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
Inaccurate MDS assessments were completed for two residents. One resident was coded with diabetes type II even though the record showed no orders, monitoring, treatment, or care plan interventions for diabetes, and staff confirmed the diagnosis was not actually present. Another resident was coded as needing isolation or quarantine for an active infectious disease, but the record contained no documentation of related care or services, and staff confirmed the coding was done in error.
Failure to Protect Residents from Abuse: Two residents with severe cognitive impairment were involved in a resident-to-resident altercation after screaming and yelling escalated to punching and slapping around the arms. An LNA removed one resident and reported the incident to an LPN, while the facility’s investigation documented that both residents were assessed with no injuries and no recall of the event; the Administrator confirmed the abuse incident occurred.
Care plans not revised after resident altercation. Two residents with severe cognitive impairment were involved in a physical altercation, with an LNA observing punching and slapping and notifying an LPN. Although both residents already had care plans addressing aggression or prior resident-resident conflict, no additional interventions were added after the incident, and the administrator confirmed the plans were not updated to reflect the event.
Narcotics were not properly documented and signed in for two residents. One nurse accepted multiple cards of oxycodone from the pharmacy but did not sign them in, and a count later showed one tablet missing from the cart. For another resident, an added supply of oxycodone was entered on the narcotic log with only one RN signature, and staff confirmed the sign-in process was not followed consistently.
A resident with dementia and difficulty walking was injured during a transfer when an LNA was reported to have been forceful, pushing the resident against a wall and causing the resident’s head and face to strike the wall and call light box. The resident cried, yelped, and sustained a skin tear and bruising while two LNAs attempted to assist with toileting and standing.
A resident at high fall risk with CVA, dementia, CKD, and vision deficits had repeated unwitnessed falls while assigned to rooms far from the nurses’ station, where staff could not reliably hear the call bells or visually supervise the area. The resident’s care plan was not consistently updated after multiple falls, some supervision interventions were cancelled, and the resident later suffered a fatal fall with SDH, cerebral hemorrhage, and multiple sinus fractures.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate resident assessments for 2 of 13 sampled residents. For one resident, the MDS dated 4/17/2026 identified a diagnosis of diabetes type II upon admission, but the medical record showed no monitoring, treatment, or physician orders for diabetes during the resident’s stay. The care plan also contained no focus, goal, or interventions related to diabetes. During interview on 7/23/2026, the RN assisting with MDS issues confirmed that the diagnosis had been included on the MDS and diagnosis list even though the resident did not actually have diabetes type II, and stated that a modification should be submitted to correct the error. For another resident, the MDS dated 3/10/2026 was modified and signed on 4/3/2026 to indicate the resident required isolation or quarantine for an active infectious disease. However, the record contained no documentation showing the resident received care or services related to isolation or quarantine. During interview on 7/22/2026, the Administrator confirmed the MDS inaccurately reflected the resident’s condition and stated that isolation had been coded in error. During interview on 7/23/2026, the RN assisting with MDS issues also confirmed the MDS had been coded in error and did not accurately reflect the resident’s care needs related to isolation and quarantine.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse when two residents with severe cognitive impairment were involved in a resident-to-resident altercation. Resident #1 had a BIMS score of 3 and diagnoses including vascular dementia, adjustment disorder with anxious mood, Type II diabetes mellitus, generalized weakness, and expressive aphasia. Resident #2 had a BIMS score of 1 and diagnoses including severe late onset Alzheimer's dementia with mood disturbance, anxiety, hypertension, and insomnia. According to the facility’s internal investigation, the two residents were heard screaming and yelling in the living area and were observed punching and slapping each other around the arms. An LNA removed one resident from the area and reported the incident to an LPN, but the witness statement indicates the LPN did not respond when told both residents’ names and that an incident report needed to be completed. The investigation further stated that an LPN assessed both residents, found no injuries and no recall of the incident, and noted both were at baseline. The Administrator confirmed the resident-to-resident abuse incident occurred.
Care plans not revised after resident altercation
Penalty
Summary
The facility failed to ensure that the care plans for two residents were revised after a resident-to-resident altercation. On 2/15/26, an LNA reported hearing screaming and yelling from two residents in the living area and then observed both residents punching and slapping each other around the arms. The LNA removed one resident from the area and notified an LPN, but the witness statement indicates the LPN did not respond to the report at that time. The facility’s internal investigation documentation confirmed the altercation occurred between the two residents. Resident #1 had a BIMS score of 3 as of 3/11/26, indicating severe cognitive impairment, and diagnoses including vascular dementia, adjustment disorder with anxious mood, Type II diabetes mellitus, generalized weakness, and expressive aphasia. Resident #1’s care plan already included interventions related to physical or verbal aggression, anxiety, agitation, calm approach, removal from setting, medications, routines, and social work involvement. Resident #2 had a BIMS score of 1 as of 6/12/26, also indicating severe cognitive impairment, with diagnoses including severe late onset Alzheimer’s dementia with mood disturbance, anxiety, hypertension, and insomnia. Resident #2’s care plan addressed risk for physical harm and psychosocial distress related to a prior resident-resident altercation. The record review and administrator interview confirmed there were no additional interventions added to either resident’s care plan after the 2/15/26 incident, despite the facility policy stating care plans are revised as residents’ conditions change.
