Gill Odd Fellows Home of Vermont
8 Gill Terrace, Ludlow, VT 05149 · Non profit - Corporation · 46 certified beds · (802) 228-4571 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (20% vs 45% nationally) — better care continuity
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (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 (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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 | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 3 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 25.6% | 19.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.4% | 6.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.9% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.7% | 2.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.4% | 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 | 0.6% | 5.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 17.3% | 17.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 2.4% | 16.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.1% | 5.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.0% | 26.8% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 42.0% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 69.6% | 78.5% | 79.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.85 | 1.52 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.58 | 2.88 | 1.80 | better |
‡ 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.
56.3% 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 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 25.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 20 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 29% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 56.3%CMS range 44.5–67.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 6.4–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 25.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 30.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 30.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 3.7–12.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.67 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 46 beds and averages 41.6 residents a day — about 90% 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 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.99 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.34 is below 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 3.11 hrs/resident/day on weekends vs 3.67 on weekdays — 15% thinner on weekends. RN hours go from 1.06 to 0.82 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 20% is below the national median of 45%.
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 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · F2026-02-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards of food service safety. Findings include:Per observation during the initial tour of the kitchen on 2/23/26 at 10:13 AM a 5-ounce box of cornbread muffin mix with an expiration date of 11/5/25, and a 5-ounce bag of tortilla strips with a date opened on 1/7/26 with no expiration date on the packaging, were identified in the dry storage area. In the freezer, there was a bag of 24 frozen fish sticks in a bag open to air, with no date on the package, as well as one bag containing 3 frozen pie crusts that was opened without an expiration/opened date. Per interview with [NAME] # 1 on 2/23/26 at 10:40 AM, they confirmed these items did not have dates, were open to air, and/or expired.Per observation on 2/23/26 at approximately 12:03 PM [NAME] # 2 was observed in the kitchen without a hair restraint while cooking, assembling, and plating food.Per interview on 2/23/26 at approximately 12:15 PM [NAME] # 2 stated staff in the kitchen do not need a hair…
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 · E2026-02-25 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews the facility failed to provide a system that enables residents to file an anonymous grievance. Findings include:Per observation on 2/25/26 at approximately 9:20 AM a grievance procedure was posted outside the dining room in the lobby. The grievance posting did not contain information regarding how to file an anonymous grievance. The posting stated if a resident has a concern or complaint to speak with the grievance officer/ Social Service Director or the Director of Nursing and lists their phone numbers. There were no blank grievance forms or a drop box to submit grievance forms observed.Per interview on 2/25/26 at 10:06 AM the Social Worker confirmed that the residents file grievances with either the Social Worker or the Director of Nursing. The Social Worker stated he did not know how a resident would file a grievance anonymously as they would have to ask a staff member for the form and submit the form back to a staff member. The Social Worker stated that blank grievance forms are located in the social work office and residents do not have…
