Union House Nursing Home
3086 Glover Street, Glover, VT 05839 · For profit - Limited Liability company · 44 certified beds · (802) 525-6600 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (4/5)
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent May 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $18,418 in federal fines (most recent 2023-10-11)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (78%) 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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 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 improved from 2 to 4 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 | 20.4% | 19.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.1% | 6.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.1% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 5.0% | 2.4% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 8.3% | 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 | 5.5% | 5.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.1% | 17.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 23.6% | 16.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 90.5% | 97.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.5% | 5.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.2% | 26.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 33.3% | 19.9% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.20 | 1.52 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 3.27 | 2.88 | 1.80 | worse |
‡ 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.
Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 44 beds and averages 43.1 residents a day — about 98% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. 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 4.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.61 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 3.31 hrs/resident/day on weekends vs 4.36 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.76 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 78% is well above the national median of 45%. 1 administrator has left in the past year.
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.
24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · Gcited before2023-10-11 · 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
Based on record review and interview the facility failed to implement appropriate interventions and provide adequate supervision to prevent accidents and injuries for 1 of 8 sampled residents (Resident #5). Findings include: Resident #5 was admitted to the facility in May 2023 with diagnoses including heart failure, chronic kidney disease stage 3, major depressive disorder, and chronic obstructive pulmonary disease (a lung disease). A review of the Minimum Data Set (MDS ; an assessment tool used to gather information relevant to care plan development among other uses) dated 7/23/23 reveals in Section B regarding hearing/speech and vision, vision is assessed as highly impaired-object identification in question, but eyes appear to follow objects. Resident #5 has a current Brief Interview for Mental Status (BIMS) score of 13 (this score reflects cognitive function and ranges from 1-15 with lower scores indicating a higher level of impairment). A record review reveals the following physician documentation dated 10/3/23 . Resident has had 4 falls since last seen. [His/her] falls are…
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.
- Actual harm · Gcited before2023-10-11 · 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 resident representative and staff interviews and record review, the facility failed to create and implement an individualized person-centered plan to render trauma-informed care to a resident with a personal history of trauma, related to witnessing a relative drown, for 1 of 20 residents sampled (Resident #30). Findings include: Record review reveals that Resident #30 was admitted in April 2021 with diagnoses including Alzheimer's disease, muscle weakness, and major depressive disorder. On 10/9/23 at approximately 12:20 PM, Resident #30's Representative noted that at times Resident #30 does not appear to have been bathed and at other times they receive reports that Resident #30 has assaultive behaviors that occur during bathing. Resident #30's Representative detailed a past traumatic event during which Resident #30 was witness to a family member drowning and has had a terror of water ever since. Per the Representative, this traumatic event was discussed with the Social Services Director during a care planning meeting. During a review of the care plan for Resident #30 an…
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 · E2026-05-07 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
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 four of four sampled residents (Res.#1, Res.#2, Res.#3, and Res.#4) were free from misappropriation of property related to medication. Findings include:Per record review of the facility's Identifying Exploitation, Theft, and Misappropriation of Resident Property policy [last revised April 2021] states, 4.Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 5. Examples of misappropriation of resident property include .f. drug diversion (taking the resident's medication) .Per review of an initial incident report from the facility to the state agency on 11/10/25, the facility investigated the allegation of drug diversion by LPN [Licensed Practical Nurse] #1 for Residents #1, #2, and #3 regarding discrepancies in controlled substance documentation and medication counts in addition to medication tampering.…
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 · D2026-05-07 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — the official record, unedited, may be distressing
Per interview and record review, the facility failed to ensure one of four sampled employees received medication administration competency prior to administering medications. Findings include:Per record review of Licensed Practical Nurse (LPN) #1's training log, there was no documentation that LPN #1 received a medication administration competency prior to starting her position. She worked for four days starting on 11/4/25 to 11/8/25 with no medication administration competency. The employee was terminated on 11/8/25 for medication diversion of Oxycodone (a medication used for moderate to severe pain), Tramadol (a medication used to treat pain), and Lorazepam (a medication used to treat anxiety). See F602 for more information.Per email notification from the Director of Nursing on 5/7/26, she confirmed that the facility did not have documentation related to medication administration for LPN #1 in writing, I could not find her med pass competency .
