A NERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING Division of Licensing and Protection HC 2 South, 280 State Drive Waterbury, VT 058712080 Survey and Certification Voicefl'TY (802) 2410480 Survey and Certification Fax (802) 241?0343 Survey and Certification Reporting Line: (888) 700?5330 To Report Adult Abuse: (800) 564?1612 June 8, 2018 Ms. Allyson Sweeney, Manager The Residence At Shelburne Bay East 185 Pine Haven Shores Road Shelburne, VT 05482-7805 Dear Ms. Sweeney: Enclosed is a copy of your acceptable plans of correction for the survey conducted on May 16,2018. 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, C>i2miaWWircm Pamela M. Cota, RN Licensing Chief Disability and Aging Services Blind and Visually Imparied Licensing and Protection Vocational Rehabilitation 8029851438 15:36:05 06?05?2018 4 i9 PRINTED: [35/232018 FORM APPROVED Division of Licensing and Protection STATEMENT or (X1) PROUIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION {x3} DATE SURVEY AND PLAN or CORRECTION NUMBER: A BUILDING: COMPLETED 1009 3- WING 05i15i201 8 NAME or on SUPPLIER STREET ADDRESS. cITv, STATE, ZIP CODE 185 PINE HAVEN SHORES ROAD BU A THE RESIDEN EAT SHEL RNE EAST SHELBURNE, VT 05482 W) in SUMMARY STATEMENT OF DEFICIENCIES in PLAN or CORRECTION ixsi PREHX (EACH MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY on Lee IDENTIFYING INFORMATION) m; CROSS-REFERENCED To THE APPROPRIATE DAT i . R100 Initial Comments: R100 . . . . R100 Initial Comments The submissmn of I An unannounced re-licensure survey and the this plan Of correction does not imply investigation of four facility reported incidents and agreement 'With the existence ofa de?ciency. one complaint was conducted by the Division of 3 Licensing and Protection on 5/14?16/20?17. There It 15 submit? in th?? 0f coopera?oni to were no regulatory de?ciencies identi?ed as a demonstrate the Resrdence at Shelburne result of the Investigations. The following Bay?s commitment to continued regulatdry deiiCie-RCIes were Identi?ed as a result improvement in the quality of our residents of the survey: care. R130 V. RESIDENT CARE AND HOME SERVICES R130 I 35:5 The Resrdence at Shelburne Bayhas stopped advertising this section of the community as part of - 5.6 Special Care Units its Re?ections Memory Care. The website has been updated, the rate sheets have been corrected and 5.5.3 The home must obtain approval from the new brochures are on rush order. licensing agency prior to establishing and operating a special care unit. Approval will be based on a demonstration that the unit will The Residence at Shelburne Bay is in the process of provide specialized services to a speci?c assessing each resident residing in this area to population. determine if their needs can be met under the AL regulations orif transfer to Special Care unit is I necessary. The Residence will work to transfer residents to SCU apartments over the next 60 days. a This REQUIREMENT is not met as evidenced by: Based on observation, record review and staff interviews the facility failed to obtain approval If licensing is necessary at that time; proper licensing i from the licensing agency prior to operating a steps will be ful?lled. All of the residents will be Special care unit. Findings include: reassessed and a decision will be made to either license this area or keep it under the AL license and Per de?nition, a Special care unit provides discontinue the security features. Specialized services to a speci?c pepulation of residents. The second floor. often referred . to as "the Dementia linit" in converSations with complem" Date: 08/05/18 staff during the survey. is a secure unit for the residents residing there who are at risk for wandering and have impaired cognition. The unit is part of the facility Reflections Memory Care program according to the facility website and the advertising brochures. The unit is secure and if any resident wearing a Wander Gard enters the Division of Licensing and Protection LABORATORY GR REPRESENTATIVES SIGNATURE