VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING Division of Licensing and Protection HC 2 South, 280 State Drive Waterbury, VT 05671-2060 http://www.dail.vermont.gov 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 July 12, 2019 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 June 3, 2019. 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, itmdovt,c6t094 Pamela M. Cota, RN Licensing Chief Disability and Aging Services Licensing and Protection Blind and Visually Imparied Vocational Rehabilitation PRIM-ED: D6/11/2019 FORM APPROV D E Division of 1..ICen in nit Protecbc STATENIEN T OF DETIC,ENCIES AND PLAN OF CORRECTION I` ER OVIDERISUPPIJERICLIA DENTIFICATION NUMBER: / MULTI=LE CONSTRUCTION A BUILIII(NG' 3) DATE SURVEY COMP, GTTO C 06/03/2019 6, WING 1012 NAME OF PROVIDER OR SUPPLIER ' STREET A9gRESS, CITY, STATE ZIF CODE 465 QUARRY HELL ROAD SOUTH BURLINGTON, VT 05403 SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S FLAN OF CORRECTION ,EACH DEFICIENCY VEST aE PRECEDED BY FLID. PREFIX (EACH CORRECTIVE ACTION SHOULD BE THE RESIDENCE AT QUARRY HILL 'XXI 0 PREFIX TAG R100 REGULATORY CR LSO IDENTIFYING INFORMATICN) TAG Initial Comments: R100 An unannounced onsite investigation of a Complaint and a Facility Reported Incident was conducted on 6/312619 There were regulatory deficiencies cited as a result of the investigation. Findings include. R178 CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 8100: Initial Comments. . V. RESIDENT CARE AND HOME SERVICES 8178 SS=F 5.11 Staff Services 5.11_ a There shall be sufficient number of 'The submission of thisplan does not constitute any admission of wrong doing. I Rather, this plan of correction is submitted in the spirit and in the letter of cooperation to demonstrate the Residence of Quarry Hill's commitment to continued quality. _..., 7'". / e? pi ,,-„,/V ro C 0., qualified personnel available at all times to provide necessary care, to maintain a safe and healthy environment, and to assure prompt, appropriate action in cases of injury, illness, fire or other emergencies This REQUIREMENT is net met as evidenced by Based on observations, record review and staff interviews the facility failed to assure a sufficient number of staff are available at all times to ensure a safe environment and to assure resident's needs are met. Findings include: Per observation, the facility has 4-1, . capacity 14 mt,,Pdt ' rots-,P,Pit .curer . Cif..... 54 J-*49M:sat the facility, There are resident rooms cn 4 floors including a secure Dementia unit (Reflections) housing 25 residents. In interview on 6/3119 at 1:05 PM, the Residential Care Director (RCD) confirmed that the facility has identified that the staffing on the night shift 11 AM-7 PM) has been inadequate and that new staffing goals have teen set. The issue that was identified by the surveyor and by the facility is that having 3 unlicensed RCAs on duty to provide care and supervision for 94 residents, which includes 25 residents in a secured unit, cannot of L cens:88 and Prntpismn zezien4 {ABORAI i DIRECTOR'S CR PROVIDERHGLIPPLIER REP:2E 'AT RE STATE FORM 745s katwente_ 0(5) CONPLETS DAT, Ti T C-,ctoebtee70-0,-- T4'86 I PRINTED: 06;11/2019 FORM APPROVED Division of Licensint-t and Protection S-CATEMENT OP CSAICTENcIES ANC PLO' OF CORRECTION 7ROV!DE OF I. EF CLiA IDENS'F•CATION NI( stitn.uny CCWP1 BULOiNG: C 1012 06/03/2019 NAME OF PROMDER OR SUPPLIER STREE7 ADDRESS ' CITY STATE, 7IP CODE THE RESIDENCE AT QUARRY HILL 465 QUARRY HILL ROAD SOUTH BURLINGTON, VT 05403 r)(4);11 , PREFIX TAG SUMMARY STATEMENT OF 0E510 ENDES • (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR I.SC IDENTIFYING INFORMATION) ID PREFIX TAG 8178 Continued From page 1 nK5) :::OMPIEEE DATE . 8176 provide a RCA for every resident area. In a review of information requested from the Reflections Care Director, the secure unit includes 2 residents who require a Hoyer Lift. The use of a mechanical lift requires 2 staff, There are 3 residents who are receiving Hospice services. All residents require some level of assistance with personal care. There are 17 residents who have some level of incontinence which requires assistance_ There are also 5 residents who exhibit various behaviors, however many of the residents are at risk for behaviors related to their Dementia diagnoses. There are also a number of residents in the facility at risk for falls. The facility is presently recruiting to fill these shifts. The Executive Director of the facility confirmed that information at 1:27 PM. In a reviewof actuai schedules, provided by the facility, for the dates 5126-6/3119. 