Woodridge Nursing Home
142 Woodridge Drive, Barre, VT 05641 · Non profit - Corporation · 153 certified beds · (802) 371-4700 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $21,453 in federal fines (most recent 2025-07-24)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- nursing-staff turnover (63%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 25.1% | 19.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.0% | 6.6% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 1.1% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.3% | 2.4% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 5.6% | 13.0% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.8% | 5.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 19.3% | 17.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 14.0% | 16.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.1% | 97.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.2% | 5.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.4% | 26.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.3% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.4% | 1.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 87.7% | 78.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.0% | 22.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 17.0% | 17.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.87 | 1.52 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.67 | 2.88 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
60.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 307 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 69.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 184 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.53 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 60.8%CMS range 54.8–65.7 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.8%CMS range 6.8–11.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 69.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 65.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 67.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.4–13.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.82 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 153 beds and averages 140.6 residents a day — about 92% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.25 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.91 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.05 hrs/resident/day on weekends vs 5.30 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 1.42 to 0.85 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · Gcited before2025-09-23 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident, as a result, 1 of 3 sampled residents (Resident #1) suffered physical harm. Findings include:Per record review, Resident #1's diagnoses include frontotemporal neurocognitive disorder. Per review of Minimum Date Set (MDS; a standardized tool used to evaluate residents' needs and improve care planning) dated 8/4/25, Resident #1 has a BIMS (Brief Interview for Mental Status) of 11, suggesting moderate cognitive impairment. Per record review, Resident #2's diagnoses include unspecified symptoms and signs involving cognitive function and awareness, major depressive disorder, unspecified dementia, and restlessness and agitation. A review of the medical record reveals a BIMS of 14, suggesting Resident #2 is cognitively intact. A review of Resident #2's Care Plan dated 6/27/25 reveals Disturbed thought process related to degenerative brain changes as evidenced by confusion, memory loss, and disorientation. with agitation and anxiety.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-09-12 · tag F0585 — failed to handle grievances — widespreadHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure residents could freely file anonymous grievances. This has the potential to impact all residents. Findings include: Per interview with five residents (Residents #114, #57,1#110, #107, and #133) at Resident Council on 9/9/25 at 1:30 PM, they stated they did not know how to file an anonymous grievance. Resident #110 stated, I often wonder who I could go to if there was a problem with staff. I don't want it getting back to me. Per record review Resident #110 has a BIMS [Brief Interview of Mental Status] score of 15, indicating s/he has no cognitive impairment.Per observation of the second floor there were no blank grievance forms able to be located. The blank grievance forms were found behind the nurses station as shown by the Unit Manager.Per review of the facility's Grievances/Complaints-Filing, Investigating and Resolving policy [last reviewed 5/30/25], there is no mention to filing grievances anonymously.Per interview with the Unit Manager on 9/9/25 at 2:15 PM she stated, There's really no way for them [residents or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-09-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety and failed to maintain a sanitary kitchen. This has the potential to impact all residents. Findings include: 1. A kitchen tour was conducted with the Dietary Manager on 9/8/253 at 9:42 AM.Per observation of the kitchen prep area, the following items were found improperly stored:Harissa seasoning with no date,Expired black sesame dated 3/11/24,White sesame marked 6/18 (no year),Expired sesame seed dated 6/21/24,Marjoram dated11/30/23,Bay leaves dated 5/6/24,All spice dated 11/27/24,The Dietary Manager stated that spices should be discarded a year after opening and confirmed that the above spices were expired.Per