TITLE (Kill DATE dad/Jar WM . (Ema: 1111).? QZ 5130/9 STATE (7 5'99 lieontinu?atton sheet of 6 lilacs (?0ch accepts el'ilis 8029851438 Division of Licensing and Protection 15:37:02 06?05?2013 5I9 PRINTED: USFZBIZDIB FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 1009 B. (X2) MULTIPLE CONSTRUCTION A. BUILDING: WING (X3) DATE su RVEY COMPLETED 05116l2013 THE RESI NAME OF PROVIDER OR SUPPLIER DENCE AT SHELBURNE BAY EAST om. STATE, ZIP none 135 PINE HAVEN SHORES ROAD SHELBURNE. VT 05482 (X4) Io PREFIX TAG 1. i SUMMARY STATEMENTOF A (EACH DEFICIENCY MUST BE PRECEDED FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDERS PLAN OF CORRECTION i (EACH CORRECTIVE ACTION SHOULD BE TO THE APPROPRIATE DEFICIENCY) tX5i COMPLETE DATE Continued From page 1 elevator the elevator will not move. Someone with cognitive skills suf?cient to use speci?c buttons must operate the elevator for those residents. The stairways are locked with key pads requiring a code. The Registered Nurse, Resident Care Director (RN, RCD) stated in an interview that all direct care staff receive education in working with residents with Dementia prior to working on the unit. In an interview on the Executive Director and the RCD confirmed that the facility has not submitted a request for approval to operate a special care unit. . V. RESIDENT CAREAND HOME SERVICES 5.11 Staff Services 5.11.b The home must ensure that staff demonstrate competency in the skills and techniques they are expected to perform before providing any direct care to residents. There - shall he at least twelve (12) hours of training each year for each staff person providing direct care to residents. The training lest include. but is not limited to, the following: (1) Resident rights; (2) Fire safety and emergency evacuation; (3) Resident emergency response procedures. such as the Heimlich maneuver, accidents, police or ambulance contact and ?rst aid; (4) Policies and procedures regarding mandatory reports of abuse, neglect and exploitation; (5) Respectful and effective interaction with residents; (6) Infection control measures, including but not limited to, handwashing, handling of linens, R130 R179 R179 Actions to correct de?ciency: A associate educational requirements per 5.11 will be brought up to date. Actions to prevent recurrence: Associate trainings will be tracked by RCD or designated nurse. The RCD or designated nurse will ensure compliance with educational requirements through audits of associate ?les weekly for 3 months, for 3 months, and quarterly ongoing. 1 Completion Date: 08/15/18 Division of Licensing and Protection STATE FORM C3QV11 "continuation sheet 2 dis 8029851438 15:37:51 06?05?2018 6 r9 PRINTED: FORM APPROVED Division of Licensino and Protection STATEMENT OF DEFICIENCIES on PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (X31 DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED C3 1009 3- WING 05I16I2018 NAME or PROVIDER OR STREET ADDRESS, CITY. STATE, ZIP CODE 185 PINE HAVEN SHORES ROAD LBU AST THE RESIDEN AT SHE RNE BAY SHELBURNE. VT 05482 no) lo SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER-S PLAN OF CORRECTION (x5, PREFIX MUST DE PRECEDEO av FULL PREFIX CORRECTIVE ACTION SHOULD as COMPLETE TAG REGULATORY OR LSC INFORMATION) m; CROSS-.REFERENCED To THE APPROPRIATE DATE 1. I R179 Continued From page 2 I R179 maintaining Clean environments, blood borne I pathogens and Universal precautions; and I (7) General supervision and care of residents. i This REQUIREMENT is not met as evidenced by: i Based on record review and staff interview the facility failed to assure that staff providing direct care to residents receive twelve hours of training each year which Includes, but tend limited to, seven mandatory topics for 5 of 5 randomly Selected staff. Findings include: Per review of training! inservice records. for the calendar year 2017,. there is no evidence of the provision of one of the mandatory topics- General . Care Supervision. In a review of five randomly selected active direct i caregivers