Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Vermont Veterans' Home during CMS and state inspections, most recent first.
A resident with nicotine dependence and respiratory failure, receiving continuous O2 via nasal cannula, was assessed as an unsupervised smoker allowed to keep cigarettes but required to request a lighter. Despite increasing agitation and confusion, the resident went to the smoking room with O2 in use, where another resident lit their cigarette, igniting the O2 tubing. Staff later observed soot on the resident’s nose and burned tubing, and the resident sustained a painful facial burn with redness and skin loss. The resident’s smoking status and O2-related hazards were not added to the care plan until after the injury, and required no-O2 smoking-room signage was not posted until after the incident, contrary to facility smoking policy.
Surveyors found multiple food storage and temperature control deficiencies, including opened and unlabeled sausages, smart dogs, hot dog buns, and hamburger buns in the kitchen freezer and storage areas, as well as expired instant grits and cheese queso in dry storage. Kitchen staff confirmed the items were expired or should have been discarded. Review of freezer temperature logs showed repeated elevated temperatures in two wing freezers, and the Food Service Coordinator acknowledged the temperatures were elevated but did not submit required work orders as outlined in the facility’s dietary food storage policy.
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the Cardinal memory care unit. In the 500 hall bathing room, the tub had chipped paint on the seat and basin, one shower stall had damaged tiles and debris, and the toilet backrest showed cracked padding and rusted framing. On both the 500 and 600 halls, surveyors observed stained and damaged ceiling tiles, including outside a resident room. Several rooms lacked proper room number signs, with the numbers instead written on the walls in magic marker. These conditions were confirmed during a tour with the Administrator, DON, and QA Nurse.
Surveyors found multiple instances where medication and treatment carts were left unlocked and unattended in resident-accessible corridors. On one unit, a medication cart and a treatment cart containing various medications, insulins, syringes, and prescription topical products were observed unlocked with a resident ambulating nearby, and the assigned RN confirmed they were not secured. On another occasion on the same unit, the medication cart was again found unlocked, which the RN Unit Manager acknowledged was contrary to expectations. On a different unit, a medication cart was observed unlocked and unattended with a resident sitting next to it, and the assigned LPN confirmed it should have been locked. The facility’s policy requires all medication compartments and carts to be locked when not in use and not left unattended if open.
A resident with nicotine dependence and respiratory failure was admitted, and although a smoking assessment documented that the resident could smoke independently with a lighter secured by nursing, the baseline care plan did not address smoking status or concurrent O2 use. Nursing notes showed the resident frequently went to smoke and required repeated reminders about O2. The omission in the care plan preceded an incident in which the resident, wearing O2 in the smoking room, had a cigarette lit by another resident; after a few puffs, the cigarette ignited, burning the O2 tubing and causing a painful superficial facial burn, including loss of skin on the nose. The ADON later confirmed that the baseline care plan lacked smoking-related interventions until after the incident, despite facility policy requiring such issues to be care planned and communicated to staff.
Surveyors found that an LPN repeatedly failed to follow required hand hygiene practices during medication administration and glucose management for two residents. The LPN did not perform hand hygiene before and after glove use while preparing and administering oral medications, eye drops, and insulin, and while using and cleaning a glucometer and disposing of used testing supplies. In an interview, the LPN acknowledged that hand hygiene is required before and after glove use, direct resident contact, medication handling, room entry, and handling contaminated equipment, and facility policy specifies that alcohol-based hand sanitizer must be used in these situations and that gloves do not replace hand hygiene.
The facility did not provide adequate supervision to prevent altercations between residents with known behavioral risks, resulting in multiple incidents of physical aggression. Additionally, a resident repeatedly sustained injuries from a bathroom fixture after staff failed to report the hazard for maintenance, despite the resident's requests and facility policy requiring such action.
Two residents with PTSD and trauma histories were not properly assessed or care planned for trauma-informed, culturally competent care. Behavioral health assessments were incomplete, lacking documentation of trauma history, triggers, and individualized interventions. Social Services staff confirmed that trauma-specific needs and care plans were not developed, resulting in a failure to address and mitigate potential triggers for these residents.
