Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gill Odd Fellows Home Of Vermont during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow professional food service safety standards, including improper storage and labeling of dry and frozen food items and failure to use required hair restraints. Open and undated items, such as baking mix, tortilla strips, fish sticks, and pie crusts, were stored in dry storage and the freezer, some exposed to air and lacking use-by or open dates. A dietary staff member was observed preparing and plating food without a hair restraint, and both that staff member and the Dietary Manager reported that staff with hair considered short enough were not required to wear hair coverings, despite a facility policy mandating hair restraints for dietary staff.
Surveyors found that the facility did not have a functional system for residents to file anonymous grievances. The posted grievance procedure instructed residents to speak with the grievance officer/Social Service Director or the DON and did not explain how to file anonymously. No blank grievance forms or grievance drop box were available in common areas. The Social Worker reported that residents must request grievance forms from staff, that forms are stored in the social work office, and that completed forms are returned to the Social Worker, the DON, or other staff, with no drop box in place. Although the admission agreement stated that anonymous grievances could be placed in a mailbox near the front lobby door, residents did not have independent access to grievance forms, effectively preventing anonymous grievance submission.
Surveyors found repeat infection control failures during medication administration, including an RN preparing and administering crushed medications in pudding without removing gloves or performing hand hygiene, while placing gloved fingers inside medication cups when giving medications to a resident. In a separate observation, a nurse’s personal drink with a lid and straw was found on a medication cart. The DON confirmed that these practices violate the facility’s hand hygiene policy and prohibition on staff drinks on medication carts due to contamination concerns.
A resident with progressive MS experienced difficulty self-propelling a wheelchair due to a dragging foot and lack of leg rests, despite staff awareness of the problem. An LNA reported the issue to nursing staff, and an OTR acknowledged the resident’s feet were dragging, provided leg rests, and educated staff on their use, noting the resident could self-propel effectively when leg rests were in place. However, the resident’s care plan for wheelchair mobility, last revised weeks earlier, was not updated to include the use of leg rests even after these issues and interventions were identified.
Surveyors identified that the facility’s medication error rate exceeded 5% when an RN failed to administer two prescribed laxative medications during observed med passes, despite documenting them as given on the MAR. In 31 observed medication opportunities, 2 doses (docusate sodium and Miralax powder) ordered for two residents were not actually administered, even though the RN stated all medications had been given. Time-stamp reports produced by the DON showed these medications as administered at the same time as other drugs, conflicting with surveyor observations and resulting in a calculated error rate of 6.45%.
Surveyors observed a medication cart in a hallway between resident rooms left unlocked and unattended while residents were self-propelling nearby. The cart contained OTC medications, syringes, topical agents, injectables, prescribed resident-specific medications, and narcotics in a separately locked compartment. An RN later returned to the cart and confirmed it had been left unlocked and acknowledged it should have been secured. The DON also confirmed that medication carts are required to be locked when not attended by the nurse on duty, demonstrating a failure to ensure all drugs and biologicals were stored in locked compartments for one of two medication carts.
A resident with dementia and intact cognition reported being physically assaulted by another resident using a walking stick. The incident was documented by staff, but the social worker and DON did not notify the administrator, state agency, or law enforcement as required. No evidence was found of proper investigation, monitoring, or required notifications following the allegation.
A resident with dementia and depression reported being struck multiple times by another resident with a walking stick. Despite the resident's request for police involvement and assurances of increased monitoring, there was no documentation of a thorough investigation, identification of the alleged perpetrator, or evidence of follow-up actions by staff, including the SW and DON.
A resident fell from a wheelchair, resulting in a fractured clavicle, but the LTC facility failed to follow its fall protocol. The necessary assessments, notifications, and documentation were not completed until four days later, when old bruising prompted further investigation. The documentation added later inaccurately reflected the actions taken and the resident's status.
A resident fell from a wheelchair, and the facility failed to ensure nursing staff had the necessary competencies to provide safe care. Despite prior fall education, an LPN did not document or assess the fall, and an LNA involved had not received recent fall education. Bruising was not documented until days later, and a clavicle fracture was discovered five days post-fall, highlighting deficiencies in staff competencies and procedures.
Food Storage and Hair Restraint Failures in Dietary Services
Penalty
Summary
Surveyors identified deficiencies in food storage and labeling practices in the facility kitchen. During an initial tour of the kitchen dry storage area, they observed a 5-ounce box of cornbread muffin mix with an expiration date of 11/5/25 and a 5-ounce bag of tortilla strips that had been opened on 1/7/26 but had no expiration date on the packaging. In the freezer, they found a bag of 24 frozen fish sticks in an open bag exposed to air with no date on the package, and a bag containing three frozen pie crusts that was opened without any expiration or opened date. A staff member confirmed that these items were either undated, open to air, and/or expired. Surveyors also observed failures to follow the facility’s own food safety policy regarding hair restraints. One staff member was seen cooking, assembling, and plating food in the kitchen without a hair restraint. In an interview, this staff member stated that kitchen staff did not need a hair restraint if their hair was of a certain length but was unable to specify the permitted length. The Dietary Manager similarly stated that staff with hair considered short enough did not need to wear a hat or hair net while preparing or assembling food and acknowledged there was no specific hair length standard used by the facility. This practice conflicted with the facility’s written Food Safety policy, which requires dietary staff to wear hair restraints to prevent hair from contacting food.
