Citations in Vermont
Statistics, citations and compliance trends for long-term care facilities in Vermont.
Statistics for Vermont (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Vermont
Expired meds were found in a medication cart and a med room, including Mirtazapine 15 mg for one resident and two OTC Bisacodyl 5 mg bottles. In addition, an RN left a med cart unlocked in a common area on a memory care unit while residents were present, and she confirmed the cart should have remained locked when unattended.
Failure to provide privacy during wound care. An LPN assessed and applied a dressing to a resident while the resident was eating lunch, with the room door open and the privacy curtain not pulled. The interaction was visible from the hallway, and the LPN and Unit Manager confirmed privacy should have been provided and that dressing care should not occur during mealtime.
Failure to care plan positioning and hearing needs. One resident was observed leaning to the right in a wheelchair with wedges and other positioning devices, and staff confirmed the resident frequently leans right and needs position changes, but positioning and wheelchair devices were not on the care plan. Another resident reported a broken hearing aid and staff said the hearing aids were being replaced by ENT, yet the care plan initially had no documentation for hearing, communication needs, or hearing aid use; those items were added later.
A resident with anxiety, major depressive disorder, and dementia had intact cognition on MDS but showed an escalating pattern of verbal and physical aggression toward staff and other residents, including swearing, name-calling, threats, and striking another resident. The resident’s care plan for potential verbal and physical behaviors was not revised with newer interventions despite repeated incidents, and the DON confirmed there was no evidence of updated care plan interventions.
An LNA verbally abused a resident after urine splashed on the LNA's face, yelling and using profanity while the resident was naked and appeared terrified. An LPN witnessed the incident, and the resident's record and the facility's investigation documented that the resident, who had dementia, was startled and terrified while the employee also made a threatening statement about wanting to punch the resident.
Failure to submit timely abuse investigation report: An LPN witnessed an LNA curse at a resident after the resident urinated in the LNA's face, and later saw the resident naked with urine on the floor and appearing terrified. The facility could not provide evidence that the required 5-day investigative report was submitted to the state agency within the required timeframe.
Expired Medications Found and Medication Cart Left Unlocked
Penalty
Summary
Drugs and biologicals were not maintained in accordance with accepted storage principles because expired medications were found in both a medication cart and a medication room. On the Beach unit medication cart, Mirtazapine 15 mg for one resident was observed expired on 5/23/26, and the nurse confirmed it was expired. In the Beach unit medication room, two over-the-counter bottles of Bisacodyl 5 mg were observed expired in 4/2026, and nurses on the unit confirmed both bottles were expired. Medication carts were also not kept locked when unattended. On the Cherrytree memory care unit, an unlocked medication cart was observed in the common area while several residents were present, and no staff member was seen at or near the cart. During interview, the RN assigned to the cart confirmed it should have remained locked when unattended and stated she failed to lock it. The facility policy stated that medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by authorized persons.
Failure to Provide Privacy During Wound Care
Penalty
Summary
Privacy during wound care was not provided for one sampled resident. During observation on 6/1/26 at 12:16 PM on the Dogwood unit, an LPN was preparing supplies from a wound care cart outside Resident #93's room while the resident sat on the side of the bed eating lunch. The LPN rolled up the resident's right shirt sleeve and began assessing the area where a bandage would be applied while the resident continued eating salad and the LPN documented and labeled the dressing. When ready to apply the dressing, the LPN asked the resident to put the salad down. The interaction was observed from the hallway with the door open and no privacy curtain pulled, and five people were seen walking by the room. The LPN later confirmed the door and privacy curtain were open and should have been closed for privacy during wound care. The Unit Manager also confirmed that it is never appropriate for a dressing to be applied or removed during mealtime and that privacy should always be provided for wound care.
