Gill Odd Fellows Home of Vermont

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by a staff member for 1 of 3 sampled residents (Resident #1).

Inspectors wroteBased on observation and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards of food service safety.

Inspectors wroteBased on observations and interviews the facility failed to provide a system that enables residents to file an anonymous grievance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices during medication administration by not practicing appropriate hand hygiene during preparation and administration of medications and the presence of a staff member's personal drink on 1 of 2 medication carts. This is a repeat deficiency for this facility, with violations cited during the previous three re-certification surveys dated 1/11/23, 1/24/24, and 3/19/25.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise a plan of care to reflect an identified concern of a decline in mobility for 1 of 13 sampled residents (Resident #27).

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure medication error rates were less than 5% or greater. There were 31 medication administration opportunities, 29 were observed to be given and 2 were omitted, resulting in errors for 2 of 6 sampled residents (Resident #14 and Resident #16). The total error rate for all observations was calculated at 6.45%.

Inspectors wroteBased on observation and interviews the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 2 medication carts.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services) in accordance with State law through established procedures for 1 resident [Resident #1] of 3 sampled residents.

Inspectors wroteBased on interview and record review, response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to have evidence that all alleged violations are thoroughly investigated regarding 1 resident [Resident #1] of 3 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure as needed [PRN] orders for psychotropic drugs are limited to 14 days for 3 of 19 sampled residents [Resident #37, #21, and #22] unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days and documents their rationale.

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to maintain facility-wide systems for the prevention, identification, and control of infection and communicable diseases of residents, staff, and visitors through surveillance, staff training, and following established policies and procedures related to proper use of personal protective equipment (PPE) specifically Enhanced Barrier Precautions (EBP) for 4 of 4 of the applicable sample (Residents #7, #11, #10, and #38).

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of 1 resident [Resident #28] of 19 sampled residents regarding physician orders not followed related to medications not administered as ordered.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 [Resident #43] of 4 sampled residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experience and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Inspectors wroteBased on interview and record review, the facility failed to provide services that meet professional standards of quality regarding proper actions following a fall which resulted in harm for one resident [Res.#1].

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff possessed and implemented the appropriate competencies and skills sets to provide nursing and related services to assure resident safety for one resident [Res.#1].

Inspectors wroteBased on record review and interview the facility failed to ensure that nursing staff were assessed for skills competency upon hire and annually, based on the care needs of the residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that professional standards of practice were followed for 3 of 26 residents in the sample. (Resident #36) related to assessment and monitoring after a choking episode, and (Resident # 188 and Resident #7 ) related to safe administration and monitoring of diabetic medications and blood glucose monitoring.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodations of needs and preferences related to a mattress for 1 of 26 residents sampled. (Resident #7).

Inspectors wroteBased on observation, interview, and record review the facility failed to accept a resident back after being transferred to an acute care facility for evaluation for 1 of 26 residents sampled. (Resident #33).

Inspectors wroteBased on observation, interview, and record review the facility failed to comprehensively assess a resident's physical needs related to requiring a Continuous Positive Airway Pressure Machine (CPAP) for 1 of 26 residents sampled. (Resident #188).

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a baseline care plan within 48 hours of admission for 2 of 26 residents in the sample (Residents #188 and #237) related to a continuous positive airway pressure (CPAP) (a machine that uses mild air pressure to keep breathing airways open while you sleep) device (Resident #188), and a baseline care plan that included instructions needed to provide effective care related to a pressure ulcer (Resident # 237).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all residents have adequate supervision to prevent accidents for 2 of 26 residents sampled (Resident #33 and Resident #12).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with Professional standards of practice for 1 of 26 residents sampled. (Resident #188). During an interview with Resident #188 on 1/22/23 5:12 P.M. a Continuous Positive Airway Pressure Machine (CPAP) was noted on the resident's bedside table. (This is a machine that uses mild air pressure to keep breathing airways open while you sleep. The air pressure delivered is determined by the pressure setting on the device.) The resident turned the machine on and there were specific settings programmed into the machine. The resident stated his/her spouse brought the machine in from home. Resident #188 said that he/she wears his/her CPAP at night, and the nursing staff does not assist him/her with the CPAP. He/she stated he/she puts it on, turns it on, and removes it him/herself. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the physician evaluated and assessed a pressure ulcer for 1 of 26 residents sampled. (Resident #33).

Inspectors wroteBased on observation and interview the facility failed to ensure proper infection control processes were followed for 2 of 26 residents sampled. (Resident #33) during a pressure wound dressing change and cleaning of a Continuous Positive Airway Pressure Machine (CPAP) for (Resident #188)