Failure to Provide a Functional System for Anonymous Resident Grievances
Penalty
Summary
The facility failed to provide a system that enables residents to file anonymous grievances, despite a posted grievance procedure and language in the admission agreement stating that anonymous grievances could be placed in a mailbox near the front lobby door. During observation, surveyors noted that the grievance posting outside the dining room in the lobby did not include information on how to file an anonymous grievance and only directed residents to speak with the grievance officer/Social Service Director or the DON, listing their phone numbers. No blank grievance forms or grievance drop box were observed in resident-accessible areas. In an interview, the Social Worker confirmed that residents file grievances directly with the Social Worker or the DON, stated he did not know how a resident could file a grievance anonymously because residents must request a form from staff and return it to staff, and acknowledged that blank grievance forms are kept in the social work office without independent resident access and that there is no grievance drop box. Although the admission agreement referenced anonymous grievance submission via a mailbox near the front lobby door, there were no grievance forms available to residents without requesting them from staff, and the actual practice required residents to submit grievances through staff, preventing anonymous filing. No specific residents, medical histories, or clinical conditions were described in the report.
Repeat Infection Control Failures During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to medication administration practices and staff personal items on medication carts. During a medication pass observation, an RN donned gloves and poured medications into individual 30 cc cups, accessed the nurse’s station refrigerator twice to obtain pudding for crushed medications, and continued preparing medications without removing gloves or performing hand hygiene. The RN then crushed pills, mixed them with pudding, and carried the cups with his gloved fingers inside the medication cups to administer the medications to Resident #41, without removing gloves or performing hand hygiene before or during this process. These actions were inconsistent with the facility’s Handwashing/Hand Hygiene Policy, which requires handwashing before and after resident contact, including during medication administration. In a separate observation, surveyors noted a large cup with a lid and straw on a medication cart during medication administration. When questioned, the nurse acknowledged the drink was hers and stated she believed it was acceptable because it had a lid. In an interview, the DON confirmed that failing to perform proper hand hygiene before or during medication preparation and placing fingers, gloved or ungloved, inside medication cups increases the risk of contamination, and also confirmed that staff drinks are not allowed on medication carts because of infection control concerns, regardless of whether the cup has a lid. The report notes this is a repeat deficiency, with similar violations cited during the previous three re-certification surveys.
Failure to Revise Care Plan for Resident Wheelchair Mobility Needs
Penalty
Summary
The facility failed to revise the care plan to address a documented decline in mobility for a resident with progressive multiple sclerosis (MS). The resident was observed attempting to self-propel a wheelchair while dragging the right foot, which inhibited movement, and the wheelchair had no leg rests installed at that time. The existing care plan intervention for wheelchair mobility, last revised on 1/12/25, did not include the use of wheelchair leg rests to improve the resident’s ability to self-propel. A licensed nursing assistant (LNA) reported awareness that the resident sometimes had difficulty self-propelling because the resident’s feet became tangled, and stated this concern had been reported to a nurse. An occupational therapist (OTR) also stated she was aware of the resident’s feet dragging and had provided leg rests for the wheelchair and educated staff to use them, noting the resident had sufficient upper body strength to self-propel when leg rests were in place. The OTR could not confirm that this intervention had been incorporated into the care plan. A subsequent observation showed the wheelchair with leg rests attached, but review of the care plan confirmed it still had not been revised to include the use of leg rests.
Medication Error Rate Exceeded 5% Due to Omitted Laxative Medications
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, resulting in a calculated error rate of 6.45% during surveyor observations. Out of 31 medication administration opportunities, 29 medications were observed to be given and 2 were omitted, affecting 2 of 6 sampled residents. During a medication pass observation, an RN administered medications to Resident #16, stated that all medications had been given, and the MAR later showed docusate sodium (a stool softener) as administered at the same time as the other medications, although surveyors did not observe this medication being given. In a separate observation, the same process occurred with Resident #14, where the RN confirmed all medications were administered, and the MAR documented Miralax powder (a laxative solution) as given at the same time as other medications, but surveyors did not observe the Miralax being administered. Per interview, the DON produced time-stamp reports indicating that both the docusate sodium for Resident #16 and the Miralax for Resident #14 were documented as administered concurrently with their other prescribed medications, which conflicted with surveyor observations that these medications were not actually given.
Unlocked and Unattended Medication Cart in Resident Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage practices when a medication cart located in the long hallway between rooms [ROOM NUMBER]-119 was observed unlocked and unattended. At approximately 11:44 AM, the cart was found without any nurse or staff member in sight, while residents were seen self-propelling in the same hallway toward the dining room. The unattended cart contained over-the-counter medications, syringes, topical medications, injectables, prescribed resident-specific medications, and narcotics stored in a separate locked compartment, as later confirmed by an RN. At 11:56 AM, the RN was observed walking from the nurse’s station toward the cart and, during an interview at 11:57 AM, acknowledged that the cart had been left unlocked while unattended and confirmed it should have been locked. In a subsequent interview, the DON also confirmed that medication carts are required to be locked when not attended by the nurse on duty. These observations and interviews established that the facility failed to ensure all drugs and biologicals were stored in locked compartments for one of two medication carts.