Failure to Care Plan Positioning and Hearing Needs
Penalty
Summary
The facility failed to care plan two sampled residents for identified needs related to positioning and hearing/communication. Resident #11 was observed sitting in a wheelchair and leaning over the right arm rest, with a high-back wheelchair, head rest, leg rests, a cushioned foot board, and two cushioned wedge devices positioned at the right hip. An LPN stated that Resident #11 leans to the right frequently and requires position changes as needed, and also noted the resident had recently received a new high-back wheelchair to assist with positioning. Record review showed Resident #11 was not care planned for positioning or for the use of additional positioning devices while in the wheelchair, and the Unit Manager confirmed this was not care planned and should have been. Resident #63 stated that one hearing aid had broken and was waiting for a replacement, and the Unit Manager stated the resident's hearing aids were being replaced by ENT. Record review of the care plan showed no documentation concerning hearing, communication needs, or use of hearing aids. The facility's OPS416 Person-Centered Care Plan policy states the interdisciplinary team will establish goals and outcomes of care and other factors related to the effectiveness of the plan of care. The DON later presented a care plan showing Resident #63 was care planned for hearing, but the hearing area and interventions had been added the same day as the interview, and the DON confirmed they were not added until that date.
Failure to Revise Care Plan for Escalating Aggressive Behaviors
Penalty
Summary
The facility failed to revise and implement a person-centered care plan for one resident with diagnoses including anxiety disorder, major depressive disorder, and dementia. The resident’s MDS assessments documented a BIMS score of 15, indicating fully intact cognition. Despite this, the record shows an escalating pattern of verbal and physical aggression toward others, including swearing at the Social Worker after being told that others felt the resident was putting them down or telling them what they could and could not do, yelling and being accusatory toward others, and calling the Social Worker names and using profanity. Additional records showed continued behavioral incidents involving another resident, including swatting that resident after a dispute over coloring paper, slapping that resident on the back, and later entering the dining room calling that resident a derogatory name and telling the nurse to f-off when redirected. Another note documented the resident threatening the same resident, stating there was no problem fighting and using profanity while leaving the room. The Social Worker confirmed the resident became jealous and possessive of belongings and seating and had acted out verbally and physically toward other residents. Although the care plan had a focus related to potential verbal and physical behaviors and was last revised earlier, there were no newer interventions documented to address the continuing escalating behaviors, and the DON confirmed there was no evidence of new care plan interventions.
Resident exposed to verbal abuse by LNA
Penalty
Summary
The facility failed to protect one resident from verbal abuse by an LNA. During the early morning hours, an LPN witnessed the LNA approach the med cart and curse at her, saying she needed to go get the resident and then cursing again that the resident had urinated in the LNA's face. The LPN then went into the resident's room and found the resident standing naked with urine on the floor and appearing terrified. While the LPN was assisting the resident with care, the LNA entered the room and cursed at the resident again about urinating in the LNA's face. The resident involved had a diagnosis of dementia. The resident's progress note documented that an LNA went into the room and cursed at the resident about urine splashing on the LNA's face, and that the resident looked startled and terrified. The facility's complaint investigation also stated that the employee was seen yelling at and using profanity at the resident after urine accidentally splashed on his face, and that the employee said he wanted to punch the resident in the face because he was so mad. The facility policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents or within their hearing distance.
Failure to Submit Timely Abuse Investigation Report
Penalty
Summary
The facility failed to submit its five-day investigative report to the Division of Licensing and Protection within the required timeframe after an allegation of abuse involving a Licensed Nursing Assistant and Resident #1. An LPN reported that while on duty, she witnessed the LNA approach her at the med cart, curse at her, and say she needed to go get Resident #1 because the resident had urinated in the LNA's face. The LPN then entered the resident's room and observed Resident #1 standing naked with urine on the floor and appearing terrified. While the LPN was assisting the resident with care, the LNA entered the room and cursed at the resident about urinating in the LNA's face. During interview, the Administrator and DON stated they could not find the five-day investigative report for the incident and were unable to provide evidence that the report had been submitted on time. The facility policy required that within 5 working days of the incident, sufficient information describing the results of the investigation and any corrective actions taken, if the allegation was verified, be reported to the state agency and other required agencies. Another facility policy stated that within 5 working days, the Social Worker, DON, and/or Administrator would complete a thorough investigation and send the investigative summary to the Division of Licensing and Protection, Adult Protective Services, and local law enforcement when used.
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Compliance trends in Vermont
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 2 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 2-month reporting lag.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 2 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 2 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
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