Narcotics Not Properly Signed In or Documented
Penalty
Summary
The facility failed to ensure narcotics were appropriately documented and signed in from the pharmacy for two residents. For one resident, the record showed an order for oxycodone IR 5 mg every 4 hours as needed for pain. An internal investigation found that the narcotic count in the East Cart was off by one tablet, with 37 tablets expected and 36 present, and the missing pill could not be located. The investigation also found that a nurse believed she had accepted four cards of narcotics from the pharmacy on a previous shift but had not signed them in and could not find them at the time of the count. The facility’s investigation concluded the discrepancy was due to documentation errors and medication removal from an incorrect resident-specific narcotic sleeve. For another resident, the narcotic log for oxycodone 5 mg tablets showed that an additional 20 tablets were added to the count, but the entry was signed by only one licensed nurse. During interview, the nurse confirmed the additional tablets were only signed by one nurse and stated she had been told different things about whether two licensed nurses were required to sign off narcotics added to the log. The Administrator confirmed the oxycodone pill could not be found and that the nurse did not follow the appropriate protocol for signing in narcotics.
Physical abuse during resident transfer
Penalty
Summary
The facility failed to protect a resident with dementia and difficulty walking from physical abuse by staff during a transfer. The resident’s care plan called for extensive assist of 1-2 with a rolling walker and use of a Hoyer lift as needed. After the resident vomited and was assisted to the toilet by two LNAs, the resident became weak and was unable to stand. During the transfer attempt, one LNA was reported to have been forceful with the resident, causing the resident to hit the head on the wall and the face on the call light box, and the resident sustained a skin tear measuring 3 cm x 2.7 cm x 0.1 cm. A witness statement from the second LNA described that instead of helping the resident sit back on the toilet and try again, the first LNA pushed the resident up against the wall while trying to keep the resident standing, then forcibly sat the resident back down and later attempted to stand the resident again while pulling up a brief. The resident cried, yelped, and was heard to say yes when told, "I can't pick you up on your own. You are heavy, you need to help us, or you will end up on the floor." The DON later confirmed the resident had sustained a skin tear and bruising on the right arm during the transfer, and the second LNA confirmed the resident had been forceful with, injured, crying, and scared.
Failure to Provide Adequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and failed to provide adequate supervision to prevent avoidable accidents for one resident who was at high risk for falls and required supervision while walking. The resident had diagnoses including cerebral infarction, diplopia, chronic kidney disease, subarachnoid hemorrhage, and sequelae of cerebral hemorrhage, and the record showed 10 falls since 2/27/26, with 9 of them unwitnessed. The resident’s care plan identified fall risk related to confusion, deconditioning, gait and balance problems, incontinence, vision and hearing problems, and disease process, and also identified the need for supervision with toileting, ambulation, and transfers using a four-wheeled rolling walker. The resident lived in a group of three private rooms located far from the nurses’ stations and not visible from either nearby unit. The call bell system for those rooms alerted a different nurses’ station than the unit assigned to provide care, and staff interviews confirmed that staff assigned to the resident’s rooms could not reliably hear or know when the call bells were activated unless they walked to that hallway. Staff also stated that it was impossible to supervise a resident with a significant fall risk in those rooms and that the rooms were difficult to supervise because of their distance from the unit and the call bell arrangement. After repeated falls, the resident’s care plan was not consistently updated to address the pattern of incidents or the need for increased supervision. Following falls in the room and bathroom, interventions were added that addressed issues such as loud activities, bathroom water valves, privacy curtains, keeping the walker close, footwear, and nighttime safety checks, but the record showed that some interventions were later cancelled and that the care plan was not updated after several subsequent falls. The resident had additional unwitnessed and witnessed falls in the room, including falls with injury such as a fractured and dislocated finger, scalp laceration, bruising, and lacerations. On 6/30/26, the resident had two falls in one day; after the second fall the resident was found face down on the floor, soiled in stool and urine, and was sent to the hospital where a subdural hematoma, cerebral hemorrhage, and multiple sinus fractures were identified. The resident was placed on comfort measures and died on 7/1/26 from injuries sustained in the fall.
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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 3 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 3-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 3 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 3 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 3 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).
Trusted data from CMS and state health departments
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