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Greensboro Nursing Home

47 Maggie's Pond Road, Greensboro, VT 05841 · Non profit - Corporation · 30 certified beds · (802) 533-7051 Medicare & Medicaid certified

Call the home — (802) 533-7051 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 2026
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
 
Pharmacy
Walgreens6.2 mi
82 Vt Route 15 W · (802) 472-6961 · Call to confirm hours
Grocery
767 Main St · (802) 533-2631 · Call to confirm hours
Park
81 Lauredon Ave · Typically dawn to dusk
Place of worship

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 5 of 5
Long-stay residentspeople who live here 5 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 held steady at 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased11.2%19.3%15.4%better
Long-stay residents who lose too much weight1.2%6.6%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.0%2.4%2.0%better
Long-stay residents with depressive symptoms23.7%13.0%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.1%5.9%3.3%better
Long-stay residents whose ability to walk worsened6.3%17.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication6.9%16.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%97.5%95.3%typical
Long-stay residents with pressure ulcers1.1%5.3%4.7%better
Long-stay residents with worsening bladder/bowel control26.7%26.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table5.2%19.9%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.1%1.4%better
Long-stay hospitalizations per 1,000 resident days1.181.521.67better
Long-stay outpatient ER visits per 1,000 resident days2.592.881.80worse

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.

45.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.1%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
0.48U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.28hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 35% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF45.1%CMS range 33.1–58.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 6.8–16.410.7%Oct 2022–Sep 2024no 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 dischargenot 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 dischargenot 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 dischargenot 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 identifiednot 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 settingnot 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 dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot 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 worsenednot 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 hospitalizationnot 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 SNFs1.111.02Oct 2022–Sep 2024CMS 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

0.78
RN hours/ resident / day
0.70
LPN hours/ resident / day
2.63
Aide hours/ resident / day
4.11
Total nurse hours/ resident / day
0.48
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 30 beds and averages 26.4 residents a day — about 88% occupied, or roughly 4 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 4.11 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.78 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.63 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 3.66 hrs/resident/day on weekends vs 4.29 on weekdays — 15% thinner on weekends. RN hours go from 0.90 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

4
deficiencies at the latest standard inspection (2026-05-20)
9
at the previous standard inspection (2025-06-11)

Deficiencies are fewer than at the previous inspection — improving. 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.

