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
Failure to complete required skin assessments and maintain ordered wound care: A resident with lymphedema, CVI, diabetes, and chronic pain had ordered compression wraps removed and not replaced, leaving both lower legs open to air with redness, a blister, and open areas on the shins. An LPN reported the change in skin integrity and the lack of a current skin assessment over several days, while the unit manager and DON confirmed the last skin assessment was not done within the required weekly timeframe and should have been completed after the change was reported.
A resident was injured when staff failed to properly use a Hoyer lift during a chair-to-bed transfer. An LNA asked a Support Aide to help, even though the aide’s role did not include lift transfers and she had no training on how to assist with them. The resident fell to the floor during the transfer and sustained a head strike, RUE pain, and bilateral hip pain; the roommate with BIMS 15 reported that the resident was dropped by the staff using the lift.
Lack of Mechanical Lift Competency for Direct Care Staff: A resident sustained a witnessed fall from a Hoyer lift during a transfer by two staff members and was later noted to have pain in the RUE and bilateral hips, with a head strike also documented. Review of staff files showed one LNA had no documented mechanical lift training or competency, and a Support Aide who sometimes helped with Hoyer transfers reported she had not received facility training on transfers or lift use.
Failure to communicate a dialysis dietary recommendation for a resident with DM2, CKD stage 5, and elevated phosphorus. Dialysis labs showed a phosphorus level of 7.8 and noted to encourage avoiding ice cream, but the resident continued receiving dairy items such as ice cream, yogurt, and milk. The UM described a process for sharing new diet orders via a communication slip, yet the Dietary Mgr could not find one and the Dietary Tech said the recommendation was never communicated or entered into the system.
Failure to prevent resident elopement: A resident with intact cognition, a walker, and documented fall risk left the facility without authorization and walked about 0.7 miles to a spouse’s apartment after learning the spouse was hospitalized. Police located the resident and returned them to the facility. Staff later confirmed the resident exited through the front door while a visitor entered, and the resident had balance issues, poor safety awareness, and shortness of breath with ambulation.
The facility failed to notify the LTC Ombudsman of the transfer or discharge of three residents. Record review showed no documentation of Ombudsman notification for the residents, and the Administrator confirmed the facility does not notify the Ombudsman’s office for planned transfers or discharges to other SNFs.
Failure to complete required skin assessments and maintain ordered wound care
Penalty
Summary
The facility failed to provide quality care to a resident with lymphedema, chronic venous insufficiency, diabetes, chronic pain, depression, and anxiety by not completing required skin assessments and not maintaining ordered lower-extremity wound care. The resident reported that the legs had been unwrapped for days, that the bandages had been removed earlier in the week before a shower and had not been replaced, and that the open areas on the legs hurt a lot. At the time of the interview, both lower legs were open to air, reddened, with a dime-sized blister on the inner aspect of one lower leg and two open areas on both shins. The resident had physician orders for knee-high compression to both lower extremities with kerlix, coban, and tubigrip. Facility policy, the resident’s orders, and the care plan required weekly systemic skin assessments and assessments as needed. The medical record showed the last skin assessment was completed 12 days earlier. An LPN stated she removed the bandages and observed swelling, a blister, and skin breakdown, then reported over several days that the resident’s skin assessment had not been completed and the legs remained unbandaged. The unit manager confirmed the facility was waiting for wound care orders and acknowledged that a skin assessment should have been completed after the nurse reported the change in skin integrity. The DON and wound care nurse also confirmed the last skin assessment had been completed 12 days earlier and that an assessment should have been completed weekly and after the nurse’s report.
Improper Mechanical Lift Transfer Resulted in Resident Fall
Penalty
Summary
The facility failed to ensure that one sampled resident remained as free from fall-related accidents as possible when direct care staff did not properly use a mechanical lift during a transfer. Facility policy stated that employees responsible for resident movement must be trained and competent in transfers, lifts, and positioning/repositioning, and that a full-body mechanical lift is to be used for residents with no weight-bearing ability or other indicated medical conditions, with two or more caregivers present. The resident involved was being transferred from a chair to a bed using a Hoyer lift when a witnessed fall occurred, and the resident sustained a head strike, pain in the right upper extremity, and bilateral hip pain. The fall investigation and interviews showed that an LNA and a Support Aide were present during the transfer, but the Support Aide’s job description did not include transferring residents with mechanical lifts and she stated she had not received training on how to transfer or assist in transferring a resident. The Support Aide also stated she occasionally assisted LNAs with Hoyer lift transfers, while the LNA stated she had asked the Support Aide to assist and did not know the Support Aide was unable to help with the lift transfer. The resident’s roommate, who had a BIMS of 15, stated that the LNA and the person who brings water and towels attempted to move the resident with a lift machine and dropped the resident on the floor. The facility educator stated that the Support Aide role does not include transferring residents or assisting with transfers and confirmed that the LNA had no evidence of completing mechanical lift competencies.
