Deficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% worse than Vermont average
Vermont average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Deficiencies: 2
Aug 18, 2025
Visit Reason
The inspection was conducted to assess compliance with resident rights related to dignity and respect during feeding assistance, and to evaluate food storage practices in accordance with professional food safety standards.
Findings
The facility failed to provide dignity and respect to residents requiring feeding assistance, with staff referring to residents as 'feeders' and insufficient staffing for feeding. Additionally, the facility failed to store food properly, with uncovered frozen vegetables found in the freezer and lack of labeling and dating, violating food safety policies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide dignity and respect to residents requiring feeding assistance; staff referred to residents as 'feeders' and insufficient staffing for feeding. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store food in accordance with professional standards; uncovered frozen vegetables without expiration dates found in freezer storage. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 8
Staff feeding residents: 4
Uncovered boxes: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Assistant | Interviewed regarding feeding assistance and staffing | |
| Administrator | Confirmed staff should not refer to residents as 'feeders' | |
| Assistant Dietary Manager | Confirmed items should be covered in storage area | |
| Dietary Manager | Confirmed items in storage should be covered, labeled, and dated |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 31, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident-to-resident physical abuse incident involving two residents with Alzheimer's disease and behavioral disturbances.
Findings
The facility failed to protect one resident from physical abuse by another resident, as evidenced by a clipboard-throwing incident causing a minor skin tear. The investigation verified the abuse, and the facility's policies on abuse prevention were reviewed.
Complaint Details
The complaint investigation verified physical abuse between Resident #1 and Resident #2 on 6/12/24. Resident #2 was both a victim and aggressor in verbal and physical altercations, posing safety risks.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to protect residents from physical abuse by another resident resulting in a small skin tear. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Skin tear size: 0.5
Date of incident: Jun 12, 2024
Inspection Report
Routine
Census: 130
Deficiencies: 10
Sep 3, 2024
Visit Reason
The inspection was conducted as a routine recertification survey to assess compliance with federal regulations related to resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care and assistance with activities of daily living (ADLs), incomplete and non-person-centered care plans, inadequate assessment and care for residents with trauma histories, insufficient nursing staff to meet resident needs, medication errors with late administration, expired medications in storage, unsafe water temperatures exceeding 120°F, lack of adequate infection prevention and control measures during a COVID-19 outbreak, and failure to provide adequate activities and engagement for residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Level of Harm - Potential for minimal harm: 1
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to provide a respectful and dignified dining experience and assistance with ADLs for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement complete, person-centered care plans that meet residents' needs with measurable timetables and actions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents were assessed for injuries and complications after a fall, and failure to follow up appropriately. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide proper assistance for residents unable to perform ADLs, including feeding, transferring, and hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide engaging activities and support residents' preferences for independent and group activities, including outdoor time and weekend activities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure resident environments were free from accident hazards related to unsafe water temperatures exceeding 120°F. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide trauma-informed care and develop care plans addressing trauma triggers for residents with PTSD. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide sufficient nursing staff to meet resident needs and ensure timely care and medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to remove expired medications and biologicals from use, including expired glucose control solution, COVID tests, and diabetic emergency kit medications. | Level of Harm - Potential for minimal harm |
| Failure to implement an infection prevention and control program consistent with CDC and state health department recommendations during a COVID-19 outbreak, including inadequate testing, PPE use, masking, and isolation precautions. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents tested positive for COVID-19: 42
Residents with dementia or Alzheimer's: 75
Residents not up to date with COVID-19 immunizations: 61
Medication error rate: 72
Water temperature: 127.3
Residents requiring assistance: 49
Residents requiring assistance: 11
Residents requiring assistance: 45
Residents completely dependent: 25
Residents completely dependent: 15
Residents completely dependent: 25
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 24, 2024
Visit Reason
The inspection was conducted following a complaint investigation regarding the facility's failure to provide timely written notification to a resident about their transfer/discharge and their right to appeal.