hired before 2101? the following was identi?ed: Staff #1 completed the 6 mandatory inservices and an additional inservice for a total of 7 hours but has no further documented education. Staff #2 and #3 have no documented education hours. Staff #4 has no mandatory inservice education and has one hour of education on Harassment in the Workplace. Staff #5 has no mandatory inservice education and has one hour of education on Aging, Death. Dying. The RCD con?rmed on the afternoon of 5/16/18 that there is no further education or training 5 information available for the year 2017. R247 VII. NUTRITION AND FOOD SERVICES R247 ss=F Division of Licensing and Protection STATE FORM am If continuation sheet 3 DI 6 80298513138 Division of Licensing and Protection 15:38:32 06?05?2018 7 t9 PRINTED: 05/239018 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PHOVIDERISUPPLIEFUCLIA MULTIPLE CONSTRUCTION (X3) oars sunvev AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 1009 3- 0511612018 NAME OF PROVIDER 0R SUPPLIER THE RESIDENCE AT SHELBURNE BAY EAST STREET ADDRESS. CITY. STATE. ZIP CODE 135 PINE HAVEN SHORES ROAD SHELBURNE. VT 05482 7.2 Food Safety and Sanitation 7.2.b All perishable food and drink shall be i 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. ?1 This REQUIREMENT is not met as evidenced by: Based on observations, the facility failed. to assure that all perishable foods were labeled, dated and held at proper temperatures. This i practice had the potential to affect all residents Of i the home. Findings Include: During the initial tour of the kitchen on commencing at 2 PM, the following perishable j_ foods were not labeled and [or dated in 3 accordance with regulations and safe food I handling practices: Walk-in cooler observations - seafood salad dated 5/10/18 (out dated); 1 . green salad - no Iabetldate; . .5 sliced cooked meat - no dalettabet, was roast beef per the Food Service Director dessert bars no labetldate. were lemon bars, per; fruit salad - no labelldate; block of cooked meat - no Iabelldate . was roast beef per the 3 containers sauces no labeltdates, were various types of demi glace per the mashed sweet pdtatoes dated 516MB (out dated); mashed white potatoes labeled (out dated). {in) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER-s PLAN or CORRECTION x5) PREFIX - (EACH MUST BE Pneceoeo 8? FULL PREFIX (EACH CORRECTIVE ACTION SHOULD as COMPLETE TAG REGULATORY OR 1.50 IDENTIFYING TAG CROSS-REFERENCE) To THE APPROPRIATE DATE . DEFICIENCY) Continued From page 3 R247 7.2 Food Safety and Sanitation All refrigerators and freezers where emptied, cleaned, and inspected. All food that was not properly labeled or any food that had been stored for longer than 3 days was discarded. All associates were rte?educated on the LCB policy of "Date Marking Ready to Eat Hazardbus Food" and was placed in associate files) We initiated a daily walk through to be completed by FSD or designer: of all coolers and reach-ins to check for food storage compliance. Food will be dated immediately after it is defrosted and ready to use. Division of Licensing 'and Protection STATE FORM ?continuation sheet :1 of 6 8029851438 15:39:20 06?05-2018 8 I9 PRINTED: 05232018 FORM APPROVED Division of Licensing and Protection STATEMENT OF DEFICIENCIES Ixn MULTIPLE CONSTRUCTION (x3) OATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A Emma COMPLETED 1009 3- WW5 05116I2018 NAME OF OR SUPPLIER STREETADDRESS, CITY, STATE. ZIP CODE 185 PINE HAVEN SHORES ROAD THE RESIDENCE AT SHELBURNE BAY EAST SHELBURNE, VT 05482 W) In SUMMARY STATEMENT OP DEFICIENCIES tD PROVIDERS PLAN OF CORRECTION (its; PREFIX (EACH DEFICIENCY MUST BE PRECEDEO aY FULL CORRECTIVE SHOULD BE COMPLETE TAG REGULATORY OR IDENTIFYING INFORMATIONI TAG CROSSFREFERENCED TO THE APPROPRIATE DATE DEFICIENCY) R247 Continued From page 4 . . Per interview with the F30 at the end of the observation, he confirmed that all perishable foods should be labeled and dated, he was i uncertain about the'safe food dating timelines and said that