- Potential for harm · F2026-02-19 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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 — the official record, unedited, may be distressing
Based on observations and interviews the facility failed to ensure that drugs and biologicals in the medication storage room were within their expiration date. Findings include: Per observation on 02/10/2026 at 2:23 PM, of the medication storage room the following expired medications were noted: 2 bottles of Naproxen Sodium 220mg 50 caps expired 7/20252 bottles of Caltrate Bone Health Advance 60 tablet expired 12/20252 bottles of Cranberry 450mg 100 tablet expired 12/20252 bottles of Vitamin E 180mg/400IU 100 soft gels expired 12/20253 bottles of Vitamin D 10mcg/400IU 100tabsexpired 5/20254 bottles of CoQ10 100mg 30 soft gels expired 5/20251 bottle of Biotene Dry Mouth Rinse 16oz expired 11/20252 boxes of Antidiarrheal 2mg 24 caps expired 7/20251 box of Antidiarrheal 2mg 12 caps expired 10/20254 boxes of Acid Reducer 10mg 90 tabs expired 6/20252 bottles of Bisacodyl 5mg 100 tabs expired 4/2025 1 bottle of stool softener 100mg 100tabs expired 7/2025 Per interview on 02/20/2026 at approximately 2:45 PM, the Unit Manager confirmed that the above medications were expired.
- Potential for harm · E2026-02-19 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure 1 of 6 Licensed Nursing Assistants (LNA) had completed the mandatory 12 hours of annual training, and 2 of 6 LNAs had completed dementia training.Findings include: Per review of employee Human Resources files for permanent and contracted staff, the facility had no evidence of the required 12 hours of annual training for LNA #4, hired on 9/8/20/23. LNA #3 with a date of hire of 12/3/1991 and LNA #5 with a date of hire of 4/16/2018 did not have evidence of dementia training. Per interview on 2/2/26 at approximately 3:30 PM, the RN Nursing Supervisor was unable to provide any evidence that LNA #4 had completed their required 12-hour annual training, and LNA #3 and LNA #5 had received the mandatory dementia training. The RN Nursing Supervisor confirmed that the employee files reviewed contained the only documentation the facility had for staff training.
- Potential for harm · Dcited before2026-02-19 · 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 observation, interview and record review, the facility failed to protect a resident's right to a dignified existence by failing to provide access to the first floor of the building in a manner that provided safety and comfort for 1 applicable resident in the sample (Resident #1). Findings include:On 2/9/26 at 12:22 PM and 2/11/26 at 12:30 PM, Resident #1 was observed eating lunch in his/her room.During an interview with Resident #1, on 2/11/26 at 3:58 PM, s/he indicated that s/he recently went to the hospital, and the facility staff used a stair-chair to transport her/him down the stairs to the ambulance. S/He expressed a fear of being dropped on the stairs while being carried down the stairs in the stair-chair. Resident #1 indicated s/he enjoyed taking the elevator to the 1st floor to meet with social services. Over the past few weeks, s/he was unable to access the 1st floor because the elevator was out of service. Resident #1 reported missing the first-floor visits. S/he stated that fear of the chair prevented him/her from visiting the first floor; and s/he preferred to…
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 · D2026-02-19 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide the Notice of Medicare Non-Coverage at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies were ending for 1 of 3 residents reviewed (Resident #32). Findings include: Per review of Resident # 32's BNP notice, it revealed the resident's services ended on 10/19/25 and the letter was dated 10/20/25 which did not provide the resident with the required 48-hours. Per interview on 2/11/26 at 1:44 PM, The MDS coordinator confirmed that Resident #32 was not notified that their services were ending on 10/19/25 until 10/20/25, which is less than the required 48-hour notification. Per interview on 2/12/26 at approximately 9:25 AM, the Social Services Director stated Resident #32 had been informed in September of 2025 that their benefits would end on 10/19/25 based on a letter the facility had received from the insurance company. Per interview on 2/12/26 at approximately 9:50 AM, the Social Services Director confirmed that neither Resident #32 nor their family were informed at least…
