Deficiencies (last 3 years)
Deficiencies (over 3 years)
19.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
348% worse than Vermont average
Vermont average: 4.4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 11
Nov 13, 2025
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with federal and state regulations regarding resident care, safety, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate cleanliness and housekeeping, improper foot care, failure to ensure timely physician visits, inadequate dementia care interventions, medication storage access issues, unsafe food storage and handling, lack of effective medical director oversight, deficient infection prevention and control program, delayed COVID-19 vaccination implementation, and insufficient nurse aide training.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to treat resident with dignity and respect during feeding assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a safe, clean, comfortable, and homelike environment; repeated deficiencies in housekeeping and sanitation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate foot care for a resident with diabetes and peripheral vascular disease. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure physician visits occurred as required by regulations for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement dementia care interventions to address resident's grief and anxiety. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to restrict access to medication storage rooms to authorized personnel only. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store food safely and maintain sanitary conditions in food storage and preparation areas. | Level of Harm - Minimal harm or potential for actual harm |
| Failure of Medical Director to fulfill responsibilities for coordinating medical care and implementing resident care policies. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide an effective infection prevention and control program, including delayed COVID-19 vaccination and poor environmental sanitation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to educate and offer COVID-19 vaccination to residents and staff timely and properly document vaccination status. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide evidence of required annual nurse aide training for continuing competence. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents tested positive for COVID-19: 16
Staff tested positive for COVID-19: 8
Housekeeping hours: 8
Housekeeping hours: 13
Housekeeping hours: 8
Housekeeping hours: 7
Housekeeping hours: 10
Housekeeping hours: 7
Housekeeping hours: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Assistant (LNA) | Observed not sitting at eye level while assisting resident with feeding | |
| Administrator | Confirmed facility practice and staffing issues | |
| Travel LPN #1 | Confirmed housekeeping and cleanliness concerns | |
| Physician | Reported prioritizing urgent care over regulatory visits and acknowledged facility cleanliness issues | |
| Director of Nursing (DON) | Confirmed lack of podiatrist and nurse aide training records | |
| Registered Nurse (RN) | Confirmed resident's toenails were long and should be trimmed | |
| Medical Director | Acknowledged regulatory visits behind schedule and lack of communication among providers | |
| Licensed Practical Nurse (LPN) | Left medication room unattended with delivery person | |
| Dietary Staff Member | Confirmed expired food items and improper food storage | |
| Infection Preventionist (IP) | Confirmed housekeeping staffing shortages and cleaning issues |
Inspection Report
Annual Inspection
Deficiencies: 9
Jun 25, 2025
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements for nursing home care and facility conditions.
Findings
The facility was found deficient in multiple areas including maintaining a safe, clean, and homelike environment, proper use and documentation of psychotropic medications, comprehensive and updated care planning, adequate supervision to prevent accidents, proper medication storage, staff performance evaluations, and food safety and sanitation. Several deficiencies were repeat citations from the previous survey.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure a safe, clean, comfortable, and homelike environment including proper linens for bariatric beds and cleanliness of bathing areas and resident rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents are free from unnecessary psychotropic medications by administering PRN psychotropic medications without a discontinued date or documented rationale. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement a comprehensive care plan by not notifying the provider of specific symptoms for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to review and revise resident care plans timely for falls and pressure ulcers for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents remained free from accidents related to resident altercations and falls due to inadequate supervision and ineffective interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete annual performance evaluations for Licensed Nursing Assistants. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to safely store locked medications; medication carts were found unlocked and unattended. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to employ a qualified dietitian full-time or designate a qualified director of food and nutrition services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store food in accordance with professional standards and maintain a sanitary kitchen, including expired food items and debris on kitchen floors. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 23
Bariatric bed sheets: 5
Bariatric bed sheets: 20
Psychotropic medication administration dates: 8
Resident #39 wound size: 4
Resident #39 wound size: 5
Resident #39 wound size: 0.1
Resident #34 fall date: 2025
LNA #1 hire date: 2024
LNA #2 hire date: 2001
LNA #3 hire date: 2021
Dietitian work days: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Assistant | Reported running out of bariatric sheets and clean laundry | |
| Administrator | Confirmed conditions of facility environment and staffing issues | |
| Unit Manager | Confirmed psychotropic medication issues and environmental concerns | |
| Director of Nursing | Confirmed failure to notify provider and care plan deficiencies | |
| Licensed Practical Nurse | Reported resident behaviors and falls | |
| Registered Dietitian | Confirmed part-time status and multiple facility coverage | |
| Kitchen Staff Member | Confirmed expired food and kitchen sanitation issues |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 25, 2025
Visit Reason
The inspection was conducted due to complaints and concerns regarding the facility's failure to review and revise resident care plans related to falls and pressure ulcers, and inadequate supervision leading to resident-to-resident altercations and falls.