4 of the 8 completed night shifts had only 3 Residential Care Assistants (RCAs) on duty. All night shift totals include one RCA who s also a Medication Technician (MT). That RCA is responsible for administering any medications needed during that shift There are no licensed nurses on duty during the 11 PM-7 AM shift there is a nurse on-call For the projected 13 day period of 5/3-15/19 there are 3 night shifts with 3 RCAs on duty. In an interview on 6/3/19 at 1:45 PM the Reflections Care Director (ROD), who is responsible for the staffing schedule, stated that there no accurate schedules available prior to the 5126/19 date, and that all schedules, going forward, are in progress. It is also noted that there are times when staff are assigned to 16 hour shifts. Dnn-S:dn ,)f STA7E FORM PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE (APPROPP.IATE DEFICIENCri and F. -HAAR:E.:1cl: ds, R178 Action to Correct Deficiency: The Community will maintain records of actual staff on duty for a minimum of 30 days prior. R178 Steps to Prevent Recurrence: The Community will implement and utilize new scheduling function through, the Community's HRM system that will track actual staff on duty electronically. R178 Monitoring of Future Systems: The Community will be able to monitor the use •of this scheduling system in real time via the existing HRM system. Complete Date: 8/1/19 -7• (7, PRIN Div+sicn of Licens STA f R.N1NT OP ANC PLAN CE '20PFEAC1C.' cIIPPLIRR;CLA IDENTIFICATION NUMBER.: (52) MULTIPLE CONSTRUCTION A. BUILDING: IXIL) DATE SUR)), Eir COMPLY: C 06/0312019 1012 NAME OF PROVIDER OR SUPPLIER STREETACDRESS, CITY, STATE, ZIP CODE THE RESIDENCE AT QUARRY HILL 465 QUARRY HILL ROAD SOUTH BURLINGTON, VT 05403 (54) PREFIX TAG -SUMMARY STATEMEN I CR DEFICIENCIES ISACH DEFICIENCY MOST BE PRECEDED BY EI.ILL REOULATCIRY OR LUC IDEINT!prING INFORMATION) R183 Continued From page 2 R183 V. RESIDENT CARE AND HOME SERVICES sS=C 5.11 Staff Services 5,11,f There shall be at least cne (1) staff member on duty and in charge at all times. In homes with more than fifteen (15) residents, there shall be at least one (1) responsible staff member on duty and awake at all times. There shall be a record of the staff on duty, including names, titles, dates and hours on duty_ This REQUIREMENT is not met as evidenced by: Based on record review and staff interview there are not accurate records of actual staff on duty, including names, Niles, dates and hours on duty. Findings include: Per interview on 6/3119 at 1:45 PM the Reflections Care Director (ROD), who is responsible for the staffing schedule, stated that there no accurate schedules available prior to the 5/26i- 9 date S/he stated that a new scheduling process is being adopted. ID PREFIX rAo R183 R183 PROVIDER'S PLAN CP CORRECTION CORRECITIVR AC f ION SHOULD BE OROS:R.-REFERENCED TO THE APPROP PLATE DEFICIENCY) 551 COMP LET LVJF. R183 Action to Correct Deficiency: [Night shift staffing levels (11pm - 7am) will be set to adequately provide a safe environment for all residents in all assisted living areas. These staffing levels will take into consideration the number of residents on services in Assisted Living and all residents in the Special Care (Memory Care) Neighborhood including their acuity into the equation. R183 Steps to prevent Recurrence: The community will consider all viable options to ensure adequate staffing is available including internal staff, agency staff, and staff available from other LCB Senior Living communities. R183 Monitoring of future systems: The Community will review staffing levels i on a daily basis to ensure adequate levels on the night shift (11pm - 7am) moving forward. * Complete Date * 7/1/19 ,/,,c 7. // C'v/SII/r, of Licensr.g End PNxIeFU.c1 E'r-A.T R. FORM 0.5111):2010 ,IPC=ROVED d Prote "ic ' ."-.) /Si('