ABCDEFGHIJKL

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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Fcited before2026-05-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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, interview, and policy review, it was determined that the facility failed to store food in accordance with professional standards for food service safety. This has the potential to impact all residents. This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey dated 6/11/25. Findings include: During observations and interview on 5/19/26 at 2:49 PM, a dietary staff member confirmed there were no expiration dates for the following items:-Two six-pound ten-ounce cans of cream style corn in dry storage.-One six pound can of mandarin oranges in a light syrup in dry storage.-Twelve ounces of a turkey gravy mix in dry storage.-One gallon of buttermilk ranch dressing in the refrigerator.-One gallon of creamy Italian dressing in the refrigerator.-One sixteen-ounce container of a beef base in the refrigerator.During observations and interview on 5/20/26 at 10:51 AM with the kitchen manager, she stated that there are some food items that don't arrive with an expiration date. The kitchen manager then confirmed 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-20 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 interview and record review, the facility failed to ensure a resident's medical record clearly communicated the resident's code status for 1 of 17 sampled residents (Resident #4). Findings include:Per record review, Resident #4 did not have a COLST (Clinician Orders for Life-Sustaining Treatment). The resident's profile page in the Electronic Health Record (EHR) stated Resident #4 was a full code. Resident #4 has a care plan intervention dated 2/26/26 that stated the resident was a DNR/DNI (Do not resuscitate/Do not intubate) and that care limiting orders were in place if the resident were to be found unconscious, without a pulse, or not breathing. Additionally, there was no code status order. A provider note from 3/12/26 states the resident code status is a full code (Cardiopulmonary Resuscitation and Intubation).Per interview with Resident #4's responsible party on 5/18/26, she reported that Resident #4 has a code status of a DNR.Per interview with the Nurse Manager on 5/19/26 at 9:09 AM and 10:04 AM, she confirmed that there should be a code status order for the 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 one resident [Resident #28] of 17 sampled residents remained free from physical abuse regarding a resident-to-resident altercation. This is a repeat deficiency for this facility, with the violation cited during a previous partial survey dated 12/22/25. Findings include: Per record review, Resident #26 has diagnoses that include dementia with behavioral disturbance, visual hallucinations, Alzheimer's disease, anxiety disorder, and cognitive communication deficit. Review of Resident #26's Care Plan reveals the resident is identified as having the potential to be physically aggressive to other resident's related to Dementia, history of aggressive behaviors: resident to resident- [Resident #26] struck another resident [8/16/2024].Resident #26's Care Plan also identifies the resident as having a behavior problem related to inability to accept minor and major changes in h/her environment, poor impulse control manifested by pacing, yelling, history of hallucinations, swearing, muttering to self, refusing to participate in…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-20 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop 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 via background checks had been implemented for 2 of 5 employees (LNAs #1 and #2). Findings include:Per record review of the facility policy titled Background Screening Investigations no date, it states Our facility Conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents ( direct access employees).Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment.Per record review, LNA (Licensed Nursing Assistant) #1 was hired on 7/8/25 and LNA #2 was hired on 8/29/25. LNA #1 and LNA #2 did not have [NAME] State Criminal background checks prior to 5/19/26.Per interview on 5/20/26 at 10:02 AM, the Administrator confirmed that the [NAME] State Criminal background checks had been completed yesterday,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-03-30 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    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 documentation was accurate and true for one of three sample residents (Resident #1). Findings include:Per record review, Resident #1 has diagnoses of COPD [Chronic Obstructive Pulmonary Disease, Type II Diabetes, Atrial fibrillation [a condition in which the heart beats irregularly] and Parkinson's disease. Resident #1 had a BIMS [Brief Interview of Mental Status] score of 3 as of 1/15/26 indicating cognitive impairment; was dependent on staff for ADLs [Activities of Daily Living] and hygiene; and was at risk for falls related to deconditioning, gait/balance problems, and Parkinson's.Per review of a nursing progress from 2/19/26, it states, Pt [Patient] was trying to transfer self from [his/her] wheelchair to without assistance. This writer was in the room with [his/her] roommate and witnessed this. Pt stood up and sat back down on the floor on [his/her] rear. Once on [his/her] rear [s/he] started turning towards the nurse and laid out. Stated I was going to bed, but the floor misses me laughing and cracking jokes.…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-22 · tag F0552 — pattern
    Ensure 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 three of three residents sampled (Resident#1, #2, and #3) were able to be informed to make treatment decisions by failing to have the resident or resident representative sign consent for prescribed psychotropic medication. Findings include:Per review of Resident #1's medical record, Resident #1 has a BIMS [Brief Interview of Mental Status] score of 3 as of 10/27/25 indicating they have cognitive impairment. Resident #1 is dependent on staff for ADLs [Activities of Daily Living] and hygiene. S/he has medical diagnoses of Alzheimer's Disease and peripheral vascular disease. On 12/11/25 Resident #1 was prescribed Quetiapine fumarate [an antipsychotic medication used to treat symptoms of psychosis] 25 mg [milligram] tablet: Give 25 mg by mouth one time a day related to Alzheimer's Disease with early onset.Per review of Resident #2's medical record, s/he has a BIMS of 0 as of 12/16/25, indicating severe cognitive impairment. They have medical diagnoses of Alzheimer's disease, epilepsy and depression. Resident #2 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-22 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse by a visitor for 2 of 3 sampled residents (Resident #1 and Resident #3). Findings include:Per record review of Resident #1, a progress note written by the Social Worker on 12/17/25 states, The Central Supply Manager came to staff and reported that this resident's [spouse] was being verbally abusive to this resident. Another family member of a different resident came to staff and told our DON [Director of Nursing] that this residents [spouse] confronted another resident and was verbally abusive. The staff member, central supply manager has put in a report to APS [Adult Protective Services].Per record review of Resident #1, a progress note written by the DON on 12/17/25 states, Visitor came to this writer and ADON [Assistant Director of Nursing] at 1:25 PM to report that resident's [spouse] was in the hallway next resident's room [ROOM NUMBER] when [Resident #3] was walking by with [her/his]…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-22 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 interview and record review, the facility failed to report incidences of abuse for 2 of 3 sampled residents (Resident #1 and Resident #3). This is a repeat deficiency for this facility, with violations cited during the previous recertification surveys dated 6/11/25. Findings include:Per record review of Resident #1's chart, progress note written by the Social Worker on 12/17/25 states, The Central Supply Manager came to staff and reported that this resident's [spouse] was being verbally abusive to this resident. Another family member of a different resident came to staff and told our DON [Director of Nursing] that this residents [spouse] confronted another resident and was verbally abusive. The staff member, central supply manager has put in a report to APS [Adult Protective Services].Per record review of Resident #1's chart, progress note written by the DON on 12/17/25 states, Visitor came to this writer and ADON [ Assistant Director of Nursing] at 1:25 PM to report that resident's [spouse] was in 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-22 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 thoroughly investigate an allegation of verbal abuse, send a summary of the investigation to the State Survey Agency, and take appropriate corrective action for 2 of 3 sampled residents (Resident #1 and Resident #3). Findings include:Per record review of Resident #1, a progress note written by the DON on 12/17/25 states, Visitor came to this writer and ADON [Assistant Director of Nursing] at 1:25 PM to report that resident's [spouse] was in the hallway next resident's room [ROOM NUMBER] when [Resident #3] was walking by with [her/his] walker. [Resident #1's spouse] per visitor statement got into [Resident #3's] space and pointed [her/his] finger at [Resident #3] and stated [He/she] is my [spouse] and you need to leave [him/her] alone. I do not want you around [him/her] at all. Per visitor [Resident #3] started to tear up and visitor intervened and asked [Resident #3] to walk into the main dining area and have a seat. [Resident #1's spouse] then took…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-06-11 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to ensure medications were removed from the medication storage room when expiration dates were reached. Findings include: Per observation on [DATE] at 1:18 PM of the medication cart, an 8 oz [ounce] Spectrum Hand Sanitizer was found with an expiration date of [DATE]. A package of (3) Sani-cloth germicidal disposable wipes were found in the medication cart with an expiration date of 1/25. On [DATE] at 1:20 PM LPN#1(Licensed Practical Nurse) confirmed that these medications/biologicals were expired and stated, I'll get rid of these.