most foods will last 1 week. For review of the policy/procedure regarding perishable food labeling and dating, foods should be dated when they are made Upand discarded aneI 33133I5- The?e' wt?tfedtem: inthebwelk?in it R252 V11 Nutrition and Food Service: I coo er a were I an I Is as avIng een pu . I from the freezer for re-use (including corned beef 7'2 Food Storage and Equipment 5 from March). When asked about these foods. the I FSD said that they did not re-date these items Immediately, a weekly and bi-weeldy cleaning I and had "ods?ef'?clwmel" Qu'dan?f 0d schedule was created and initiated. All! areas of I recommen Ime Ines assure oo were . -. used within recommended timelines. were Cleaned ?3 ??dUde 1100." I Ventdatlon screens, trash cans, worktn such as R2522 VII. NUTRITION AND FOOD SERVICES R252 walls, sinks and I equipment. All food handlers were re- - . educated on cleaning supply storage outside of . .. 7.2 Food torege an Equrpmen the kitchen. 1 7.3.b Areas of the home used for storage of I food, drink. equipment or utensils shall be R200 i - constructed to be ready Cleaned and shall he All culinary associates that handle food were kept clean This REQUIREMENT is not met as evidenced by: Based on observations, the facility failed to assure that all areas of the home where foods. drinks or equipment were stored were kept clean. This practice had the potential to affect all residents of the facility. Findings include: During the initial tour of the kitchen on at 2 PM, the following areas were not clean: a. trash cans and lids used in the kitchen were heavily soiled on the outside of the containers; re-educated on our Reheating Potentially Hazardous Food policy. This included but was not limited to, . Heat processed, ready to eat food from a package or can is heated to an internal temperature of at least 135F for 15 seconds. - Reheat any precooked, processed foods that have been previously cooled to an internal temperature of 165F for 15 seconds. - Allow all food to sit for 2 minutes after heating in a microwave oven. Division of Licensing and Protection STATE FORM ?59 It continuation sheet 5 of 6 8029851438 Division Of Licensing and Protection 15:40:12 06?05?2018 9 i9 05(23f2018 FORM APPROVED b. the cooking equipment. inciuding the stove. gas grill ovens and hood ventilation screens were i soiled with a build up of dirt and grease. and. a food preparation bench with under counter shelves holding dry food supplies (flour. sugar etc.) had a build up of dust and crumbs; d. a cart storing clean dishware had crumbs and visible dust and dirt on the shelves; e. a baker?s rack for storage of sheet trays/foods had greasy visible soiling on all of the shelf glides; i. there were crumbs and dust observed under the toaster tray; under counter shelves next to the prep shelving were also soiled, g. the floor mOp and the mop bucket were stored in the midst of the food preparation area due to a lack of other appropriate spaCe per staff. in close proximity to foods being prepared; h. the wall area around the hand wash sink was visibly soiled with a build up of dirt; When a copy of the cleaning schedules was reviewed. it only addressed the cleaning to be . done on a daily basis; there was no written cleaning schedule to include all areas of the kitchen. to maintain a sanitary environment. This was con?rmed at the time of the observations on the afternoon of STATEMENT OF DEFICIENCIES (X1) (x2) MULTIPLE (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFIOATION NUMBER: A BUILDING: COMPLETED 1009 3 WM 05l16/2018 NAME OF PROVIDER on SUPPLIER STREET ADDRESS. CITY, ZIP CODE 185 PINE HAVEN SHORES ROAD URNE AST - THE RESIDENC A SHELB AY SHELBURNE, VT 05432 (mi in SUMMARY STATEMENT OF DEFICIENCIES PROVIDER's PLAN OF CORRECTION PREHX DEFICIENCY MUST BE PRECEDEO BY FULL mgr-Ix (EACH CORRECTIVE ACTION SHOULD er?: COMPLETE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE R252. Continued From page 5 -. R252 Division of Licensing and Protection STATE FORM 6659 if continuation sheet 6 ole