Findings
The facility failed to update care plans for residents with falls and pressure ulcers, resulting in inadequate interventions. Resident #1 suffered injuries from altercations with Resident #34, who exhibited aggressive behaviors and lacked proper supervision. The facility did not implement recommended 1:1 supervision or update care plans accordingly, leading to multiple falls and injuries.
Complaint Details
The complaint investigation revealed substantiated issues with care plan revisions and supervision failures leading to resident injuries, including a fall resulting in a fractured hip for Resident #1 caused by altercations with Resident #34.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to review and revise resident care plans for falls and pressure ulcers for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure adequate supervision to prevent accidents related to resident altercations and falls, resulting in injury to Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Sample size: 23
Residents affected: 2
Residents affected: 2
Wound size: 4
Wound size: 5
Wound size: 0.1
Falls: 3
Date of survey completion: Jun 25, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding lack of awareness of wounds and care plan revisions; confirmed lack of 1:1 supervision for Resident #34 |
| Wing 2 Unit Manager | Unit Manager | Confirmed care plan omissions related to pressure ulcer treatment for Resident #9 |
| Licensed Practical Nurse | LPN | Provided information on Resident #34's restlessness and behaviors |
| Physical Therapist | Physical Therapist | Observed Resident #34's unsafe wheelchair use and lack of supervision |
| Licensed Nursing Assistant | LNA | Witnessed resident altercation and reported statements from Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 17, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to properly document and notify about missing high-value personal property (hearing aids) and to assist a resident in scheduling follow-up hearing services.
Findings
The facility failed to follow processes for documenting and notifying the Durable Power of Attorney about missing hearing aids valued at $6,495 for Resident #1. Additionally, the facility did not assist Resident #1 in scheduling a follow-up appointment with audiology after the hearing aids went missing.
Complaint Details
The investigation was complaint-related, focusing on missing hearing aids for Resident #1 and failure to notify the Durable Power of Attorney or schedule follow-up audiology appointments. The Social Worker did not receive notification of the missing hearing aids and no referral or follow-up appointment was documented.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to follow processes for documenting high value personal property and notifying the Durable Power of Attorney about missing hearing aids. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assist a resident in scheduling a follow-up appointment with a provider specializing in hearing impairment after hearing aids went missing. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Value of missing hearing aids: 6495
Dates hearing aids documented missing: From 4/5/24 through 4/25/24 nursing notes documented hearing aids missing
Resident sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding documentation and notification processes for missing hearing aids | |
| Social Worker | Interviewed regarding notification and scheduling of follow-up audiology appointments |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 5, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to distribute resident funds within the required 30-day timeframe following discharge, eviction, or death.
Findings
The facility failed to ensure that resident funds were distributed within 30 days for one resident out of three sampled. Specifically, funds for Resident #1 were delivered 85 days after the resident passed away, contrary to the facility's policy.
Complaint Details
The complaint investigation found that the facility did not distribute funds to the individual administering Resident #1's estate within 30 days as required. The Family Representative expressed frustration due to the delay in receiving approximately $1400, which was delivered 85 days after the resident's death.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify each resident of certain balances and convey resident funds upon discharge, eviction, or death within 30 days. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Amount of resident funds delayed: 1464.6
Days delayed: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed that resident funds were not distributed within 30 days |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 2, 2024
Visit Reason
The inspection was conducted due to a complaint regarding disrespectful and undignified behavior by a Licensed Nursing Assistant toward a resident.
Findings
The facility substantiated that a Licensed Nursing Assistant spoke disrespectfully to Resident #1, failing to treat the resident with dignity and respect, as confirmed by witness statements and the Administrator's interview.