A resident with dysphagia and no natural teeth was identified as needing permanent dentures and was seen by a dentist, who instructed the facility to contact the VA for service approval. The facility did not follow up with the VA, resulting in the resident's ongoing difficulty chewing and lack of progress toward obtaining permanent dentures.
A facility failed to report an alleged abuse incident involving an LNA and a resident to the State Licensing Agency. The resident's significant other witnessed the LNA abruptly dropping the resident's wheelchair, which startled the resident. Despite an internal investigation, the facility did not report the incident, considering it a customer service issue rather than abuse.
Failure to Prevent Oxygen-Related Smoking Injury
Penalty
Summary
The facility failed to ensure a resident remained as free from accidents as possible related to the use of supplemental oxygen while smoking and did not provide adequate supervision. The resident, recently admitted to the LTC unit from residential care with diagnoses including nicotine dependence and respiratory failure, had a smoking assessment completed that identified them as an unsupervised smoker who could keep cigarettes but had to request a lighter. Nursing progress notes documented that on the night prior to the incident the resident experienced increasing agitation and confusion and was receiving 4 liters of continuous oxygen via nasal cannula. At approximately 6:20 a.m., nursing staff observed black soot on the resident’s nose and burned oxygen tubing under their nose. When questioned, the resident stated that another resident had lit their cigarette and it had caught on fire. The resident sustained a painful facial burn measuring 0.67 cm in width, 1.53 cm in length, and 0.58 cm in area, with redness and loss of skin. Review of the care plan showed that the facility had not care planned the resident’s smoking status or the hazard associated with their oxygen use until the day after the burn occurred. The facility’s smoking policy, revised previously, stated that oxygen use is prohibited in smoking areas, and the DON confirmed that the resident went to the smoking room with oxygen on and was burned when the cigarette was lit, and that a sign prohibiting oxygen in the smoking room was not posted on the door until after the injury. This deficiency was cited as a repeat violation from the prior re-certification survey.
Improper Food Storage, Labeling, and Freezer Temperature Management
Penalty
Summary
Surveyors identified a deficiency in food storage and labeling practices in the facility’s kitchen and dry storage areas. During an observation of the kitchen freezer, surveyors found an opened pack of three sausages and an opened package of smart dogs that were not dated or labeled. In the dry storage area, they observed a 10-pack of instant grits and a 13.7-ounce bag of cheese queso that were past their expiration dates. A kitchen staff member confirmed that the items were expired and that the sausages and smart dogs were opened and unlabeled. On a subsequent observation of the kitchen, surveyors again found the same opened and undated sausages and smart dogs still in the freezer, along with one open and undated package of hot dog buns and two packages of hamburger buns with no date or initials. Another kitchen staff member confirmed these items should have been discarded. Surveyors also identified a deficiency related to freezer temperature monitoring and follow-up. Review of the facility’s freezer temperature logs showed that on multiple dates, the C wing and North wing freezers were recorded at elevated temperatures of 10°F and 5°F. The facility’s Dietary-Food Storage policy required that all refrigerators and freezers meet national sanitation foundation standards, follow recommended temperatures, and that elevated temperatures be immediately brought to the attention of the Dietary Manager or designee and environmental services. In an interview, the Food Service Coordinator acknowledged that these recorded freezer temperatures were elevated and stated that the process was to notify maintenance and submit a work order, but confirmed that she did not submit work orders after these elevated temperatures were documented.
Environmental Deficiencies in Memory Care Unit
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on one of three units, specifically the Cardinal memory care unit. During observation in the 500 hall bathing room, surveyors noted the tub had chipped paint on both the seat and the tub itself, one of the two shower stalls contained damaged tiles and debris, and the toilet backrest had cracks in the padding and rust on the framing. On both the 500 and 600 halls of the Cardinal memory care unit, there were stained and damaged ceiling tiles, including outside of one resident room. Additionally, room number signs were missing outside several rooms, and the room numbers had been written directly on the walls with a magic marker. These environmental issues were observed and confirmed during a tour and interview with the Administrator, DON, and QA Nurse.
