division of licensing and Protection STATE FORM M3WT11 ilcontinuation sheet 27 ot28 PRINTED: 01318f2018 FORM APPROVED Division of Licensing and Protection STATEMENT OF {x1} {x2} MULTEPLE CONSIRUCTION a'X3} DATE SURVEY AND PLAN OF CORRECTION IDENTEFECATION NUMBER A BUELDENG COMPLETED . BWING n.m1umn Ulfuol?uid NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, crw, STATE. 25:? CODE 485 QUARRY HILL ROAD THE RESIDENCE AT QUARRY HILL OR I ?5qu (x4) is SUMMARY STATEMENT OF lo (FACH DEFICIENCY MUST BE PRECEDED BY FULL anFax (EACH sr-rouw as TAG Regulatory DR TAG To THE APPROPRIATE DATE R2530 ti From page 27 R253 shelves in the same area where dry spice containers were stored had a layer of dust and crumbs; the lower shelf of a prep table on the cook's line was heavily soiled with a buildup of grease. soiled greasy paper. and food crumbs. Additionally, the back panel of the stove back. the grill. the fryolator and the toaster all had a build-up of grease on various areas of the equipment; per review. these areas were not included on the posted cleaning schedule. The tours on ?318 and 1!3!18 were conducted with the 2 chefs working on those days. D1vis1on of L1cens1ng and Protection STATE FDRM M3WT11 If continuation sheet 28 012B