AGENCY OF HUMAN SERVICES DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING Division of Licensing and Protection 103 South Main Street Waterbury, VT 05671-2306 Voice/TTY (802) 871-3317 To Report Adult Abuse: (800) 56441612 Fax (802) 871-3318 December 22, 2014 Mr. Christopher Keough, Administrator St Joseph's Residential Care Home 243 North Prospect Street Burlington, VT 05401-1609 Dear Mr. Keough: Enclosed is a copy of your acceptable plans of correction for the survey conducted on November 13, 2014. Please post this document in a prominent place in your facility. We may follow-up to verify that substantial compliance has been achieved and maintained. If we find that your facility has failed to achieve or maintain substantial compliance, remedies may be imposed. Sincerely, WM Pamela M. Cota, RN Licensing Chief Disability and Aging Services Blind and Visually Impaired Licensing and Protection Vocational Rehabilitation Division of Licensing and Protection PRINIEU: 11/25/2014 1 FORM APPROVED STATEMENT OF DEFICIENCIEs AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: U155 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. COMPLETED 3? 11/13/2014 NAME OF ST RESIDENTIAL CARE HOME ROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 243 NORTH PROSPECT STREET BURLINGTON, VT 05401 (x43 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) PREFIX. (EACH DEFICIENCY MUST BE PRECEDEO BY FULL PREFIX (EACH CORR ECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE 1 DEFICIENCY) R100 Initial Comments: R100 St Joseph' ReSidential 12/8/14 Care Home has completed An unannounced on-Site complaint investigation comprehensive plans Of care was conducted on 11/13/14 by the Division of f0? ea?lh reeldent based 0? Licensing and Protection. The following regulatory and needs . violation was identi?ed.- . identified in the resident . assessment. R145 V. RESIDENT CARE AND HOME SERVICES R145 . 33:0 St. Joseph's Home Will 1 maintain nursing audits of 5.9.0 (2) all resident care plans to include:_ Oversee development of a written plan of care for . Physician comprehensive each resident that is based on abilities and needs and complete medical and as identified In the resident assessment. A plan diagnosis list . of care must describe the care and services . Physician orders and necessary to assist the resident to maintain collaborative health I independence and well-being; service providers . . . -. Medication administration The REQUIREMENT IS not met as evIdenced record/treatment record by: . . . Nursing notations and Ilfiasedfo'rII rctiecord and stat:r summaries ome aI assure care ans re as - current status and needs of 2 of 4 residents Nur81ng assessments reviewed. (Residents #1 and Findings include. Resident #1 care plan 4 . . . updated to include' [2/8/14 1. Per record reVIew ResIdent admitted on St ff . . . 2/22/12 with Dementia, had an annual Resident a raining regarding Assessment, dated 2/28/14, that identi?ed; the interventions with reeldent resident as having moderate cognitive dur}ng tlrf?es that the impairment. The resident was also identi?ed as reeldent 15 agitated . having been physically and verbally abusive on - Gu1d1ng the resident occasion. Progress notes during the month of away frem the source 0f November and December of 2013, revealed the distress . resident had wandered into other resident roomS . Diverting the resident' and had been verbally aggreSSive towardsother attention to sources of residents. A progress note, dated 1/26/14, strength, ie music and i indicated that Resident#1 had puthiS/her hands singing and travels abroad around the neck of Resident #2 and choked that I resident. Subsequent notes revealed the ivision of Licensing and Protection - OR PROVI REPR SIGNATURE TITLE DATE m. Wm, TATE FORM 900 mica swim 5599 5GSV11 If continuation sheet 1 of 3 PRINTED: 11/251'2014 2. Per record review Resident admitted'on 8/29/12 had a family meeting on 3/14/14 to discuss the resident's increasing behaviors, the inability of the home to continue to meet the resident's needs and the need for higher level of care. A plan was put into place, while attempting to find appropriate placement, to add a private or personal care giver to work with Resident #4 (3) times per week. A ResidentAssessrnent was conducted on 10/3/14, as the result of a signi?cant change in status, that indicated Resident had