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 · D2026-02-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 that a resident who is unable to carry out activities of daily living [ADLs] without assistance receives the proper level of assistance for nail care for 1 of 2 sampled residents (Resident #10). Findings include:Per review of the facilities policy titled Fingernails/Toenails, Care of with a revision date of 2/18, it states that nail care is daily cleaning and regular trimming. It also identifies that personal protective equipment like gloves should be used as needed.Per observation and interview on 2/9/26 at 5:07 PM, Resident #10's fingernails were observed to be long on both hands. Resident #10 was asked if their fingernails were at their desired length and they stated that their fingernails were poking into their skin when they closed their fist and that they wanted their nails shorter. Resident #10 also stated that they were able to peel one of their long fingernails off.Per interview with a Registered Nurse (RN) on 2/11/26 at 3:46 PM, she stated that the Resident #10's fingernails had been cut.…
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 before2026-02-19 · 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 interview and record review the facility failed to provide culturally competent and trauma-informed care by failing to ensure a care plan identified triggers of past trauma and provided interventions for those triggers for 1 applicable resident in the sample (Resident #8). Findings include:Per review of the facility policy Trauma-informed Care and culturally Competent Care revised 8/22, it states: Resident Care Planning, 2). Identify and decrease exposure to triggers that may re-traumatize the resident. Per record review, Resident #8 has a diagnosis of post-traumatic stress disorder. His/her care plan with a review date of 01/08/26, lists several traumatic events. The care plan goal reveals that the resident will feel safe in her living environment and not exhibit any negative psychosocial impact related to experiencing trauma triggers. Per a document titled Primary Care PTSD Screen, dated 4/17/25, it shows that Resident #8's family provided information on traumas that had affected him/her. The resident was startled easily and was afraid of stairs due to past falls.The care…
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 before2025-11-26 · 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 protect the resident's right to be free from physical abuse by a resident for 1 of 4 residents in the sample, (Resident #1). Findings include:Per record review, Resident #2 has diagnoses that include schizophrenia, major depressive disorder, and anxiety disorder. Per review of Resident #2's care plan, s/he has a care plan focus that reads, Resident has potential for behavior [related to] schizophrenia, and major depressive disorder, and has [history] of aggression towards others, initiated on 8/12/15. Per an email dated 11/26/25 from the Director of Nursing (DON), Resident #2 was involved in a resident-to-resident altercation on 8/12/24, in which Resident #2 had hit his/her roommate. Per record review, a facility reported incident (FRI) was submitted to the State Agency on 8/1/25, with an allegation of physical abuse related to a resident-to-resident altercation that occurred on 8/1/25 between Resident #1 and Resident #2. The submission revealed that Resident #2 was observed sitting in the dining area when Resident #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 · E2024-12-18 · 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 interviews and record review the facility failed to create and implement a policy related to national background checks for their employees. The facility also did not complete national background checks for 19 of the 22 Licensed Nursing Assistants (LNAs) employed by the facility. Findings include: Record review of 5 LNA human resource files revealed there was no evidence of national background checks for 3 of the LNAs sampled. The facility provided an additional list of all LNAs employed at the facility and confirmed that only three of the 22 LNAs had evidence of national background checks. Per interview with the Clinical Lead Registered Nurse (RN) on 12/18/2024 at approximately 12:00 PM, s/he stated that the facility did not complete national background checks for their employed LNAs. Per record review, a memo from [Department of Aging and Independent Living] was sent out to nursing facilities on October 5, 2022, that states, 1. Prior to employing an individual and at least annually thereafter, 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.
