Crescent Manor Rehabilitation
Both the State of Vermont and the Centers for Medicare and Medicaid Services (CMS) conduct routine unannounced inspections and scheduled surveys on every nursing facility in the state. These inspections allow surveyors to review records and identify serious concerns involving resident safety.
Surveys at even the best run nursing homes identify an average of 6 to 7 violations and deficiencies at every survey. However, these issues tend to be minor in scope.
When surveyors identify serious problems, they flag the deficiencies as hazardous violations and provide the facility the opportunity to correct the problem immediately, or within days or weeks. If the facility does not make the corrections in the appropriate timeframe allowed by state and federal nursing home regulators, the Home may be designated a Special Focus Facility (SFF) and placed on a unique watchlist.
The facility will remain under the watchful eye of investigators and must undergo many more inspections than facilities that remain in compliance.
Recently, Crescent Manor Care Centers was designated a Special Focus Facility due to serious concerns about residents’ health and well-being. Some of these concerns are listed below.Crescent Manor Care Centers
This 90-certified bed Medicaid/Medicare-participating nursing facility provides cares and services to the residents and visitors of the city of Bennington and in Bennington County, Vermont. The facility is located at:
312 Crescent Boulevard
Bennington, VT 05201
In addition to providing around-the-clock nursing care, the facility also offers dementia care and Alzheimer’s care, Huntington’s disease care, rehabilitative services, and short-term respite care.More Than $200,000 in Penalties
If the violations identified by state surveyors are egregious, Medicare, Medicaid, and the state of Vermont might issue fines against the facility in amounts that reflect the severity of each deficiency. Over the last three years, Crescent Manor Care Centers received four monetary penalties that included fines of $162,663 on 07/29/2015, $17,177 on 11/18/2015, $52,163 on 07/26/2016, and $18,876 on 03/28/2017.Current Nursing Home Resident Safety Concerns
Many families in need of placing a loved one in a nursing facility will research the Medicare.gov website to compare Homes that have available beds in their community. The federal website provides information based on a star rating summary system to help identify any serious problems quickly.
Currently, Crescent Manor Care Centers maintain a one out of five stars ranking in the summary system compared all other facilities in the US. This ranking also includes one out of five stars for health inspections, five out of five stars for staffing, and one out of five stars for quality measures.
Some of the recent concerns, violations, and deficiencies noted at the facility include:
Failure to Provide a Safe Environment Free of Abuse, Physical Punishment or Being Separated from Others
In a summary statement of deficiencies dated September 11, 2017, the state investigator noted that the facility had failed to “ensure that one [resident] remained free from physical abuse.” The findings identified by the surveyor included a resident whose medical condition caused aggression and anger.
The resident “has a history of verbal/physical aggression toward others, putting him/her at risk for abuse by other residents and staff. The interventions include if [they are] angry, give a wide berth and avoid negative instructions and confrontations and do not attempt to reason, explain or persuade as this may further antagonize.”
Even though these guidelines were in the resident’s Health Care Plan, on August 20, 2017, the resident “was exhibiting behaviors of anger toward a Licensed Practical Nurse (LPN).” When this occurred, the LPN “grabbed the resident’s wrist and lowered him/her to the floor.”
The surveyor interviewed a resident who had witnessed the incident at approximately 2:30 PM who stated that “about a week or two ago, [the Licensed Practical Nurse] was yanking on [the resident’s] arm trying to get [them] to go to his/her room.”
The witnessing resident also stated that “on August 28, 2017, when [they] came out of [their room they] witnessed that the [abused resident confronted] the Licensed Practical Nurse [who then] grabbed the resident’s and forced [them] down to the floor.” This incident was confirmed at 12:50 PM the same day by a facility’s Registered Nurse (RN) who stated that the Licensed Practical Nurse “should have walked away and not grabbed the resident’s arm.”
- In a separate summary statement of deficiencies dated April 13, 2017, the surveyors noted that the facility had failed “to ensure that one resident …received adequate supervision to prevent an accident that resulted in injury.” The resident’s medical records showed that the resident “has a history of exit seeking and wandering [eloping].”
In the early morning hours of March 24, 2017, that resident “found standing over another resident hitting [them] with [their] walker.” It was then that the assaulting resident “was taken to [their] room, where no ‘one to one’ [supervision] was initiated within 15 minutes.” In that timeframe, the second assaulting resident “was found in the floor in the entryway of the dining room [who] was assessed by the nursing staff [and was] found to have a large laceration on the back of the head.” The injured resident “was sent to the Emergency Apartment via ambulance.”
The interim Director of Nursing confirmed during an interview that “the facility did not implement their policy [of reporting and investigating the incident].” The nurse stated that “there is no documentation of the incident and there is no evidence that the Registered Nurse made an assessment of [the injured resident] after a fall from bed during the incident.”
There was also no evidence that the family was notified, and there is no statement from the resident that anyone had interviewed him/her. The Administrator stated at the time that the facility had not reported [the incident] within 24 hours.”
A review of the facility’s policy titled Resident Abuse reads in part that “the facility [must] document the incident and notify [the] family of the incident.” The surveyors noted that “there is no evidence to support that after an incident involving a resident being told to shut up by a staff member, that the family was notified of the incident. On January 6, 2017 [the assaulting resident] was told to shut up during care.”