observation of the walk in refrigerator, the following items were found improperly stored:A container of Jello with no labels or dates,A container of beef stew with no labels or dates,A container of cream cheese frosting with no use by date,A container of expired buttercream frosting marked good through 9/3/25,A container of expired cooked…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-12 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to ensure that all residents were treated with dignity in regard to dining on 2 of 3 units. Findings include: 1. Per observation of lunch service on the Evergreen unit on 9/8/25 at 12:15 PM, 7 residents were in the side room for lunch sitting at one large table, and one small side table. Lunch was being served on trays, with warming dishes, to one resident at a time. As the trays were placed on the table, the warming lids were stacked in the middle of the table. Trash was also put in the middle of the table. At 12:19 PM, while other residents were eating, Resident #39 said that s/he is really hungry. S/he was not served lunch until 12:43 PM. Resident #86, who was sitting in the common area outside of the side room since the start of lunch service was not served lunch until 12:54 PM. Per interview with the Dietary Manager on 9/10/25 at 1:35 PM, he explained that they cannot get all meals to each unit at the same time because there isn't enough staff to bring each food cart up to the unit. Per interview with the DON on 9/10/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-12 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident's right to be informed in advanced by the physician or other practitioner or professional of the risk and benefits by proposed care, of treatment alternatives or treatment options, and to choose the alternative or option he or she prefers for two of five residents in the sample. (Residents #4 and #12). Findings include: 1.) Per record review, Resident #4 has active orders for Lorazepam 1 mg [milligram] tab: Give 1 tablet by mouth two times a day for Chronic Anxiety, and Lorazepam Oral Tablet 0.5 mg [milligram]: Give 1 tablet by mouth every 12 hours as needed for increased anxiety/restlessness/agitation for 30 Days inability to redirect, both ordered on 8/28/25. Resident #4 also had an order for Lorazepam Oral Tablet 0.5 MG (milligram): Give 0.5 mg by mouth one time a day for anxiety/agitation. This medication was originally ordered on 3/25/25 and discontinued on 5/22/25. Per record review, there is no evidence that residents were educated on the use and/or risk and benefits of the medications. Per record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-12 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure that all residents had a homelike environment for multiple areas of the facility, having the potential to impact many residents. Findings include:Per observation during a walkthrough of the facility on 9/8/25 at approximately 10:30 AM, two hallways of the Evergreen Unit had multiple wheelchairs, carts, lifts, medical machines, and bags lining one side of each hall. This was observed multiple times throughout the recertification survey on 9/8/25 through 9/10/25. Per interview on 9/10/25 at approximately 3:00 PM during a facility tour with the Director of Nursing, multiple hallways of the facility had multiple items in the hallway. She confirmed that the hallway should not be a place to store lifts and wheelchairs as there are spots tucked away in the halls for the equipment to be placed.During the tour, three large approximately 15 feet by 5 feet boards were observed across from the nursing stations by the resident common sitting areas. These boards contained multiple data points related to resident care and staffing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide respiratory care in accordance with professional standards for five of five residents (Residents #86, #97, #94, #136, and #34). Findings include:1. Per record review, Resident #86 has diagnoses that include acute and chronic respiratory failure, obstructive sleep apnea, and dependence on supplemental oxygen. A 7/18/25 admission note states that Resident #86 has the following active problem requiring attention Recent acute on chronic respiratory failure requires BiPAP [Bilevel Positive Airway Pressure; a non-invasive ventilation treatment] and 1 to 2 L [liters] of oxygen. [S/He] will continue with respiratory support with BiPAP machine we will continue oxygen 1 to 2L. Resident #86 had the following physician orders Standing Order Other: O2 (oxygen) @ 2LPM via NC [nasal canula] PRN [as needed] to maintain O2 sat of above 90% May administer oxygen prn via NC/mask to maintain SP02 [peripheral oxygen saturation] of >90%; If requiring more than 2L…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure that a Resident's choice regarding his/her Advance Directives (wishes regarding life-sustaining treatment) was documented correctly, ordered, and care planned for 1 of 30 residents sampled (Resident #123). Findings include:Per record review, Resident #123's Electronic Health Record (EHR) has an Advanced Directive stating s/he wishes are do not resuscitate (DNR) and trial course of intubation (a tube to assist with breathing) and ventilation treatment for 5 days, signed 12/30/24 by the Resident. The Code Status in the EHR states DNR/DNI (Do Not Intubate), and the Care Plan (initiated on 2/28/25 and revised on 6/30/25) Focus states Advanced directive, [Resident #123] has established advanced directives-DNR/DNI, Date