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Fcited before2025-06-11 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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. Findings include: Per observation on 6/11/25 at 9:08 AM, (4) 1 pound 12 ounce packages of cream of wheat were found in the dry storage with an expiration date of 4/1/25. On 6/11/25 at approximately 9:10 AM the food service staff member confirmed these were expired stating, Sorry, I'll get rid of these. Per observation of the kitchen on 6/11/25 at approximately 9:08 AM, there was melted plastic on the wall behind the toaster. The food service worker confirmed the condition of the wall 6/11/25 at approximately 9:10 AM, stating, It's been here for about a year .It's from the toaster. Per observation on 6/11/25 at approximately 9:12 AM a room with two large freezers had hats hanging from pipes on the ceiling. Per observation there were also coats hung up on the wall, and a dirty mop bucket with mop water in it on the floor. The food service staff member confirmed the condition of the freezer room on 6/11/25 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-06-11 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to implement an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections related to Legionella prevention. Findings include: Per record review of the facility's water management program, there was no risk assessment to identify areas in the building that could grow and spread Legionella in the facility water system. Per the facility's Legionella Water Management Program policy [Revised 7/2017] states, 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease .The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: (1) Storage tanks; (2) Water heaters (3) Filters; 4) Aerators; (5) Showerheads and hoses; (6) Misters, atomizers, air washers and humidifiers ; (7) Hot tubs; (8) Fountains; and (9) Medical devices such as CPAP [Continuous…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent 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 that residents are free from chemical restraints for one of three sampled residents (Resident #4) as evidenced by administration of medications without proper indication for use and no discontinued date. Findings include: Per record review, Resident #4 has diagnoses that include: Alzheimer's dementia, major depressive disorder, and anxiety disorder. The MDS [Minimum Data Set, a comprehensive assessment of each resident's functional capabilities] record review assesses the resident is dependent on staff for activities of daily living, hygiene, and needs assistance with food and fluid intake. Per record review of a physician order on 4/10/25, it states please continue Ativan (generic name is lorazepam used to treat anxiety) in setting of hospice and comfort directed care to reduce anxiety/agitation. Risks of mood exacerbation if discontinued. Per record review there is no end date for the Lorazepam. The Director of Nursing (DON) entered the order for the Lorazepam on 4/16/25 into the electronic health record (EMR) as…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-11 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review the facility failed to ensure that an allegation of abuse was reported to facility administration, Adult Protective Services, and the State Licensing Agency. Findings include: Per record review Resident #77 was admitted in May of 2025 and began exhibiting aggressive behaviors requiring staff intervention and emergent transfer to the hospital. Review of the Accident/Incident witness interview tool dated 5/22/2025 that was completed by a Licensed Nursing Assistant (LNA) revealed that on 5/8/2025 she saw another LNA hit Resident #7 with a package of wipes. The interview tool states that the Resident was hitting the LNA and that the Resident stopped for a moment and lunged at the LNA. On 6/10/2025 at 2:15 PM the facility Administrator confirmed that the LNA who reported witnessing the other LNA hit Resident #77 with the package of wipes on 5/8/2025 failed to report it until 5/22/2025 and that she should have reported it at the time it occurred.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 one of two residents sampled (Resident #77) or the resident's representative with a bed-hold notice after discharge to the hospital. Findings include: Per record review Resident #77 was admitted on [DATE] and was transferred to the hospital on 5/9/2025. Per review of the Bed Policy [No date of revision] states, It is the policy of [the facility] to offer all residents who leave the facility for transfer to a hospital the right to return as soon as a bed is available, providing the nursing home is able to meet the medical needs of the resident and that the welfare of other residents will not be adversely affected .A copy of this policy would be sent to all residents or responsible party) at the time of transfer or leave, and documentation of such notification will be satisfied by any entry in the medical record indicating notification of the bed hold policy has been made. Further record review revealed that there was no documented evidence that…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 interviews, observations, and record review, the facility failed to review, revise, and implement resident care plans for 1 of 5 residents in the applicable sample related to falls (Residents #4). Findings include: Per record review, Resident #4 has diagnoses that include: Alzheimer's dementia, major depressive disorder, and anxiety disorder. Review of the Resident's last MDS [Minimum Data Set, a comprehensive assessment resident's functional capabilities] dated 6/8/2025 reveals that the resident is dependent on staff for activities of daily living, hygiene, and needs assistance with food and fluid intake. Nursing Progress notes dated 9/4/24, 11/1/24, 1/13/25, 2/26/25, and 5/8/25 document that the Resident had falls on each of the dates. Per policy review of Falls and Fall Risk, Managing, under section Resident-Centered Approaches to Managing Falls and Fall Risk (Last revised 2018) it states The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 interview and record review, the facility failed to coordinate and implement hospice care measures for 1 of 1 sampled resident (Resident #20). Findings include: Per record review, a Phycisian's order dated 6/10/2025 states Caledonia Home Health and Hospice services phone# . There were no other orders for hospice care, no progress notes from hospice, no updates to his/her care plan mentioning hospice care or interventions, and no way to identify when hospice provided care located in the Resident's medical record. Per review of the facility's Hospice Policy it states, .it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs .communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day .Coordinated care plans for residents receiving hospice services will include the most recent hospice plan 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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 act on a pharmacist's Medication Regimen Review (MMR) that was then ordered by a physician for 1 of 5 Residents in the sample (Resident #20). The facility also failed to ensure that monthly MMRs were completed for 1 of 5 Residents in the sample (Resident #9). 1. Per record review there was no evidence that Monthly Medication Regimen Reviews were completed for Resident #9 for the month of March of 2025. Per interview on 6/11/2025 at 10:30 AM the Director of Nursing (DON) stated that the pharmacist sends the MMRs to her and she reviews them then follows up with the physician. The DON confirmed that there was no documented evidence in the record and that she could not produce the MMRs for March of 2025. 2. Per record review, on 11/11/2024, Resident #20 had a Medication Regimen Review (MMR) completed where the pharmacist identified the need for a one time digoxin level test. The physician reviewed and signed the document stating Ok to order x1 now and again yearly with their signature dated 11/14/2024. Per record review, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to obtain laboratory services when ordered by a physician for 1 of 5 residents in the sample (Resident #20). The facility also failed to obtain laboratory results and promptly notify the ordering physician of laboratory results for 1 of 5 residents in the sample (Resident #9). Findings include: 1. Per record review the consulting pharmacist performed a Medication Regimen Review for Resident #9 dated 5/19/2025 states Resident has the following labs drawn on 5/12/2025 - BMP (basic metabolic panel) I do not see the results in Resident's chart yet. Please obtain & scan them into [Point Click Care, PCC is an electronic Health Record] for me to review next month. Further record review revealed that there was no evidence that the Resident's BMP results were obtained, reviewed, or acted on. Per interview on 6/11/2025 at 10:30 AM the Director of Nursing (DON) stated that the pharmacist sends the MMRs to her, she reviews them then follows up with the physician. The DON stated that she was unable to locate lab results for the 5/12/2025…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-07-10 · tag F0726 — failed to have competent, trained nursing staff — widespread
    Ensure 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 — an excerpt from the official record, may be distressing