Complaint Details
The complaint was substantiated based on witness statements and the facility's investigation confirming undignified and disrespectful behavior by LNA #1 toward Resident #1.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to treat Resident #1 with respect and dignity, including undignified and disrespectful verbal behavior by a Licensed Nursing Assistant. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Assistant (LNA) | Named as the staff member who behaved disrespectfully toward Resident #1. | |
| Licensed Practical Nurse (LPN) | Witness who observed the disrespectful behavior. | |
| Administrator | Confirmed the incident and agreed the behavior was not dignified or respectful. |
Inspection Report
Routine
Deficiencies: 18
May 9, 2024
Visit Reason
The inspection was a routine survey conducted from 5/6/24 to 5/9/24 to assess compliance with regulatory requirements related to resident rights, care planning, medication management, infection control, food service, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to self-determination and access, inadequate care planning and revision, medication management issues including unnecessary medications and lack of rationale for pharmacist recommendations, incomplete and inaccessible medical records, failure to maintain infection control practices, improper food handling and serving temperatures, lack of resident engagement in activities, and governance deficiencies related to policy accessibility and medical director involvement.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 16
Level of Harm - Potential for minimal harm: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Facility failed to ensure residents' right to self-determination and access by locking all doors 24/7, restricting residents and visitors from independent entry and exit. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide reasonable accommodation of resident needs, e.g., call bell access for Resident #53. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a safe, clean, comfortable, and homelike environment, including ongoing maintenance issues and privacy curtain concerns. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive care plans timely and revise care plans as resident conditions changed, including anticoagulant use and activity preferences. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide ongoing activities that meet residents' needs and preferences, with many days lacking formal activities and residents reporting boredom. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide treatment and care according to orders for residents with peripheral IVs, including lack of orders for monitoring and dressing changes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physicians and other providers review residents' total program of care at each required visit. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents are seen face-to-face by physicians at all required visits and failed to track regulatory visits. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure licensed pharmacist perform monthly drug regimen reviews with documented rationale for disagreement with pharmacist recommendations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents remain free from unnecessary drugs, including continued administration of morphine without documented rationale despite lack of pain. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature; observed dry, hard chicken patties and cold hamburgers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure meals and snacks are served at times in accordance with resident needs and preferences; no nourishing bedtime snacks offered despite 15-hour gap between dinner and breakfast. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards; observed unpasteurized eggs, unsanitary kitchen conditions, and improper food storage. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to establish a governing body that ensures facility policies are accessible to all staff; policies were not accessible and staff had to request policies from management. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to designate a medical director responsible for implementation of resident care policies and coordination of medical care; medical director not involved in facility assessment or policy development and lacks system to monitor providers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to safeguard resident-identifiable information and maintain complete, accurate, and accessible medical records; missing provider notes and incomplete documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a neutral and fair arbitration process; binding arbitration agreements did not permit selection of a neutral arbitrator or location convenient to both parties. | Level of Harm - Potential for minimal harm |
| Failed to provide and implement an infection prevention and control program; improper use of PPE for resident on precautions and inadequate cleaning of glucometer. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days without anticoagulant: 49
Hours between dinner and breakfast: 15
Temperature of hamburger: 91.8
Temperature of hamburger: 106.5
Temperature of hamburger: 129.5
Temperature of hamburger: 107.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided information on locked doors policy, facility policies access, and governance | |
| Unit Manager | Confirmed issues with medication orders, regulatory visits, pharmacist recommendations, and infection control | |
| Licensed Practical Nurse (LPN) | Observed medication pass and cleaning of glucometer | |
| Dietary Manager | Confirmed food temperature issues and kitchen cleanliness | |
| Activities Director | Provided information on activities staffing and scheduling | |
| Medical Director | Confirmed lack of provider visit documentation and regulatory visit compliance | |
| Infection Preventionist Nurse | Confirmed resident on droplet precautions not wearing mask and lack of documentation | |
| Nurse Practitioner | Discussed pharmacist recommendations and medication tapering | |
| Licensed Nursing Assistant (LNA) | Reported resident boredom and lack of activities | |
| Social Service Director | Unable to access facility policies | |
| Medical Records Specialist | Confirmed missing provider notes and lack of tracking regulatory visits |
Inspection Report
Routine
Deficiencies: 10
May 9, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, care planning, medication management, environment, food service, and other aspects of facility operations.