Initiated: 02/28/2025, Revision on: 03/25/2025), and there is an Order for DNR/DNI with a start date of 2/28/25. The Care Plan, Order, and Resident dashboard don't reflect the Resident's wishes of DNR/Trial of intubation for 5 days per her/his documented Advanced Directives.Per interview on 9/9/25 at 1:50…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure one of two sampled residents (Resident #4) were free from chemical restraints. Findings include:Per review of Resident #4's medical record, Resident #4 has a BIMS [Brief Interview of Mental Status] score of 4, indicating the resident has cognitive impairment. Resident #4 has diagnoses of Type II Diabetes, CHF [Congestive Heart Failure], anxiety disorder, and chronic pain syndrome. Resident #4 needs substantial/maximal assistance with ADLs [Activities of Daily Living] and hygiene.Per record review, Resident #4 has an order for Lorazepam 0.5 mg [milligram]: Give 1 tablet by mouth every 12 hours as needed for increased anxiety/restlessness/agitation for 30 Days inability to redirect. The order was placed on 8/28/25 and was to be discontinued on 9/27/25. Per record review of the Medication Administration Record, Resident #4 has received the prn [as needed] medication three times. Per record review of the facility's Pharmacy Services policy [last revised 11/18/24] states, e. Psychotropic Drugs. Based on a comprehensive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-12 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that their policies related to screening for abuse had been implemented for 1 of 5 Employees reviewed (Licensed Nursing Assistant #1). This is a repeat deficiency for this facility, with violations cited during the previous recertification survey dated 11/6/24 and partial survey dated 7/24/25. Findings include: Based on interview and record review, the facility failed to ensure that their policies related to screening for abuse had been implemented for 1 of 5 employees reviewed (Employee #1). The detailed findings are as follows:Licensed Nursing Assistant (LNA) #1, who was a contracted LNA, was hired on 9/3/2025. There was no evidence in the employee file that the Adult Registry review was conducted as required.The facility policy titled Prevention of Abuse Prohibition states that the facility will comply with and review the [NAME] Abuse and Child Protection Registry. Per interview on 9/10/2025 at 5:16 PM the Director of Nursing (DON) provided a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure resident's care plans were updated with pertinent information related to their care for two of 30 sampled residents (Residents #40 and #97). Findings include:1.) Per review of Resident #40's medical record, s/he has diagnoses of Parkinson's Disease, hypertension, and muscle weakness. Resident #40 is dependent on staff for hygiene and needs substantial/maximal assistance with ADLs [Activities of Daily Living]. As of 6/16/25, Resident #40 has a BIMS [Brief Interview of Mental Status] score of 0, indicating Resident #40 has cognitive impairment. Per record review of a post fall evaluation on 5/30/25 states, Date / Time of Fall: 05/30/2025 2:38 PM Fall was witnessed. Who witnessed fall: LNA [Licensed Nursing Assistant]. Fall occurred in the hallway. Activity at the time of fall: Being pushed down the hallway in w/c [wheelchair], put foot down on carpet while being pushed and fell out of w/c. Reason for the fall was evident.Did an injury occur as a result of the fall: Yes. Injury details: Hematoma (R)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 21 citations
- Potential for harm · D2025-09-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were free from accidents and hazards for two of 30 sampled residents (Residents #40 and #45). Findings include:1.) Per review of Resident #40's medical record s/he has diagnoses of Parkinson's Disease, hypertension, and muscle weakness. Resident #40 is dependent on staff for hygiene and needs substantial/maximal assistance with ADLs [Activities of Daily Living]. As of 6/16/25, Resident #40 has a BIMS [Brief Interview of Mental Status] score of 0, indicating Resident #40 has cognitive impairment. Per record review of a post fall evaluation on 5/30/25 states, Date / Time of Fall: 05/30/2025 2:38 PM Fall was witnessed. Who witnessed fall: LNA [Licensed Nursing Assistant]. Fall occurred in the hallway. Activity at the time of fall: Being pushed down the hallway in w/c [wheelchair], put foot down on carpet while being pushed and fell out of w/c. Reason for the fall was evident.Did an injury occur as a result of the fall: Yes.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Per observation, interview, and record review, the facility failed to ensure that residents with urinary catheters received appropriate treatment and services to prevent urinary tract infections for 2 of 2 sampled residents (Resident #3 & 27). Findings include: Per record review, Resident #3 reveals medical diagnoses which include:Urinary tract infection (an infection in any part of the urinary system);Neuromuscular Dysfunction of Bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should);Acute Kidney Failure (when the kidneys suddenly can't filter waste products from the blood);Retention of Urine (bladder doesn't completely empty when urinating); andChronic Kidney Disease (a long-term condition where the kidneys do not work as well as they should)Resident #3 has orders for an indwelling Foley catheter (a tube that is maintained in the bladder to drain urine constantly). It is