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 before2026-02-25 · tag F0880 — failed to prevent and control infections — patternProvide 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, interview, and record review, the facility failed to follow standard infection control practices during medication administration by not practicing appropriate hand hygiene during preparation and administration of medications and the presence of a staff member's personal drink on 1 of 2 medication carts. This is a repeat deficiency for this facility, with violations cited during the previous three re-certification surveys dated 1/11/23, 1/24/24, and 3/19/25. Findings include:During a medication administration observation on 2/24/2026 at 9:20 AM, a Registered Nurse (RN) put on gloves and poured medications into individual 30 cc (1oz) cups. He accessed the nurse's station refrigerator twice to obtain pudding to use for crushed medication administration. The RN did not remove his gloves or perform hand hygiene before continuing to prepare medications for administration. The RN crushed the pills and mixed them with the pudding. Without taking his gloves off and performing hand hygiene the RN carried the cups with his gloved fingers inside the medication cups 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 · D2026-02-25 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to revise a plan of care to reflect an identified concern of a decline in mobility for 1 of 13 sampled residents (Resident #27). Findings include: Per a record review, Resident #27 has a diagnosis of progressive multiple sclerosis (MS). Per observation on 2/24/25 at 9:45 am, Resident #27 was noted to be dragging his/her right foot while attempting to self-propel his/her wheelchair, inhibiting his/her movement. There was no leg rests installed on his/her wheelchair. Per a record review, Resident #27's care plan intervention for wheelchair mobility (last revised on 1/12/25) did not address the use of wheelchair leg rests when in his/her wheelchair to improve his/her ability to self-propel. Per an interview with LNA #1 on 2/24/26 at 3:35 pm, she was aware that sometimes Resident #27 did have a problem self-propelling in his/her wheelchair because [his/her] feet get tangled up. She stated she had reported it to a nurse. Per an interview on 2/24/26 at 3:45 pm with an OTR (Occupational Therapist, responsible for…
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 · D2026-02-25 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview the facility failed to ensure medication error rates were less than 5% or greater. There were 31 medication administration opportunities, 29 were observed to be given and 2 were omitted, resulting in errors for 2 of 6 sampled residents (Resident #14 and Resident #16). The total error rate for all observations was calculated at 6.45%. Findings include:During a medication administration observation on 02/24/2026 at 9:50 AM, the Registered Nurse (RN) administered medications to Resident #16 and stated, That's all for [Resident #16].Per record review of the Medication Administration Record (MAR) it was noted that one prescribed medication (docusate sodium, stool softener) was documented as administered by the RN but was not observed to be given. During a medication administration observation on 2/25/2026 at 9:40 AM, the RN administered medications to Resident #14 and confirmed that all medications for Resident #14 were given. Per record review of the (MAR) it was noted that one prescribed medication (Miralax Powder [laxative solution])…
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 · D2026-02-25 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 2 medication carts. Findings include: Per observation on 2/23/26 at 11:44 AM, a medication cart in the long hallway between room [ROOM NUMBER]-119 was unlocked. There was not a nurse or a staff member present within sight of the medication cart. Residents were observed self-propelling in this hallway towards the dining room. At 11:56 AM, an RN (Registered Nurse) was observed walking from the nurse's station around the corner towards the medication cart.Per interview with this RN on 2/23/26 at 11:57 AM he confirmed the medication cart contained over the counter medications, syringes, topical medications, injectables, prescribed resident specific medications and narcotics in a separate locked compartment. The RN confirmed the cart was left unlocked while unattended and that it should have been locked.Per interview on 2/24/26 at approximately 2:30 PM, the DON (Director of Nursing)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-06 · 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 that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services) in accordance with State law through established procedures for 1 resident [Resident #1] of 3 sampled residents. Findings include:Per review of Physician Assessment Notes for Resident #1, dated 7/17/25 and 7/24/25, Resident #1 has a primary medical history of dementia, depression and insomnia, does not evidence any signs of cognitive impairment, h/her insight and judgement are good/intact, there are no indications today of audio hallucinations or visual hallucinations or delusions, no indication of risk to h/herself or others, and is a good historian.An interview was conducted with Resident #1 on 8/6/25 at 9:30 AM. The resident stated A couple of nights ago a [resident] came into my room and hit me 7 times with my…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-06 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to have evidence that all alleged violations are