Unlocked Medication and Treatment Carts Left Unattended in Resident Areas
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep drugs and biologicals stored in locked compartments as required by facility policy and professional standards. On the [NAME] Unit, a medication cart and a treatment cart were observed unlocked in the hallway with no staff present, while a resident was ambulating near the medication cart. The RN assigned to the cart confirmed both carts were unlocked. The medication cart contained medications including inhalers, topical patches, syringes, topical medications, insulins, prescribed resident-specific medications, and narcotics in a separate locked compartment. The treatment cart contained wound cleansers, prescription topical creams/pastes, and prescription topical powders. On a subsequent observation on the same unit, the medication cart was again found unlocked, and the RN Unit Manager confirmed it should not have been unlocked. On the North Village Unit, surveyors observed another medication cart unlocked and unattended in the corridor, with a resident sitting next to it. The LPN assigned to that cart confirmed it was not locked as required. The RN Unit Manager and the facility’s written policy on Medication Labeling and Storage both state that compartments containing medications and biologicals must be locked when not in use and that carts used to transport such items are not to be left unattended if open or otherwise available to others.
Failure to Include Smoking and Oxygen Use in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission that addressed a resident's smoking needs, including the resident's use of oxygen, despite documented nicotine dependence and respiratory failure. The resident was admitted with these diagnoses, and a smoking assessment indicated that the resident was capable of holding their own cigarette and smoking unsupervised, with the requirement that nursing secure the lighter and make it available as needed. Nursing progress notes documented that the resident went to smoke multiple times and had to be repeatedly reminded to wear oxygen. However, the baseline care plan in effect from the resident's prior residential care unit admission did not address the resident's smoking status or oxygen use until a later date. The deficiency culminated in an incident in which the resident, while on oxygen, went to the smoking room and had another resident light a cigarette. After taking two puffs, the cigarette caught fire in the resident's face, burning the oxygen tubing and leaving black soot on the resident's nose. The resident sustained a painful superficial burn to the face, including loss of skin from the tip of the nose, with specific measurements documented in the nursing notes. During an interview, the ADON confirmed that the residential care unit care plan served as the baseline care plan on admission and was unable to provide documentation that the baseline care plan addressed the resident's smoking needs until the day after the burn incident, contrary to the facility's smoking policy requiring smoking-related privileges, restrictions, and concerns to be noted in the care plan and communicated to staff.
Failure to Follow Hand Hygiene Protocol During Medication and Glucose Management
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene during medication administration for two of nine sampled residents. During an observation of medication administration, an LPN had nine missed opportunities to perform required hand hygiene, failing to use hand sanitizer or soap and water before and after glove use while preparing and administering oral medications to Resident #1. The same LPN also did not cleanse hands before and after glove use when preparing eye drops and glucose testing for Resident #89, instilling eye drops, testing blood glucose with a glucometer, cleaning the glucometer, disposing of used testing supplies, preparing an insulin injection, administering the insulin injection, and upon completion of the injection. In an interview, the LPN acknowledged that hand hygiene should be performed before and after putting on gloves, direct resident contact, preparing or handling medications, visiting a resident’s room, and after handling contaminated equipment such as a glucometer. The facility’s Hand Hygiene Policy states that gloves do not replace hand hygiene and that an alcohol-based hand sanitizer with at least 62% alcohol must be used before preparing or handling medications, before and after direct resident contact, and after glove removal. These observations, interviews, and record reviews demonstrated that the facility did not ensure staff adherence to its own hand hygiene policy and infection control standards during medication preparation and administration and during the use and cleaning of a glucometer for Resident #1 and Resident #89.