connected to a collection bag that requires frequent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to store drugs in accordance with currently accepted professional principles for 1 of 30 sampled residents. Findings include:Per observation on 9/8/25 at approximately 3:00 PM, the following medications were found in Resident #86's room: Clotrimazole External Cream 1 % (Clotrimazole (Topical)), Tacrolimus External Ointment 0.1 % (Tacrolimus (Topical)) and Hydrocortisone External Cream 2.5 % (Hydrocortisone (Topical)). Resident #86 had a roommate.Per interview on 9/8/25 at 3:04 PM, a Licensed Practical Nurse stated that Resident #86 did not have a medication self-administration assessment completed to determine if s/he could have medications in his/her room. She stated that if s/he did, the medications should be in a lock box. Per interview with the Unit Manager on 9/9/25 at 3:54 PM, she confirmed that Resident #86 did not have a medication self-administration assessment and shouldn't have the medications in his/her room. To have medications in the room, a resident would need a medication self-administration assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review facility failed to ensure a resident was provided adaptive devices used to promote adequate hydration for one of one (Resident #2). Findings include:Per record review, Resident #2 was admitted to the facility with diagnoses that include type 2 diabetes mellitus, essential tremor, and mild cognitive impairment. Review of Resident #2's care plan reveals that s/he has a swallowing problem related to a medical decline and that s/he had choked on a meatball. Care plan interventions include the use of a 2 handled mug with spouted lid. The care plan also indicates a focus initiated on 1/25/2021 of an alteration in fluid balance related to immunosuppressive medication use, history of renal transplant, uropathy, indwelling foley catheter, history of aspiration pneumonia, and diabetes. Interventions include Encourage to drink fluids of choice and ensure access to favorite beverages, diet ginger ale with small amount of cranberry for color.The care plan also states recommend seated in Broda chair for meals. Items within reach, set up is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-07-24 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement national background checks on two out of five employees sampled. Findings include: Per record review of five employees' personnel files, RN [Registered Nurse] #1 and LPN [Licensed Practical Nurse] #1 did not have national background checks in their employment file. RN#1 was hired in 8/13/12 and LPN#1 was hired on 8/25/14. RN#1 has worked at the facility for almost thirteen years without a background check. LPN#1 has worked at the facility for approximately 10 years without a national background check.Per record review of the facility's Prevention of Abuse policy [last reviewed 11/18/24] states, A. Before new employees are permitted to work with residents, [The facility]'s human resources shall conduct a comprehensive hiring process which will include in-depth interviewing practices and careful examination of references.B. [The facility] shall comply with CORI Law.C. [The facility]'s Human Resources will contact The [NAME] office of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-24 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 7 sampled residents (Resident #2). Findings include:Per record review of Resident #2's care plan dated 5/29/2025, Resident #2 is a quadriplegic, has cerebral palsy and decreased range of motion. Resident #2's care plan also mentions that the Resident requires a mechanical lift with assistance from two staff members to move. Resident #2's Brief Interview for Mental Status (a score assessing memory and cognitive function) is 14 out of 15 indicating that Resident #2 is cognitively intact.Resident #2 was observed on 7/23/2025 at 12:50 PM having difficulty repositioning himself in bed raising concern that Resident #2 wouldn't have been able to move away from Resident #1 who is able to mobilize in wheelchair independently per his/her care plan dated 6/25/2025.Per record review, an administration note dated 7/8/2025 states resident exhibiting concerning behavior several times this evening where staff observed [him/her] sitting in his/her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-24 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to identify, investigate, and report to the State Survey Agency an incident of sexual abuse for 1 of 7 residents (Resident #2). Findings include:Per record review, the facility abuse policy titled Prevention of Abuse reviewed on 11/18/2024 states, [facility] will report any alleged patient abuse sexual abuse, mistreatment, neglect, or misappropriation of resident property to [NAME], APS, and the [NAME] Police Department whenever the facility has reasonable cause to believe that a resident experience abuse, mistreatment, neglect, or misappropriation of property.Per record review, a Social Workers progress note revealed that Resident #2 experienced forced observation of masturbation causing Resident #2 to feel very uncomfortable and scared A Social Workers progress note dated 7/9/2025 revealed that Resident #2's roommate (Resident #1) was observed rummaging through [Resident #2's] personal belongings and then he was found sitting beside [Resident #2's] bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-04 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to ensure that 1 of 3 sampled