Based on observation, interview, and record review the facility failed to ensure consultation with the attending physician during a COVID-19 outbreak, and failed to notify the physician of positive COVID-19 results for 3 of 11 residents who tested positive for COVID-19 (Residents #6, #7, and #12). The facility also failed to notify the physician after a resident physically assaulted another resident causing injury (Resident #1 and #4), and at the time of significant changes in condition regarding development of pressure ulcers (Resident #9). …
F580 citations in Vermont
Notifying of changes · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F580 more often than its own record predicts
1.29 times the share F580 takes of citations nationally.
Of every deficiency written in Vermont in 2025, this is the portion that was F580.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F580 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, interview, and record review, the facility failed to notify the resident's physician of a significant health change, weight loss, for 1 of 2 sampled residents (Resident #71). Findings include: Record review shows that Resident #71 has diagnoses that include Alzheimer dementia with behavioral disturbance, diverticular disease of colon (digestive track disorder), Type 2 diabetes mellitus, and major depressive disorder. Resident #71 has an MDS (Minimum Data Set, a resident assessment tool) dated 6/9/26, showing a BIMS (Brief Interview for Mental Status) result as non-completed due to the resident being rarely or never understood. Record review shows that Resident #71 weighed 200 pounds on 6/7/26. The weight documented for Resident #71 on 7/8/26 was 154 pounds. …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2023 | 1.10% | 0.77× |
| 2024 | 0.63% | 0.42× |
| 2025 | 1.92% | 1.29× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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