thoroughly investigated regarding 1 resident [Resident #1] of 3 sampled residents.Findings include:Per review of Physician Assessment Notes for Resident #1, dated 7/17/25 and 7/24/25, Resident #1 has a primary medical history of dementia, depression and insomnia, does not evidence any signs of cognitive impairment, h/her insight and judgement are good/intact, there are no indications today of audio hallucinations or visual hallucinations or delusions, no indication of risk to h/herself or others, and is a good historian.An interview was conducted with Resident #1 on 8/6/25 at 9:30 AM. The resident stated A couple of nights ago a [resident] came into my room and hit me 7 times with my walking stick [Resident picked up a grabber/reaching tool on an end table next to a television and held it up]. I was hit on the back [left] side of my head and my shoulder. I have no idea what has happened since. They may…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-19 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 as needed [PRN] orders for psychotropic drugs are limited to 14 days for 3 of 19 sampled residents [Resident #37, #21, and #22] unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days and documents their rationale. Findings include: 1.) Review of Physician Orders for Resident #37, dated 3/18/24, reveal an order for Lorazepam [an anti-anxiety psychotropic medication] 0.5 milligrams- give one tablet by mouth every 8 hours as needed for 365 days. Per review of Resident #37's medical record, there was no documentation of a Physician rationale for ordering the PRN psychotropic medication for longer than the 14 day limit. 2.) Review of Physician Orders for Resident #21, dated 3/2/25, reveal an order for Ativan [brand name for Lorazepam] Oral Tablet 0.5 milligrams-Give 2 tablet by mouth every 2 hours until 8/19/2025 [order is > 5 months]. Per review of Resident #21's medical record, there was no documentation of a Physician rationale for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-19 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, it was determined that the facility failed to maintain facility-wide systems for the prevention, identification, and control of infection and communicable diseases of residents, staff, and visitors through surveillance, staff training, and following established policies and procedures related to proper use of personal protective equipment (PPE) specifically Enhanced Barrier Precautions (EBP) for 4 of 4 of the applicable sample (Residents #7, #11, #10, and #38). Findings include: Per observation on 3/19/2025 at approximately 2:00 PM, a Licensed Nursing Assistant (LNA) was observed emptying an indwelling catheter bag containing urine without wearing a protective gown. When asked if gowns were available, she explained that the staff are not instructed to wear a gown when emptying urine from a catheter bag. Per observation on 3/19/2025 at approximately 9:00 AM, a facility tour revealed no signage or indication to the staff that Enhanced Barrier Precautions (EBP) were required for residents with indwelling medical devices (urinary…
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 14 citations
- Potential for harm · D2025-03-19 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to notify the physician of 1 resident [Resident #28] of 19 sampled residents regarding physician orders not followed related to medications not administered as ordered. Findings include: Per record review, Resident #28 was admitted to the facility with diagnoses that include Parkinson's Disease [Parkinson's disease (PD) occurs when brain cells that make dopamine, a chemical that coordinates movement, stop working or die. PD causes tremors, slowness, stiffness, and walking and balance problems]. Review of Physician Orders reveals the resident was ordered the medication Amantadine- give 1 capsule by mouth in the evening related to Parkinson's Disease. Review of Res.#28's Medication Administration Record for January 2025 records Resident #28 did not receive the Amantadine medication as ordered on 6 days, including 5 consecutive days. [1/23 - 1/27/25, 1/29/25]. Nursing Progress notes record on 1/23/25 the medication is Unable to give, incorrect dose with no further documentation. On 1/24/25 Nursing Progress notes read Spoke with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that 1 [Resident #43] of 4 sampled residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experience and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Findings include: Per review of the facility's Trauma-Informed Care policy [approval date 3/5/24]: The facility must ensure that residents receive culturally competent care in accordance with professional standards of practice and accounting for resident experiences and preferences to eliminate triggers that may harm the resident. Policy procedures include: Assessments, screening and early identification begins with the resident's admission to the facility and periodically with behavioral and/or condition changes, and The resident's comprehensive care plan will reflect goals and approaches to address mental health, including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-12 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide services that meet professional standards of quality regarding proper actions following a fall which resulted in harm for one resident [Res.