residents (Resident #1) was treated with dignity and respect in relation to staff-to-resident interaction. Findings include: Per record review, Resident #1 has resided at the facility since 2022 and has a diagnosis of dementia. Per review of a facility-reported incident reported to the State Survey Agency, a family member reported to the facility their concerns regarding the treatment of Resident #1 by a staff member. The family member indicated that Resident #1 was yelled at by Nurse #1, which caused Resident #1 to cry. The facility investigation revealed an interview with a family member dated 8/29/2024, which reads, I feel this nurse [Nurse#1] does not like [Resident #1] .S/he is rude and blunt. The facility's 5-day investigation report submitted to the State Agency contained statements from several staff members indicating that Nurse #1 had been overheard being loud and rude to Resident #1 and other residents more than once. The 5-day report substantiated the allegations that Nurse #1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-06 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure two residents [Resident #73, and Resident #84] of three sampled residents remained free from physical abuse. Findings include: Per record review of Resident #73's progress notes, on 4/1/24 at approximately 1:00 PM, Resident #25 entered Resident #73's room and struck Resident #73. Resident #73 pushed the emergency light in his/her room and staff intervened. Resident #73 had their vital signs taken and was assessed by nursing staff. Per record review of Resident #73's progress notes, the resident sustained scratches on the right side of his/her neck and right elbow and was shaken by the incident. An interview was conducted on 11/6/24 at 2:07 PM with LNA#1, who was the caregiver during the incident. LNA #1 stated the emergency light went off in Resident #73's room. LNA #1 ran down the hall and found Resident #25 at doorway of Resident #73's room. S/he was attempting to push through, and the two residents began fighting. Per record review of Resident #25's care plan, there are no updated interventions after the incident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-06 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to revise a Resident's care plan to include interventions needed to prevent pressure injury for 1 out of 5 residents in the sample (Resident # 47) who was identified as a high risk for pressure injury. Findings include: Per record review Emergency Department notes dated 1/19/2024 Resident #47 fell and sustained a fractured right hip on 1/19/2024. S/He was treated for pain at the hospital then returned to facility for comfort focused care Per the MDS [Minimum Data Set - a comprehensive resident assessment tool] dated 1/30/2024, the Resident was identified as a high risk for pressure injury. The MDS Coordinator documented the following assessment [Resident #47] has no PI [pressure injury] at this time. Braden score of 14 [per facility definition the Braden Scale is a validated pressure injury risk assessment tool used by RNs (Registered Nurse) and LPNs (Licensed Practical Nurse) to assign a level of pressure injury risk to trigger appropriate interventions for pressure injury prevention]. [S/he] is at high risk for skin integ…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent pressure injuries caused by deep tissue injury (DTI) (A form of pressure injury that is purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) by failing to implement preventative measures per facility policy and professional standards, for one of 5 Residents in the sample, (Resident #47). Findings include: Per record review an Emergency Department note dated 1/19/2024 reveals that Resident #47 fell on 1/19/2024 and sustained a fractured hip. S/He was treated for pain at the hospital then returned to facility for comfort focused care on 1/24/2024. On 1/23/24 Resident #47's care plan was updated with the following intervention: pressure reducing mattress and wheelchair cushion. Per the MDS [Minimum Data Set - a comprehensive resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-06 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility failed to ensure that residents who are trauma survivors receive trauma informed care that mitigates triggers that may re-traumatize residents for 2 of 4 residents (Resident #10 and #71). Findings Include: 1. Per interview on 11/6/24 at approximately 2:00 PM, Resident #10 stated that s/he has had bad experiences in his/her past that get brought up when other residents say sexual things. Per record review, Resident #10's care plan reads, The resident has a psychosocial wellbeing problem r/t [related to] trauma of children molested by [spouse]. No triggers recorded ., revised 6/18/24, and Resident is at risk for re-traumatization R/T history of past life trauma ., revised on 9/17/2024. Resident #10's care plan does not include any identified triggers. Facility policy titled Trauma Informed Care, last reviewed on 7/18/23 reads, Woodridge will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-06 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure that monthly pharmacist drug regimen reviews, recommendations, and attending physician responses are completed and documented in the resident record for 1 of 5 sampled residents (Resident #71). Findings include: Per record review, Resident #71 has had multiple physician orders over the past year for the antipsychotic quetiapine. A pharmacist's medication regime review for Resident #71 in