Failure to Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident physical abuse as required by regulation. A resident with a history of dementia, depression, and insomnia, but with intact cognition and judgment, reported being struck multiple times by another resident using a walking stick. The resident expressed distress over not being informed about the incident's consequences and stated a desire for police involvement. Documentation in the progress notes indicated the resident's complaint but did not identify the alleged perpetrator or document any monitoring of the involved residents. The social worker followed up with the resident but did not notify the physician, family, state agency, or law enforcement about the allegation. Interviews with facility staff revealed that the social worker did not report the abuse allegation to the administrator or appropriate authorities. The DON, after interviewing the alleged perpetrator, determined the abuse was unlikely and did not report the incident to the State Survey Agency, despite acknowledging that all abuse allegations are required to be reported. There was no evidence of required notifications or investigations being conducted or documented as per regulatory requirements.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated for a resident with a history of dementia, depression, and insomnia, who was assessed as having intact cognition and judgment. The resident reported being struck multiple times by another resident using a walking stick, expressing distress over not being informed about the incident or its consequences, and requesting police involvement. There was no documentation that the police were contacted or that the resident was communicated with by management regarding the incident. Progress notes indicated that the nurse did not witness any physical aggression and found no injuries, but stated that both residents would be monitored closely. However, there was no documentation of the identity of the alleged perpetrator or evidence of increased monitoring for either resident. The social worker confirmed knowledge of the alleged perpetrator's identity but did not document it or contribute to a formal investigation. The DON acknowledged that an investigation was required but confirmed there was no written record of interviews or evidence that the abuse allegations were thoroughly investigated.
Failure to Follow Fall Protocols Leads to Undocumented Injury
Penalty
Summary
The facility failed to provide services that meet professional standards of quality following a fall incident involving a resident. The incident occurred when a Licensed Nurse's Aide was pushing the resident in a wheelchair, resulting in the resident falling out of the wheelchair. Despite the fall meeting the facility's definition of a fall, the necessary actions outlined in the facility's 'Managing of a Fall Policy and Procedure' were not followed. This includes a comprehensive assessment, notification of the physician, monitoring, reassessment, and proper documentation. The Director of Nursing (DON) confirmed that there was no documentation of any evaluations, vital signs, neurological checks, or assessments conducted on the resident following the fall. Additionally, there was no record of the fall in the resident's medical record until two days later, when an 'Incident Order' was initiated. Even then, the necessary assessments and documentation were not completed. The Assistant Director of Nursing later added documentation to the resident's medical record, but it inaccurately reflected the actions taken and the resident's status. Four days after the fall, a nurse performing a skin check documented old bruising on the resident's right shoulder and forehead, which was consistent with the fall. An X-ray revealed a right clavicle fracture. The facility's failure to ensure appropriate assessment, notification, and documentation occurred until four days later, when the bruising prompted diagnostic testing, highlights the deficiency in adhering to professional standards of care.
Deficiency in Staff Competency and Documentation Following Resident Fall
Penalty
Summary
The facility failed to ensure that nursing staff possessed and implemented the appropriate competencies and skills to provide nursing and related services to assure resident safety. This deficiency was highlighted by an incident involving a resident who fell from a wheelchair. Despite the fall meeting the facility's definition of a fall, the Director of Nursing (DON) was not informed of the incident as a fall, and there was a lack of proper documentation and assessment by the nursing staff involved. The Licensed Practical Nurse (LPN) who reported the incident via voicemail had attended a Fall Procedure education session nine days prior but failed to document the fall or conduct an assessment as required. Additionally, the Licensed Nurse's Aide (LNA) who was involved in the incident had not received any fall education since 2023. The Assistant Director of Nursing (ADON) confirmed that the education provided included instructions for documentation and assessment, which were not followed. The ADON also added a note to the resident's medical record two days after the fall, despite no immediate assessment being documented. Furthermore, there was a delay in documenting and reporting bruising observed on the resident after the fall. The bruising was not documented until three days later, and there was inconsistency in the documentation by LNAs. The DON and ADON were unaware that LNAs could document skin observations, leading to further confusion and lack of proper reporting. Ultimately, a mobile X-ray revealed a right clavicle fracture five days after the fall, indicating the severity of the incident and the deficiency in staff competencies and procedures.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ludlow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springfield Health & Rehab | 11.6 mi | — | 16 | 4 |
| Cedar Hill Health Care Center | 15.3 mi | ★★★★★ | 0 | 0 |
| Elm Wood Center At Claremont | 18 mi | ★★★★★ | 1 | 0 |
| Mountain View Center Genesis Healthcare | 19 mi | ★★★★★ | 7 | 0 |
| The Pines At Rutland Center For Nursing & Rehabili | 19.2 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.