Show the remaining 12 citations
- Potential for harm · Ecited before2024-12-18 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 ensure Care Plan interventions were implemented for three residents [Resident #27, Resident #39, and Resident #294] of 21 sampled residents. Findings include: 1. Per review of the medical record for Res. #27, the resident has a Care Plan focus that states Resident is at risk for alteration in skin integrity related to immobility, urinary incontinence, a Care Plan goal that states Resident will be free from alteration in skin integrity and the Care Plan has interventions that include Weekly skin check by Licensed Nurse. All of the aforementioned Care Plans were initiated on 6/27/24 and have not been revised. A review of nursing documentation titled Assessments for Resident #27 showed skin checks done on 6/22/24, 7/23/24 and 8/27/24, only 3 times in 24 weeks. 2. Per review of the medical record for Res. #39, the resident has a Care Plan focus that states Resident is at risk for alteration in skin integrity related to incontinence, immobility, a Care Plan goal that states Resident will be free from alteration in skin…
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 before2024-12-18 · 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 interview and record review, the facility failed to ensure that two residents [#39 & #11] of 21 sampled residents remained as free of accident hazards as possible regarding adequate supervision, implementing interventions to reduce hazards and risks, and assessing interventions for effectiveness. Findings include: 1.) Per record review, Res. #39 was admitted to the facility with diagnoses that include Alzheimer's disease, anxiety disorder, and muscle weakness. A Quarterly Fall Risk assessment dated [DATE] identified the resident as a High Risk for falls, determining the resident was disoriented, had a history of recent falls, with poor vision, poor safety judgement and attempted to get out bed and chairs unsafely. Review of Res.#39's Care Plan identifies the resident as is at risk for falls due to unsteady gait when tired, Alzheimer's disease, and history of falls. Record review reveals Resident #39 had sustained 4 falls in the past 2 months, including 2 falls on back-to-back days on 11/23 & 11/24/24.…
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 · D2024-12-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 21 sampled residents (Resident #20). Findings include: Per observation on 12/17/24 at 1:37 PM Resident #20 unwrapped a gauze dressing covering a wound on their hand. The dressing was visibly soiled with blood. Resident #20 unwrapped the gauze until it was dangling from their hand and touching the floor of the dining area/TV room. At this point a staff Licensed Nursing Assistant [LNA] who was not wearing gloves began to redress the wound with the same gauze. Moments later a staff Registered Nurse [RN] came over to assist. The RN providing care to the resident was also not wearing gloves. Once Resident #20's hand was fully wrapped the staff RN secured the gauze with the original tape which had been stuck to the arm of Resident #20's chair. In an interview with the facility's Director of Nursing [DON] on…
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 · D2024-02-28 · 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 interview and record review, the facility failed to ensure a timely report of an incident of suspected resident-to-resident abuse for 2 of 2 residents (Resident#1 and Resident #2). Findings include: Review of a nursing progress note from 1/8/24 revealed that Resident #1 had approached Resident #5 and started to pull on Resident #5's wheelchair, when s/he told Resident #1 to stop, Resident #1 became angry and slapped Resident #5 on the right arm. A review of the facility's internal investigation file related to this incident on 1/8/24 revealed confirmation from Adult Protective Services (APS) that a report for this incident had been made to that agency however, there was no documentation or confirmation to support that a report had also been made to the State Agency (SA) which is a requirement. An interview on 2/20/24 with the Director of Nursing (DON) revealed that s/he believed s/he had reported the incident to APS and to the SA via an email sent through the facility fax machine. However, when this surveyor reviewed the ASPEN Complaint Tracking System (ACTS) on 2/20/24…
