Based on record review and interviews with the resident and facility staff, the facility failed to promote and support the resident's choice (1 of 4 sampled, Resident #1) to participate in preferred activities and interact with members of the community, both inside and outside the facility, leading to an unsafe discharge. Findings include: Per record review, Resident #1 entered the facility on 6/27/18, following [MEDICAL CONDITION] (paralyzed in the lower body), caused by trauma. There was also a clear history of [MEDICAL CONDITION] among the admitting diagnoses. Resident #1 had a medical order allowing 1 beer per day. A note on 1/21/19 relates that Resident #1 was non-compliant with the 1 beer per day order, and thus the order was discontinued. …
F561 citations in Vermont
Self-determination · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F561 more often than its own record predicts
2.50 times the share F561 takes of citations nationally.
Of every deficiency written in Vermont in 2025, this is the portion that was F561.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F561 findings written in Vermont, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation, record review, and staff interview, the facility failed to honor residents' choices as outlined in their care plan for 1 of 3 sampled residents (Resident #3). Findings include: Per record review, Resident #3 has diagnoses including major depressive disorder, post-traumatic stress disorder, schizoaffective disorder, and borderline personality disorder. Per record review, a facility grievance dated 10/13/25 denotes that Resident #3 did not wish to have LPN #2 care for them. A progress note from 10/15/25 written by the Director of Nursing (DON) states they Spoke with resident regarding grievance against nurse. …
Based on interviews and record review, the facility failed to accommodate a resident's request to leave the facility for 1 of 27 sampled residents (Resident #477) who wanted to attend a family gathering and failed to have a system to inform residents and/or their representative on the need to request and the process to request to leave the facility. Findings include: Record review reveals that Resident #477 was admitted to the facility on [DATE] for subacute rehab following hospitalization for bowel surgery, sepsis, and pneumothorax [collapsed lung]. On 6/12/2023 at 2:53 PM, Resident #477 and their spouse revealed their disappointment about not attending a family gathering the previous day [6/11/2023]. …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2023 | 0.55% | 1.05× |
| 2024 | 0.95% | 2.31× |
| 2025 | 0.96% | 2.50× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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