    Based on interview, staff education record review, and the facility assessment, the facility failed to ensure that licensed nurses and licensed nursing assistants were assessed for competency and skill sets to provide care and respond to each resident's individualized needs. This has the potential to affect all residents. Findings include: Per review of 3 sampled Licensed Nursing Assistant's (LNA's) employee training files revealed 1 LNA file that lacked evidence of any competency evaluation required to demonstrate that they had the necessary skills to provide care needed. Review of the education and competency file for 3 Licensed Nursing Assistants (LNAs) revealed 1 LNA had no evidence that they were assessed for competency in the skills needed to care for the residents. 3. Review of the education and competency file for 3 Licensed Practical Nurse (LPN) revealed that 2 of the 3 had no evidence of annual competency evaluation of the skills needed to care for the residents. Per interview on 7/10/24 at 1:21 PM, the Administrator confirmed that there was no evidence of competency…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-07-10 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on staff interviews and record review, the facility failed to employ either a full-time dietitian and/or a part-time dietitian; and a certified Director of Nutrition Services. Findings include: Per review of the Dietary Manager's employee file there was no documented evidence of the certification required for Dietary Managers. An interview was conducted with the facility's administrator on 7/9/24 at approximately 4:10 PM. The administrator stated that the facility does not have a full-time dietitian. S/he also confirmed that the facility does not have a certified Director of Nutrition Services.