February 2024 recommends the following: Per the November 2017 Medicare MEGA Rule regulations, PRN [as needed] Antipsychotic orders can only be for 14 days. If order is to be continued, it needs to be reassessed every 14 days and clinical rationale documented every 14 days. Resident has the following order: Quetiapine 12.5 mg [by mouth every 12 hours] prn agitation May we clarify this order to: Quetiapine 12.5 mg [by mouth every 12 hours] prn agitation x 14 days Please document rationale for continuing this order. The pharmacist's medication regime review recommends changing the physician order for PRN Quetiapine to have a duration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-07 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure that residents received services according to professional standards of quality with regard to following wound care orders/documentation for one of three sampled residents (Resident #1). Findings include: Per order review, a wound care order was placed on 2/24/2024 to start at 7:00 AM that day that reads, Right heel fissure. Daily wound care or PRN (as needed) if it becomes soiled or dislodged. Remove dressings, cleanse well with wound cleanser, dab dry with gauze. Betadine to affected area. Place Maxorb II onto affected area, cover with ABD pad. Wrap with gauze and ACE wrap. Per review of Resident #1's TAR (treatment administration record), the wound dressing is marked as having been changed by LPN #1 on 2/24/24 and 2/25/24 despite LPN #1 confirming that they did not change the dressing on either day. Based on a review of the facility's self-report investigation records, the facility substantiated the allegation that Resident #1's wound…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility failed to ensure that residents receive treatment and care for wounds according to professional standards of care and the comprehensive care plan for one of three sampled residents (Resident #1). Findings include: Based on a review of the facility's self-report investigation records, the facility substantiated the allegation that Resident #1's wound dressings were not done on 2/24/2024 and 2/25/2024. On 2/26/2024 at approximately 1:00 PM, Wound Nurse #1 reported to the Nurse Manager that Resident #1 had a left heel dressing that was dated 2/23/24, despite having orders for a wound dressing every day. Per an email statement sent on 2/28/24 to the facility, LPN #1 (licensed nurse practitioner) wrote, On the last weekend on the 24th and 25th I was the nurse on hall 3. The Resident [Resident #1] had a treatment that was to be done on days. I had intentions of doing the treatment, I even looked at the dressing, but forgot to go back and perform the treatment. I had all intentions of doing this treatment as I did everyone else's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-27 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, staff interview, and record review, the facility failed to ensure that allegations involving abuse are reported no later than 2 hours to the Administrator of the facility and the State Survey Agency for Resident #1. Findings include: 1. Per interview on 10/25/23 at approximately 2:00 PM, Resident #1 stated that they have issues with a few LNAs (licensed nursing assistants) who provide them with personal care. Resident #1 stated that they frequently report concerns to the facility's LES (Life Enrichment Specialist) and that these concerns have included allegations of rough treatment and threatening statements. Per interview on 10/25/23 at approximately 2:30 PM, the LES stated that they speak with Resident #1 frequently about their concerns, and that one of the concerns shared with the LES includes an allegation that 2 LNAs threatened to refuse to provide care for Resident #1. The LES does not remember exactly when this allegation was made, but it was at least several weeks prior, if not more. The LES confirmed that they had not alerted the Administrator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-23 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview and record review, the facility failed to ensure that residents received the treatment and care in accordance with professional standards of practice and the comprehensive care plan related to pain management for 1 resident [Res.#67] of 31 sampled residents. Findings include: Review of Res.#67's medical record reveals the resident was admitted to the facility on [DATE] with diagnoses that included Chronic Pain and Chronic Gout, and whose Care Plan identified the resident as having pain related to chronic lower back pain and age-related osteoporosis, osteoarthritis, gout, and Peripheral Vascular Disease. Review of Physician Orders for Res.#67 include CBD Oil Drops- Give 10 drops sublingually two times a day for chronic pain [CBD oil (Cannabidiol) is derived from the cannabis plant and prescribed to provide a reduction of inflammation and pain relief]. Per interview with Res.#67 on 8/23/23 at 9:22 AM the ordered CBD oil helps with a whole bunch of things, including pain. An interview was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-23 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure that 2 applicable residents (Residents # 92 and 60 ) in the sample of 25 were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. Findings include: 1. Resident # 92 was admitted [DATE]. Review of provider progress notes between 8/22/22 - 8/22/23 shows that the Resident was not seen by a physician as required by regulation. This was confirmed by the Unit Manager on 8/22/23 at 12:44 P.M 2. Resident # 60 was admitted on [DATE]. Review of provider progress notes between 8/22/22 - 8/22/23 shows that the Resident was not seen by a physician as required by regulation. This was confirmed by the Unit Manager on 8/22/23 at 12:44 P.M