#1]. Findings include: Per review of the Lippincott Manual of Nursing, The standards of care for professional nursing include assessment, diagnosis, implementation and evaluation. Departure from Standards of Care include: Failure to adhere to facility policy or procedural guidelines, failure to monitor or observe a patient's clinical status adequately, failure to make prompt, accurate entries in a patient's medical record. [Lippincott Manual of Nursing Practice-11th Edition 2018] An interview was conducted with the Director of Nursing [DON] on 11/12/24 at 2:22 PM. The DON stated on 10/26/24 at approximately 4:00 AM, s/he received a voicemail from a Licensed Practical Nurse [LPN] at the facility. The DON provided a printed transcript of the voicemail. Per review of the transcript, the LPN reported a Licensed Nurse's Aide [LNA] was pushing Res.#1 in a wheelchair down a hallway.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-12 · 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 — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure nursing staff possessed and implemented the appropriate competencies and skills sets to provide nursing and related services to assure resident safety for one resident [Res.#1]. Findings include: An interview was conducted with the Director of Nursing [DON] on 11/12/24 at 2:22 PM. The DON stated on 10/26/24 at approximately 4:00 AM, s/he received a voicemail from a Licensed Practical Nurse [LPN#1] at the facility. The DON provided a printed transcript of the voicemail. Per review of the transcript, the LPN reported a Licensed Nurse's Aide [LNA #1] was pushing Res.#1 in a wheelchair down a hallway. The LPN stated Res.#1 had a fall .kind of fell out of the wheelchair and [s/he] didn't land hard. The DON reported to the State Agency that s/he did not know or was not told that Res.#1 suffered a fall, despite confirming during interview that the statements in the voicemail received on 10/26/24 met the facility's definition of a fall. Per interview with the ADON on 11/12/24, the ADON confirmed that s/he conducted Fall…
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 · Fcited before2024-01-24 · tag F0726 — failed to have competent, trained nursing staff — widespreadEnsure 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 record review and interview the facility failed to ensure that nursing staff were assessed for skills competency upon hire and annually, based on the care needs of the residents who reside in the facility. Findings include: Per review of employee training and competency records, nursing staff did not have evidence of annual skills competency evaluations. An employee record for a Registered Nurse (RN) who was hired on 11/20/23 had a Competency Checklist dated 12/7/23. This checklist lists various skills and offers instructions as follows: 1. Observe each skill below 2. Provide a Pass or fall rating 3. Place an N/A for any skill that doesn't applying current resident population. Any skill failed will need follow up. This checklist was signed by the RN who assists with staff education on 12/7/2023. However, there were no actual competencies present in the file. A Licensed Practical Nurse (LPN) hired on 2/4/2021 had competencies completed in 2023 for hand washing and IV's. However, there was no Competency Checklist completed, and there were no other competency reviews for 2023…
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 before2024-01-24 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure that professional standards of practice were followed for 3 of 26 residents in the sample. (Resident #36) related to assessment and monitoring after a choking episode, and (Resident # 188 and Resident #7 ) related to safe administration and monitoring of diabetic medications and blood glucose monitoring. Findings include: 1. Per record review Resident #36 experienced a choking episode which required oropharangeal suctioning. A SBAR (Situation, Background, Assessment, Request form) Note written by the Registered Nurse (RN) on duty on 9/21/2023 states LNA (Licensed Nurse Assistant) brought resident to me, from Lunch room, to Nurse station. Resident was breathing rapidly and pointing to [his/her] mouth, unable to speak or cough. This RN obtained code cart and used suction and yankeur to clean mouth back of throat and illicit cough which produced chocolate milk. Resident immediately felt better. The progress note states that both the Director of Nursing and the Physician were notified however, there were no…
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 · D2024-01-24 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
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 provide reasonable accommodations of needs and preferences related to a mattress for 1 of 26 residents sampled. (Resident #7). Findings include: Per telephone interview on 1/23/24 at 8:38 AM with Resident #7's family member he/she has been advocating for Resident #7 to receive an air mattress because of the resident's back pain, but the facility refuses to provide one. The family member stated the reason provided is that the resident does not qualify for an air mattress as he/she can move in bed independently and that Resident #7 does not have any open skin. The family member states that she has told them that s/he is willing to pay for the air mattress and the facility just needs to work with her/him to get it. During an interview on 1/23/24 at 9:09 AM Resident #7 was observed sitting in a recliner chair in his/her room. Resident #7 stated that s/he sleeps in the chair all the time because his/her bed is not comfortable. Resident #7 also said that when s/he requested a new mattress the facility did provide…