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 before2024-01-02 · 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 interviews and record review, the facility failed to ensure a resident's right to be free from physical abuse for 1 of 3 sampled residents. (Resident #2) Findings include: Resident #1 has resided at this facility since 5/19/22, with diagnoses that include Alzheimer's, severe vascular dementia, and an agitation-induced psychotic disorder. Resident #2 has resided at the facility since 9/19/23 with diagnoses that include end-stage lewy body dementia and parkinsonism. Per record review, a witnessed resident to resident incident occurred between Resident #1 and Resident #2 on 12/9/23 at 5:47 AM. Resident #2 was standing in the doorway of his/her room, Resident #1 walked up to Resident #2 without speaking and hit her/his legs with her/his cane. Resident #2 attempted to move Resident #1 out of his way by grabbing his shirt; both residents fell to the ground. The investigative summary indicates Resident #2 could recall the incident and stated [Res. #1] whacked me three times on both legs [he/she] starts trouble with everyone. A review of statements by two witnesses dated 12/9/23 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 · F2023-10-11 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based upon interview and record review, the facility failed to ensure it used the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week for 52 days from April 1st, 2023, to Oct. 1st, 2023. Findings include: A review was conducted of the facility's staffing schedules from April 1st, 2023, to Oct. 1st, 2023 regarding nursing care provided to the facility's residents. Review of the staffing schedule for April 2023 revealed 10 days with no RN scheduled [4/3, 4/6, 4/10, 4/14, 4/17, 4/20, 4/24, 4/25, 4/26, 4/27]. May 2023 included 6 days with no RN coverage [5/8, 5/21, 5/22, 5/27, 5/28, 5/29], June 2023 included 3 days [6/10, 6/11, 6/28] and July 2023, 7 days [7/4, 7/5, 7/6, 7/15, 7/16, 7/20, 7/29]. August 2023 documented 15 days without RN coverage, including 5 consecutive days [8/1, 8/5, 8/8, 8/10 thru 8/14, 8/17, 8/18, 8/22, 8/26, 8/27, 8/30, 8/31] and September thru October 1st, 2023, included 11 days with no RN scheduled [9/2, 9/3, 9/8, 9/9, 9/10, 9/12, 9/14, 9/22, 9/23, 9/24, 10/1]. An interview was conducted with the facility's Administrator [ADM] and…
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 · E2023-10-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment was maintained for the residents of the facility. Findings include: A tour of the facility was conducted with the Maintenance Director on 10/11/23 at 8:57 AM. Observations of resident environment issues were confirmed by the Maintenance Director during the facility tour and included: room [ROOM NUMBER] & 9- shared bathroom- wood baseboard molding with peeling paint, vinyl wall covering with chipped and curling edges. Areas of the door frame with bare wood or have peeling paint, and there are insulated wires without conduit running above the toilet around the door frame. The bathroom mirror has multiple chipped and bare edges. room [ROOM NUMBER]- the baseboard radiator beneath the window has bent and detached front panels, exposing bare metal radiator fins. room [ROOM NUMBER]- The room's baseboard radiator against the far wall is bent, paint scratched off, and missing the inner…
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 before2023-10-11 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 develop a comprehensive care plan that is individualized and meets the needs identified for each resident based on the diagnosis and medications prescribed for 2 of 20 residents sampled (Resident's #13& #15). Findings include: 1. Resident #13 was admitted to the facility in April 2023 with diagnoses including acute respiratory failure with hypoxia (deprivation of adequate oxygen supply), chronic heart failure, major depressive disorder, and diabetes type II. Medications include insulin orders: Novolog FlexPen 100 unit/milliliter solution use sliding scale three times per day (sliding scale dose is based on the results of current blood sugar level) and Lantus SoloStar 100 units/milliliter inject 40 units. A review of the resident care plan reveals the diagnosis of diabetes, and the use of insulin is not included as a focus area. Diabetes and the use of insulin can result in unstable blood sugar levels that may cause hypoglycemia (low blood sugar) or hyperglycemia (elevated blood sugar) both of which present with signs and…
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 · E2023-10-11 · tag F0657 — failed to keep the care plan current — patternDevelop 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 interview and record review, the facility failed to revise a comprehensive care plan for 2 of 20 Residents sampled (Residents #13 & #25) to include interventions that address Resident #13's impaired vision and request for large print reading material, and invite/educate Resident #25 regarding care plan meetings. 1.Resident #13 was admitted in April 2023 with diagnoses including hypoxia (the deprivation of adequate oxygen supply), chronic heart failure, major depressive disorder, and type 2 diabetes. During an interview with Resident #13 on 10/9/23 at approximately 9 AM Resident #13 mentioned having requested large-print reading materials but having only rarely received such materials. They stated they enjoyed reading but could not indulge in this pastime due to poor eyesight. A review of section B (hearing, speech, vision) of the Minimum Data Set (a system used to assess each Resident for numerous uses including care planning purposes) dated 7/28/23 notes Resident 13's vision is assessed to be highly impaired- object identification in question but eyes appear to follow…