- No harm found · B2025-09-12 · tag F0577 — patternAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to provide state survey results for residents and resident representatives to readily view. Findings include:Per observation on 9/9/25 at 1:25 PM there were no state survey results available on the second floor where all residents reside.Per interview with Resident #114 during resident council on 9/9/25 at approximately 1:30 PM, s/he stated, It would be nice if we could have access to it [state survey results], I can't get to the first floor because I can't walk. Per record review Resident #114 has a BIMS [Brief Interview of Mental Status] score of 14, indicating that Resident #114 has no cognitive deficit. Resident #114 is dependent on staff for ADLs [Activities of Daily Living] and hygiene.Per interview with the Activities Director on 9/9/25 at 2:28 PM, she confirmed state survey results are not posted on the second floor and are only on the first floor of the building.
- No harm found · Ccited before2024-11-06 · tag F0607 — failed to have anti-abuse policies — widespreadDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review and staff interview, the facility failed to develop written policies and procedures that include all the required regulatory topics related to screening, training, prevention, and identification. Findings include: Per review of facility policy titled, Preventing, Reporting, and Investigating Resident Abuse, Mistreatment, Exploitation and Neglect, published on 3/14/24, the following required components are missing: Screening, -screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit abuse, neglect, and exploitation of resident property; and -screening prospective residents to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility Training -training new and existing nursing home staff and in-service training for nurse aides in the following topics which include: o Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation; o…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-11-06 · tag F0943 — widespreadGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to develop and implement an effective abuse, neglect, exploitation, misappropriation of resident property, and dementia management training program for all staff. Findings include: A review of all educational materials used to train staff on abuse, neglect, exploitation, misappropriation of resident property, and dementia management was reviewed while investigating allegations of abuse. The materials provided included a power point titled Preventing & Reporting Resident Abuse, Misappropriation, Exploitation, and Neglect (AMEN) and another power point titled Abuse and Neglect. These training materials do not include: - Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators; - Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. While the training does include definitions of abuse, neglect, exploitation, and misappropriation of resident property, the training materials do not include:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$21,453 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $21,453 — penalty dated 2025-07-24
- Medicare payment denial — starting 2024-01-27 for 31 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to UNIVERSITY OF VERMONT HEALTH NETWORK — 3 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.3 | -0.3 vs chain |
| Health inspection | 2 of 5 | 2.7 | -0.7 vs chain |
| Staffing | 4 of 5 | 3.0 | +1.0 vs chain |
| Quality measures | 3 of 5 | 3.0 | ≈ chain avg |
The other 2 homes this chain runs (chain average 2.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| THE UNIVERSITY OF VERMONT HEALTH NETWORK INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/17/2014 |
| CARLSON, KRISTIN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2025 |
| CLOUSER, RYAN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2024 |
| COLMAN, CONSTANCE | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 04/28/2018 |
| COSTELLO, KATHERINE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/28/2025 |
| DELLIPRISCOLI, MICHAEL | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2024 |
| EAPPEN, SUNIL | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 11/28/2022 |
| HARE, ERICA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/03/2023 |
| JUDY, JOYCE | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 12/12/2013 |
| MISEK, JOAN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 12/01/2019 |
| MULLER, LISA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 12/01/2021 |
| SMITH, BENJAMIN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 03/26/2025 |
| WHITMAN, TIMOTHY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/05/2025 |
| NOONAN, ANNA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF | — | since 07/24/2017 |
| PATNAUDE, KIMBERLY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/15/2021 |
| WERNEKE, CHRISTINE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 11/19/2024 |
CMS files one row per role, so the 34 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in VT
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Vermont Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 475045. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.