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F0610
D

Failure to Protect Resident During Abuse Investigation

Burlington, Vermont Survey Completed on 12-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement effective measures to prevent further potential abuse during the investigation of an abuse allegation involving a resident who was cognitively intact and independent with activities of daily living. The resident, who had diagnoses including COPD, anxiety disorder, major depressive disorder, and Wernicke's encephalopathy, reported that a staff member yelled at them, pushed them causing a fall, and later bounced them on the bed. The resident also indicated that another staff member had engaged in similar behavior. Documentation showed that the alleged incident occurred late in the evening, and the resident was monitored following the accusation. Despite the facility's policy requiring protection of residents from further harm during investigations, records and interviews confirmed that the accused staff members were not removed from the facility but were instead reassigned to other units. Schedule reviews indicated that both staff members continued to work in the facility during the investigation period. The administrator confirmed that the accused staff were not removed from the facility while the investigation was ongoing.

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