Findings
The facility failed to notify Resident #1 in writing of their transfer/discharge and did not inform them of their right to appeal. The only notice was given to the resident's family member by phone and email. Resident #1 confirmed not receiving any discharge notice and expressed confusion about the discharge.
Complaint Details
The complaint investigation was triggered by a facility reported resident to resident incident. The facility implemented an involuntary discharge for Resident #1 on 5/2/24 but failed to notify Resident #1 in writing of the discharge or their right to appeal. The family member was notified by phone and email, but Resident #1 was not informed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide timely notification to the resident in writing of a transfer/discharge and appeal rights. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Date of discharge: May 2, 2024
Date of admission: Mar 8, 2024
BIMS score: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed that only the family member was notified of discharge by phone and email | |
| Social Service Specialist | Confirmed Resident #1 was his/her own person during facility stay |
Inspection Report
Complaint Investigation
Deficiencies: 6
Jun 14, 2023
Visit Reason
The inspection was conducted following complaints regarding the facility's failure to accommodate a resident's request to leave the facility, inadequate care plan revisions to prevent falls, unsafe and cluttered environment in shower and tub rooms, lack of annual staff performance reviews, inadequate supervision to prevent falls, and failure to provide appropriate dementia care.
Findings
The facility failed to accommodate a resident's request to leave the facility due to lack of a system to inform residents about the pass request process. The shower and tub rooms were cluttered and in disrepair, not promoting a homelike environment. The facility failed to revise care plans with effective fall prevention interventions for a resident who experienced multiple falls. Adequate supervision to prevent falls was not ensured. Annual performance reviews for staff were not completed since 2021. The facility also failed to provide appropriate individualized care for a resident with dementia exhibiting aggressive behavior, lacking documented interventions to ensure safety and respect for religious beliefs.
Complaint Details
The complaint investigation focused on multiple issues including failure to accommodate a resident's request to leave the facility, inadequate care plan revisions to prevent falls, unsafe environment in shower and tub rooms, lack of annual staff performance reviews, inadequate supervision to prevent falls, and failure to provide appropriate dementia care. The findings confirmed these deficiencies.
Severity Breakdown
Level of Harm - Potential for minimal harm: 2
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to accommodate a resident's request to leave the facility and lacked a system to inform residents about the pass request process. | Level of Harm - Potential for minimal harm |
| Failed to ensure that the resident shower and tub rooms were kept orderly and sanitary, resulting in clutter and disrepair. | Level of Harm - Potential for minimal harm |
| Failed to ensure comprehensive care plans were revised with person-centered, effective interventions to prevent falls for a resident who experienced multiple falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents received adequate supervision to prevent falls and/or injury from falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete annual performance reviews for staff members. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to recognize and competently address the physical, mental, and psychosocial needs of a resident with dementia, lacking individualized care approaches and interventions to prevent injury during combative refusals of care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 27
Residents affected: 1
Residents affected: 1
Residents affected: 1
Staff members sampled: 5
Staff members missing reviews: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed lack of written policies for pass requests and failure to revise care plans after falls |
| Unit Manager | Unit Manager | Confirmed lack of communication about pass orders and absence of care plan interventions for dementia resident |
| Therapy Director | Therapy Director | Confirmed therapy clearance for resident's ability to transfer in and out of vehicle |
| Administrator | Administrator | Confirmed lack of admission process to inform residents about pass requests and absence of annual staff performance reviews |
| Licensed Nursing Assistant | Licensed Nursing Assistant | Provided information on aggressive behavior of dementia resident and care challenges |
Inspection Report
Deficiencies: 1
Mar 21, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with residents' rights regarding receiving written notice before room changes.
Findings
The facility failed to provide written notice to residents or their representatives before room transfers for 3 sampled residents, contrary to facility policy requiring written notification.
Severity Breakdown
Level of Harm - Potential for minimal harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure each resident's right to receive written notice, including the reason for the change, before the resident's room in the facility is changed for 3 of 3 sampled residents. | Level of Harm - Potential for minimal harm |
Report Facts
Residents affected: 3
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