Lack of Mechanical Lift Competency for Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff had the specific competencies and skill sets necessary to meet residents’ needs related to the use of a mechanical lift. A fall investigation showed that a resident sustained a witnessed fall from a mechanical lift during a transfer from a chair to a bed by two staff members. A provider progress note documented that the resident was being evaluated after the fall from a Hoyer lift and reported pain in the right upper extremity and bilateral hips, with a head strike also noted. The facility assessment, last updated 11/11/25, identified that residents required services including transfer assistance with a mechanical Hoyer lift and stated that staff would be trained and evaluated for competencies related to lift assistance. Review of four LNA training files showed that one LNA lacked documented training or competency for operating a mechanical Hoyer lift. An interview with a Support Aide revealed that she occasionally assisted LNAs with Hoyer lift transfers but had not received facility training on how to transfer or assist in transferring a resident. The facility Educator stated that the Support Aide’s role did not include transferring residents or assisting with transfers, especially with a mechanical lift, and confirmed that all direct care staff were required to complete specific training and annual competency assessment to operate a mechanical lift; she also confirmed that the LNA had no evidence of completing the mechanical lift competencies.
Failure to Communicate Dialysis Dietary Recommendation
Penalty
Summary
The facility failed to ensure communication and coordination between staff and all departments regarding a special dietary recommendation for one resident with type 2 diabetes, disorders of phosphorus metabolism, stage 5 chronic kidney disease, and a Monday, Wednesday, Friday dialysis schedule. Dialysis nutrition labs showed a phosphorus level of 7.8, and the dialysis note requested that the resident be encouraged to avoid ice cream. The resident’s record showed that after this recommendation was sent to the facility, the resident continued to partake in dairy products, including ice cream, yogurt, and milk. The resident’s orders and care plan did not reflect the dialysis recommendation. During interview, the Unit Manager stated that residents returning from dialysis have a dialysis book for new orders or recommendations, and that staff communicate dietary changes through a Diet Order and Communication slip for new diet orders, recommendations, or short-term diet adjustments. The Dietary Manager was unable to locate a Diet Order or Communication slip for the resident for the month of June. The Dietary Tech stated that she was not aware of the dialysis recommendation and that it had not been communicated to dietary staff. She confirmed that the recommendation was not in the system and should have been entered.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to maintain safety and prevent elopement for one resident. Resident #1, who had a BIMS score of 14 and was documented as able to ambulate independently with a walker or wheelchair and at risk for falls, left the facility without authorization and was later found by police at their spouse’s apartment. A progress note stated the resident left the facility on an unauthorized leave of absence, and the facility’s elopement drill documentation recorded the resident as missing at 9:42 PM and returned at 10:12 PM by police. Resident #1 stated they left in a hurry after learning their spouse was in the hospital, did not use the facility’s leave-of-absence protocol, and walked with a walker approximately 0.7 miles to the apartment complex because they did not have a ride and were not thinking clearly. The physical therapist reported the resident had balance issues, poor safety awareness, and frequently became short of breath with ambulation. The police report indicated the facility called after the resident had been gone for about 30 minutes, and the administrator confirmed camera footage showed the resident exiting through the front door as a visitor entered, with the facility unaware the resident had left grounds at the time.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the long-term care Ombudsman of the transfer or discharge of 3 sampled residents. Record review for Resident #1, Resident #2, and Resident #3 showed no documentation that the Ombudsman was notified of their transfer/discharge. During interview, the Administrator confirmed that the facility does not notify the Ombudsman’s office for planned transfers or discharges to other skilled nursing facilities.
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Compliance trends in Vermont
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 1 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 1-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: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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 Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 1 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 1 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).
No tags meet the emerging criteria for this period — nothing rare is spiking right now.
Trusted data from CMS and state health departments
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