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 · D2024-01-24 · tag F0626 — isolatedPermit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accept a resident back after being transferred to an acute care facility for evaluation for 1 of 26 residents sampled. (Resident #33). Findings include: Per the record review Resident #33 was admitted to the facility on [DATE] for Long Term Care with diagnoses of Parkinson's and Dementia with Psychotic disturbance. Progress notes written between 9/19/23- 9/21/23 reveal that Resident #33 began exhibiting aggressive behaviors, was placed on 1:1 supervision for safety, and was then transferred to the hospital on 9/21/23. A review of the hospital Discharge summary dated [DATE] reveals that Resident #33 was seen in the emergency department (ED) and the initial workups was unremarkable. The facility refused to allow Resident #33 to return and s/he stayed in the ED for a week. A Social Services progress note written on 9/19/23 states that the Director of Social Services (DSS) spoke to Resident #33's spouse and explained that the facility could…
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 · D2024-01-24 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 comprehensively assess a resident's physical needs related to requiring a Continuous Positive Airway Pressure Machine (CPAP) for 1 of 26 residents sampled. (Resident #188). Findings include: During an interview with Resident #188 on 1/22/23 5:12 P.M. a Continuous Positive Airway Pressure Machine (CPAP) was noted on the resident's bedside table. (This is a machine that uses mild air pressure to keep breathing airways open while you sleep. The air pressure delivered is determined by the pressure setting on the device.). Resident #188 stated that he/she wears his/her CPAP at night, and the nursing staff does not assist him/her with the CPAP. He/she stated s/he puts it on, turns it on, and removes it him/herself. Per record review Resident #188 has a diagnosis of sleep apnea (A potentially serious sleep disorder in which breathing repeatedly stops and starts.) requiring the use of the CPAP. A physician's order is in place for CPAP at night and for naps every evening and night shift document refusals to wear or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-24 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop a baseline care plan within 48 hours of admission for 2 of 26 residents in the sample (Residents #188 and #237) related to a continuous positive airway pressure (CPAP) (a machine that uses mild air pressure to keep breathing airways open while you sleep) device (Resident #188), and a baseline care plan that included instructions needed to provide effective care related to a pressure ulcer (Resident # 237). Findings include: 1. During an interview with Resident #188 on 1/22/24 5:12 PM a CPAP machine was noted on the bedside table. Resident #188 said that he/she wears his/her CPAP at night and that the nursing staff does not assist him/her with it. Resident #188 stated s/he puts it on his/herself, turns it on, and removes it him/herself. He/ She also stated it has not been cleaned since he/she has been in the facility which has been about 2 weeks. Per record review Resident #188 was admitted to the facility on [DATE] with a diagnosis…
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 · D2024-01-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure all residents have adequate supervision to prevent accidents for 2 of 26 residents sampled (Resident #33 and Resident #12). Findings include: 1. Per record review Resident #33 has diagnoses of dementia with psychotic disturbance and Parkinson's disease. A Brief Interview for Mental Status (BIMS) dated 9/13/23 revealed Resident #33's score of 9 (A BIMS score is a cognitive screening measure that evaluates memory and orientation.) A BIMS score of 9 indicates moderate cognitive impairment. Resident #33's care plan date initiated 9/14/23 has the following focus: Resident is at risk for falls. The goal is resident will not sustain an injury from falls through the review date with interventions including close supervision for safety- impulsivity and frequent checks while in the room for safety. A review of LNA task documentation shows no documented evidence that staff is providing close supervision or frequent checks. Further record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide respiratory care consistent with Professional standards of practice for 1 of 26 residents sampled. (Resident #188). During an interview with Resident #188 on 1/22/23 5:12 P.M. a Continuous Positive Airway Pressure Machine (CPAP) was noted on the resident's bedside table. (This is a machine that uses mild air pressure to keep breathing airways open while you sleep. The air pressure delivered is determined by the pressure setting on the device.) The resident turned the machine on and there were specific settings programmed into the machine. The resident stated his/her spouse brought the machine in from home. Resident #188 said that he/she wears his/her CPAP at night, and the nursing staff does not assist him/her with the CPAP. He/she stated he/she puts it on, turns it on, and removes it him/herself. He/She also states it has not been cleaned since he/she has been in the facility which has been about 2 weeks. Per record review…