The facility initiated an investigation on January 8, 2017, and found that there was no evidence that the incident was documented, nor that the family was notified. A subsection of the policy reads:
“Allegations of abuse, neglect or exploitation will be reported within 24 hours of the incident.” “The facility will conduct an internal investigation which includes the following areas: Complete event report; Family/responsible party notification; Written/signed statement by the resident or of the person that interviewed the resident.”
Failure to Develop, Implement, and Enforce Policies That Forbid Mistreatment, Neglect or Abuse of Residents
In a summary statement of deficiencies dated September 11, 2017, the state investigator noted that the facility had failed to “ensure that [one resident] was free from misappropriation of resident property.” The state surveyor’s findings revealed that on August 25, 2017, the resident “made an allegation to a Licensed Nursing Assistant (LNA) that a Licensed Practical Nurse (LPN) “had been physical with him/her and took all of the snacks out of [their] drawer in the room.”
The resident also stated that “last week, [the LPN] had grabbed hold of [them] and pushed [them] onto the bed; and that the LPN had been verbally aggressive with [them].” The resident stated that “snacks have been purchased by the Activity Director for the resident and were to be consumed as the resident desired.”
The facility’s Registered Nurse stated at 12:50 PM that day that “the resident had the right to have snacks in [their] room. The Staff Development Nurse confirmed later that day that because of the resident’s medical condition, the resident “may have snacks in the room as long as they are unopened and not needing refrigeration. It was confirmed at this time that the [Licensed Practical Nurse] should not have removed the snacks.”
Failure to Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment
In a summary statement of deficiencies dated September 11, 2017, the state investigator noted the facility had failed to “ensure that allegations of abuse [involving residents] were thoroughly investigated and reported to the [appropriate] State Agency and the Adult Protective Services.”
The state investigator reviewed reports from the facility alleging ‘resident-to-resident’ abuse between two different residents. However, there “was no evidence that a complete and thorough investigation was conducted by the facility. There was no evidence at the facility reported the incident within the required timeframe.” The investigator stated that the facility’s Licensed Practical Nurse, Staff Development Nurse, or the former Director of Nursing Services never reported “the incident to the State Agency and APS; and there was no explanation as to why it was not reported.”
It was also noted that there “was no evidence that the incident was investigated and that a summary was done within the five-day time frame. Review of information that the facility has in the investigative folder presents with a typewritten paper and handwritten note [stating] ‘August 10, 2017, correct date’.” There is documentation indicating the corrected date was the “date the incident actually occurred.
Per interview with the administrator,” it was noted that they “were not aware of the incident as it was not reported to [them] until after the interim Director of Nursing Services informed [them] and concurred that it was not investigated or reported.”
- In a separate summary statement of deficiencies dated December 28, 2016, the investigator noted that the facility had “failed to report a witnessed ‘resident to resident’ incident.” The findings in this deficiency involved a reported incident occurring at 3:00 PM on October 14, 2016, where a resident was “observed by a staff member” striking another resident. It was also noted that the “facility did not report the incident until October 17, 2016.”
After an interview with the facility’s Director of Nursing, it was “confirm that the incident occurred on a Friday afternoon [and] it was not reported until the following Monday afternoon, which made it greater than the required 24 hours of reporting.” After an interview with the Administrator it was confirmed that “an allegation of abuse [must] be reported within 24 hours and that the expectation is that if the Director of Nursing is not available to file a report, nursing staff should make the initial phone call to report.”
Failure to Develop, Implement, and Enforce a Program That Investigates, Controls and Keeps Infection from Spreading
In a summary statement of deficiencies dated September 11, 2017, investigators noted that the facility had “failed to prevent the development and transmission of communicable diseases and infections [for one resident].” The documents reveal that on the afternoon of September 11, 2017, the Licensed Nursing Assistant (LNA) “was observed performing personal hygiene” for a resident after donning clean gloves and removing the resident’s brief, the LNA cleansed the resident from the front and back and reapplied a clean brief.”
However, numerous times when obtaining wipes “from the wipe container several times” the LNA used their dirty gloves.
Failure to Provide Care for Residents in a Way That Keeps or Builds Their Dignity and Respect of Individuality
In a summary statement of deficiencies dated March 28, 2017, the state investigator noted the facility had failed to “assure that [one resident] was treated [with] respect: [in a] dignified manner.” Surveyors based the deficiency on the fact that on January 6, 2017 “an incident occurred during care” for a resident who “requires the assistance of two staff members to provide care. During care, the resident was yelling out, and one Licensed Nursing Assistant witnessed another Licensed Nursing Assistant tell the resident to shut up.”
During the incident, a Licensed Practical Nurse “came to the room to investigate whether the resident was yelling out and also for the verbal interaction.” The Register Nurse Unit Manager was interviewed in midafternoon on March 17, 2017, and stated that the resident “did not have any ill effects from the verbal interaction,” but that “the resident was not treated respectfully and should not have been told to shut up.”
If you, or loved one, suffered a severe injury while residing in any nursing facility, including at Crescent Manor Care Centers, hiring the skills of nursing home negligence attorney could help. With legal representation, you can ensure that your rights are protected while you seek and obtain financial compensation for your damages. An attorney can make sure all the necessary paperwork and documents are filed in the appropriate courthouse before the state statute of limitations expires.
These types of cases are handled through contingency fee arrangements. This legal agreement allows you to receive immediate advice, counsel, and representation without the need for any upfront payment. Your legal services will be paid only after the law firm representing you successfully resolves your compensation claim through a negotiated out-of-court settlement or with the funds awarded at the conclusion of a jury trial.
Learn more about the laws and regulations that apply to Vermont nursig homes here.