a moderate cognitive impairment and exhibited behaviors that included; socially inappropriate, verbally and physically abusive on occasion and a risk of wandering In attendance was St. Joseph's Director of Nursin and three of the resident's children. Issues discussed were as follows: .Toileting - The resident seems unaware of bowel movements, and is not able to clean himself. .The resident continues to ,have altered memory and periods of lucidity wherein he is oriented to person and place. FORM APPROVED Division of ticensinq and Protection STATEMENT or DEFICIENCIES (xn' (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN or CORRECTION NUMBER: A BUILDING: COMPLETED 0155 3- 11/13/2014 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 243 NORTH PROSPECT STREET ST JOSEPH RESIDENTIAL CARE HOME BURLINGTON, VT 05401 . (x4) ID. SUMMARY STATEMENT or DEFICIENCIES In PLAN or CORRECTION (x5) PREFIX DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORR ECTIVE ACTION as COMPLETE TAG REGULATORY oR INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) R145 Continued From page 1 R145 . Continual monitoring following: on 5/4/14 Resident #1 was involved in particularly during evening a verbal confrontation with other residents, hours 1? r001? areas - becoming increasingly aggressive toward them, .Educating residents to which reportedly frightened other residents who walk away from confrontation verbalized fear that Resident#1_ mightpunch one and seek assistance from a - - of them; on 5/18/14 Resident #1 reportedly staff member . pushed another resident and made him/her cry; . Activities Director will on'6/24/14 the resident pushed Resident#5, provide resident' 1 with upsetting him/her and on '7/4/14 Resident #1 tasks during ,the day to arm_ Despite these incidents, the care plan, contributions to the Home whiCh had not been updated since 2/3/14 did not address the ongoing aggressive behaviors (See Attached) revealed in May, June and July of2014. ln . addition, although the care plan states to 'monitor frequently' it does not define whatthat means. A care plan meeting was held ror resident #4 on 10/29/1412/8/14 .The at 2:00 AMht'h?em' resident, who used a rolling walker for ambulating, was "found on stairs w/out [his/her] down one ?ight of for [his/her] confused Assisted back to . room via Although the resident's care .5 plan, dated June 2013, had been Updated on attempting" to exit the building via the stairwell near his room. Summary of Care Plan Meetin The three adult children 9 ivision of Licensing and Protection TATE FORM 6399 If continuation sheet 2 of 3 PRINTED: 11f25/2014 . FORM APPROVED of LicenSInq and Protection - STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED 0155 BY 11I13I2014 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. CODE 243 NORTH PROSPECT STREET ST JOSE RESIDENTIAL CARE HOME BURLINGTON, VT 05401 (x4) 10 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) FREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG To THE APPROPRIATE DATE DEFICIENCY) . R145 Continued From page 2 R145 who were present at the meeting agreed that their father requires a higher level of care. This was discussed with resident #4 in his room, and he verbally agreed with a plan to move him to a higher level of 10/14/13 to re?ect "increasing incidences of aggressive or threatening behaviors" it had not been revised to re?ect the increase in wandering behaviors and the need for heightened supervision and monitoring of the resident. The covering RN and LPN both con?rmed, during interview on the afternoon of11l13/14, that the care facility - care pians for Residents #1 and #3 did not reflect Res ident 4 care plan either resident's current status or needs. updated to 1110111518: .A large red stOp sign has been placed on the door outside the resident's room as a visual deterrent from using the stairs. . .St. Joseph's nursing staff will continue to provide the resident with ERC level of care. .The Activities Director will continue to encourage resident's participation in Home activities. .St. Joseph's Home has assisted family members with finding a suitable, secure Level II facility. Resident #4 is currently on a waiting list for one facility, and will remain at St. Joseph's until a room opens at the facility (See Attached) rision of Licensing and Protection FORM 6599 5G8V11 If continuation sheet 3 of 3