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 · D2024-01-24 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
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 the physician evaluated and assessed a pressure ulcer for 1 of 26 residents sampled. (Resident #33). Findings include: Per record review an Admit/Readmit Screener form written on 9/29/23 Section 3 Skin Integrity reflects that Resident #33 had a blister and reddened buttocks. There are no measurements documented for the blister and no measurement or description of the reddened buttocks documented on the form. A progress note written on 9/29/23 states .scratching marks noted in lower legs and knees. Red areas in buttocks and dry skin noted throughout the body. There is no note regarding the blister on the sacrum nor is there evidence that physician was made aware of the blister or reddened areas. Review of a Wound- Weekly Observation tool dated 10/5/23, the blister on the sacrum worsened to an open wound that measures 25 millimeters(mm) in width, 12 mm in length, and 2 mm in depth, the wound bed is 100% slough and there was a noted odor to the wound. In Section A. Communication 1a. Date Medical…
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 before2024-01-24 · 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 ensure proper infection control processes were followed for 2 of 26 residents sampled. (Resident #33) during a pressure wound dressing change and cleaning of a Continuous Positive Airway Pressure Machine (CPAP) for (Resident #188) Findings include: 1. During an observation on 1/23/24 at 2:10 p.m. of a dressing change to a pressure ulcer on Resident #33's sacral area, the Registered Nurse (RN) removed the dirty dressing from the wound with a gloved hand laying the dirty dressing on the bed covers. The RN did not remove her/his gloves, did not sanitize her/his hands, and did not apply clean gloves after removing the dressing. S/he then handled the medicated ointment tube and applied ointment to her/his gloved finger and applied the ointment that was on her/his gloved finger to Resident #33's open wound. The RN picked up the clean dressing and applied it to the resident's sacral area. S/he picked up the dirty dressing on the bed covers, removed her/his gloves, and disposed of the dirty dressing and gloves, and washed his/her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ALLEN, EVERETT | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF; ADP OF THE SNF | since 05/01/2000 |
| BENOIT, MARTHA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; TRUSTEE OF THE SNF; ADP OF THE SNF | since 05/01/2022 |
| DEVEREUX, DENNIS | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; TRUSTEE OF THE SNF; ADP OF THE SNF | since 05/01/2015 |
| GEORGE, SANDRA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF; ADP OF THE SNF | since 05/01/2013 |
| JONES, BRANDIN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; TRUSTEE OF THE SNF; ADP OF THE SNF | since 08/14/2025 |
| MERRIFOX, DYLAN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF; ADP OF THE SNF | since 04/17/2025 |
| THOMSON, GEORGE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; TRUSTEE OF THE SNF; ADP OF THE SNF | since 06/01/2022 |
| YORK, ZACHARY | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF; ADP OF THE SNF | since 08/14/2025 |
| CALORAS, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2019 |
| CONWAY, ASHLEY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/02/2024 |
| COPLEY, TONYA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 05/19/2025 |
| FARNSWORTH, RALPH | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/17/2014 |
| FERLAND, LINDSEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2026 |
| GREEN, NICOLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 11/01/2023 |
| KINIRY, WANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 11/01/2023 |
| LITTLE, MORGAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 07/29/2024 |
| MCELWAIN, MAEGAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2026 |
| MOORE, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2024 |
| OLIVO, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/17/2026 |
| REICHERT, JANUARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/17/2016 |
CMS files one row per role, so the 45 rows in the source record cover these 20 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.
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
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
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 475052. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-25, 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 →
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