    Nutrition and Dietary Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Fcited before2024-07-10 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, the facility failed to establish and maintain a water management program to minimize the risk of Legionella ( a bacteria that causes inflammatory conditions of the lungs) and other opportunistic pathogens in building water systems that would include an assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas Acinetobacter) could grow and spread; and measures to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them. Findings include: Per interview on 7/10/24 at approximately 11:00 AM, the Director of Nursing (DON), who is the Certified Infection Preventionist, indicated s/he did not have knowledge of a water management program specific to this facility. The maintenance director and the administrator were also asked for evidence of the program. Both confirmed they had no knowledge of the existence of such a program and confirmed that an assessment of the building had not been performed and a program to minimize the risk of Legionella and other opportunistic…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-10 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for 1 applicable resident (Resident #13), the facility failed to protect the resident's privacy and treat the resident with respect and dignity. The facility also 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, 7 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. Findings Include: 1. Per record review, Resident #13 has resided at this facility since [DATE]. S/he has a BIMS (Brief Interview for Mental Status) score of 3, which is indicative of severe cognitive impairment. Her/his diagnoses include dementia (a loss 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
BAUM, ELIZABETHIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2023
HICKEY, ROSALYNDIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 11/01/2014
HUNT, ILAIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2024
LAMMERT, SARAHIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2023
ROGERS, WILLIAMIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2021
STONE, JOHNIndividualCORPORATE DIRECTORsince 03/24/2022
BRAUN, AMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/13/2025
MORGAN, SARAHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2015

CMS files one row per role, so the 15 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$4.1M
Net patient revenuemost recent cost report
+0.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 0%Medicare 13%Other / private 87%

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$449per resident / day
operating cost
$13,652per month
≈ monthly operating cost
$451per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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

Paying with Medicaid

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.

Typical monthly cost in Vermont
$14,113/mo
Nursing home (semi-private)
$15,528/mo
Nursing home (private)
$8,597/mo
Assisted living

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 475043. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-20, 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.

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