Based upon observation, interview, and record review, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment was implemented, as indicated in a Do Not Resuscitate [DNR] order, for 1 resident [Res. #37] of 31 residents with DNR orders. This citation is at the immediate jeopardy level due to significant risk of serious harm as a result of the noncompliance to this resident and the 30 other residents with DNR orders. Findings include: A review of Res. #37's medical record reveals the resident has complex medical issues and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Res. #37 on [DATE] at 4:19 PM. The resident reported that on [DATE] his/her heart stopped and s/he had stopped breathing. …
F578 citations in Vermont
Advance directives · Resident Rights Deficiencies
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.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F578 less often than its own record predicts
0.68 times the national share — cited less often here than elsewhere.
Of every deficiency written in Vermont in 2025, this is the portion that was F578.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F578 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 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. …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2024 | 1.27% | 1.29× |
| 2025 | 0.64% | 0.68× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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