Findings
The facility was found to have multiple deficiencies including restricting resident access by locking all doors 24/7, failure to develop and revise comprehensive care plans for anticoagulant use and pain management, failure to ensure residents were free from unnecessary medications, medication errors related to anticoagulant discontinuation, unsafe and unpalatable food temperatures, and failure to provide nourishing snacks between dinner and breakfast. Additional issues included missing resident clothing, inadequate call bell access, environmental maintenance concerns, and failure to involve residents in scheduling Resident Council meetings.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility locked all doors 24 hours a day, restricting resident self-determination and access to persons and services outside the facility. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents had the right to get up at the time they want and failed to resolve missing clothing issues for several residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to schedule Resident Council meetings at times determined by residents and failed to treat residents with dignity during meal service. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a safe, clean, comfortable, and homelike environment including repeated falling chair rail strips, inaccessible call bells, floor indentations, and tied-up privacy curtains. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive care plan addressing anticoagulant use for Resident #23 until several months after admission. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise care plans timely to reflect changes in resident condition and preferences for Residents #23 and #62. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident #23 remained free from unnecessary drugs, continuing morphine without documented pain or evaluation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident #23 was free from significant medication errors, including a 49-day gap in anticoagulant administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature, with multiple observations of cold or dry food. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide nourishing snacks at bedtime despite a 15-hour gap between dinner and breakfast, and failed to involve Resident Council in discussions about meal timing. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days without anticoagulant: 49
Hours between dinner and breakfast: 15
Temperature of hamburger: 91.8
Temperature of hamburger: 106.5
Temperature of burgers: 129.5
Temperature of burgers: 107.5
Replacement cost: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LNA #1 | Licensed Nursing Assistant | Confirmed doors always locked and staff forbidden to give codes to residents or visitors. |
| LNA #2 | Licensed Nursing Assistant | Confirmed Resident #47 is on list to be gotten up by night shift. |
| Administrator | Confirmed doors locked since October 2022, no policy for locked doors, unaware of Resident #47 early wake time, and acknowledged missing clothes and Resident Council scheduling issues. | |
| Social Worker | Unaware of Resident #47 missing clothes and replacement costs. | |
| Unit Manager | Confirmed Resident #62 meal delay and care plan requirements for anticoagulant use. | |
| Therapy Director | Uncertain about status of leg bag for Resident #23. | |
| Director of Nursing | Confirmed anticoagulant care plan requirements and NP visit status. | |
| Nurse Practitioner | Reviewed Resident #23 record and confirmed taper of morphine medication. | |
| Dietary Assistant #1 | Described steam table setup and food temperature issues. | |
| Dietary Assistant #2 | Confirmed low food temperatures and reheating procedures. | |
| Dietary Manager | Confirmed food temperature and palatability issues. | |
| Medical Director | Confirmed Lovenox order should not have stopped on 12/14/23. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Apr 26, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to provide timely notification of resident transfers/discharges, failure to provide written bed-hold notices upon transfer, inadequate respiratory care for a resident, failure to post nurse staffing information daily, and improper food storage and safety practices.
Findings
The facility failed to notify residents and the Ombudsman timely about transfers/discharges, failed to provide bed-hold notices before residents returned, did not provide appropriate respiratory care for one resident, failed to post accurate nurse staffing information daily, and did not store or monitor food safety properly in the kitchen.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to notify residents and the Ombudsman of transfers/discharges, failure to provide timely bed-hold notices, inadequate respiratory care for Resident #66, failure to post accurate nurse staffing information, and improper food safety practices.
Severity Breakdown
Level of Harm - Potential for minimal harm: 3
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to notify the resident and/or resident's representative in writing of a transfer/discharge and send a copy to the Ombudsman for 2 residents. | Level of Harm - Potential for minimal harm |
| Failed to provide a written bed-hold notice upon transfer to 2 residents or their representatives in a timely manner. | Level of Harm - Potential for minimal harm |
| Failed to provide safe and appropriate respiratory care consistent with professional standards for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post nurse staffing information daily including actual hours worked by licensed and unlicensed nursing staff. | Level of Harm - Potential for minimal harm |
| Failed to store, prepare, distribute and serve food in accordance with professional standards, including uncovered and unlabeled food items and missing monitoring documentation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: Many
Food temperature monitoring missing occasions: 17
Food temperature monitoring missing occasions: 47
Food temperature monitoring missing occasions: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding notification and bed-hold notice deficiencies | |
| Unit Manager (UM) | Interviewed regarding respiratory care deficiencies | |
| Administrator | Confirmed nurse staffing posting and food safety monitoring deficiencies |
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