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 · D2023-10-11 · 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 staff Interview and record review the facility failed to follow Pharmacist's recommendations concerning a stop date for psychotropic medication for 1 of 5 residents sampled (Resident #25). Findings include: Per record review Resident #25 has diagnoses that include Major depressive disorder and nightmares. Review of Resident #25's physician orders reveals a current order for Clonazepam 0.5 milligrams (mg) by mouth every 6 hours as needed (PRN) for agitation. (Clonazepam is used as a treatment for panic attacks, insomnia, and symptoms related to chronic anxiety and anxiety disorders). A Consultant Pharmacist Medication Regime review dated 9/1/2023 to 9/17/2023 states attn [attention] Nursing this consult is repeated from July and August as I cannot locate that it had been addressed in response to my consult from last month. The physician authorized to extend the following order by 90 days; Clonazepam 0.5 mg every 6 hours as needed, please update the order in the Electronic Medication Record (EMR) to have an end date of 9/25/23. During interview on 10/10/2023 at 12:12 p.m. the…
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 · D2023-08-09 · 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 on interview and record review, the facility failed to provide pain medication and/or non-pharmacological interventions for 1of 3 residents in the applicable sample (Resident #1). Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] for palliative and end-of-life care related to metastatic breast cancer and pneumonia. S/he died on the morning of [DATE]. A review of the physician's orders reveals an order for Morphine 0.2 ml (milliliters) to be given intramuscularly every two hours as needed for pain. A physician's order dated [DATE] indicates a pain screen was to be performed every shift. Per review of a pain screen from [DATE] at 6:33 AM, it showed that the resident's pain was assessed and medication was given accordingly. Upon further review of the the Medication Administration Record (MAR) and nursing documentation there was no evidence that pain medication was administered to Resident #1. Per review of the facility's internal investigation, a statement provided by 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.
- No harm found · Ccited before2024-05-15 · tag F0550 — failed to protect resident dignity and rights — widespreadHonor 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 each resident has a right to self-determination and access to persons and services outside of the facility by locking all doors to the facility 24 hours a day, seven days a week. By creating a locked facility, there is a failure to ensure the right of each resident to exercise their rights as a citizen (or resident) of the United States or make personal choices about going outside without interference. This can potentially affect all residents of the facility and all visitors, including family, legal representatives, and advocates. During an observation on 5/15/24 at 9:20 AM, this surveyor encountered a barrier to entry. The front door to the facility was locked. The only way to gain access was to press a doorbell, which alerted the staff. A staff member then had to come and physically open the door. The staff member explained that to exit the facility, a staff member would have to access a keypad on the side of the door and enter a code to open the door . Per observation on 5/15/24 at 9:40 AM, another entrance to the…
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
$18,418 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $7,901 — penalty dated 2023-10-11
- $10,517 — penalty dated 2023-10-11
- Medicare payment denial — starting 2024-01-11 for 32 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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FRANCIS E CHENEY JR ESTATE | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 50% | since 02/01/2024 |
| WELLS FARGO BANK, N.A. | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 02/10/2007 |
| RUSSELL, PATRICIA | Individual | 5% OR GREATER SECURITY INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; GENERAL PARTNERSHIP INTEREST; ADP OF THE SNF | — | since 01/01/1999 |
| ATWOOD, DALE | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 07/15/2024 |
| BERGERON, TRAVIS | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/23/2025 |
| CUMMINGS, HOLLY | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/28/2025 |
| RICE, WARREN | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/28/2025 |
| FATIGATI, MARIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/24/2022 |
CMS files one row per role, so the 20 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners 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.
About 96% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.
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 475036. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-19, 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.