Failure to Prevent Resident Altercations and Address Environmental Hazards
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident altercations and did not maintain an environment free from accident hazards for several residents. In one incident, two residents with known histories of behavioral issues and prior altercations were left unsupervised on a porch, resulting in a physical altercation. Both residents had care plans indicating risks for aggression and wandering, yet there was no evidence that staff were supervising them at the time of the incident. Facility leadership confirmed that these residents were left together without supervision despite their documented behavioral histories. Another deficiency involved a resident with a history of entering other residents' rooms and being difficult to redirect. This resident's care plan lacked interventions to address their wandering or to provide supervision. As a result, altercations occurred between this resident and another, including an incident where one resident physically assaulted the other in response to repeated room entries. These events were confirmed by facility leadership and documented in progress and incident notes. Additionally, a resident with mobility challenges and a need for physical assistance during transfers repeatedly sustained knee injuries due to a poorly placed toilet paper holder in their bathroom. Despite multiple requests to staff to have the fixture moved, no maintenance request was entered as required by facility policy. The resident expressed frustration and distress over the lack of response, and the Director of Environmental Services confirmed that no action had been taken to address the hazard, even though staff had the means and responsibility to do so.
Failure to Provide Trauma-Informed, Culturally Competent Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents with a history of trauma, including PTSD. For one resident, the medical record documented a diagnosis of PTSD, a history of military combat, and specific triggers such as startle responses and flashbacks. Despite this, the Behavioral Health Clinical Assessment was incomplete, lacking documentation of current mental health issues, trauma history, symptoms, triggers, identified needs, and a recommended plan of care. The resident's care plan did not address PTSD or include interventions to mitigate triggers, and the Social Services staff confirmed that the resident was not care planned for trauma-related needs. Another resident with diagnoses of PTSD, anxiety, and depression was also not fully assessed for trauma-related triggers. The Behavioral Health Clinical Assessment identified a history of trauma but did not specify the type or provide further information. There was no evidence in the resident's record or care plan regarding identification of triggers or strategies to avoid re-traumatization. Interviews with Social Services staff and the Director of Social Services revealed a lack of awareness and use of trauma assessment tools, and it was confirmed that trauma-specific triggers and care planning had not been completed for this resident.
Failure to Provide Routine Dental Services for Resident Needing Dentures
Penalty
Summary
A resident admitted with dysphagia and edentulism was assessed as having chewing difficulties and was using temporary dentures, with a need for permanent dentures identified upon admission. The resident was seen by a dentist, who noted the need for new dentures and indicated that the Veterans Administration (VA) would be contacted to determine service approval and whether the dentist could proceed with care. However, there is no documentation that the facility followed up with the VA as instructed by the dentist. The resident later reported not knowing when the next dental appointment would be and expressed concern about the lack of follow-up regarding the need for new dentures. The Unit Manager confirmed that the process to contact the VA was not completed and could not ensure that the resident's dental needs were being addressed. The resident continued to experience nutritional risk and chewing difficulties due to being edentulous with only temporary dentures.
Failure to Report Alleged Abuse to State Licensing Agency
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Licensing Agency as required. A resident's significant other placed a camera in the resident's room during a period of restricted visitation due to COVID. On a specific date, the significant other witnessed a licensed nursing assistant (LNA) allegedly abusing the resident by abruptly dropping the resident's wheelchair into a reclined position, which startled the resident. The significant other reported this incident to the facility nearly a year later, believing the LNA had been dismissed. However, upon seeing the LNA still employed, the significant other raised the issue again. The Deputy Administrator confirmed that the LNA was placed on leave and an investigation was conducted by the Human Resource Department, but the incident was not reported to the State Licensing Agency. The facility Administrator stated that the initial report was considered a customer service or resident rights issue rather than an abuse allegation, and the second report was not submitted because the previous investigation found the claim unsubstantiated. This oversight resulted in a failure to comply with mandatory reporting requirements for suspected abuse.
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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 Bennington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Center For Living & Rehabilitation | 0.9 mi | ★★★★★ | 7 | 0 |
| Crescent Manor Care Ctrs | 1 mi | ★★★★★ | 10 | 0 |
| Bennington Health & Rehab | 1.2 mi | ★★★★★ | 6 | 0 |
| The Center For Nursing And Rehab At Hoosick Falls | 7.9 mi | ★★★★★ | 2 | 0 |
| Williamstown Commons Nursing & Rehab | 12.7 mi | ★★★★★ | 10 | 0 |
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