Based on observation, interview, and record review the facility failed to provide a clean, comfortable, and homelike environment throughout the second floor of the building for 1 of 2 floors related to flooring and odor control. Findings include:Upon entrance to the facility on 4/26/2026 at 4:15 PM, a strong odor resembling urine was detected on the East Wing's second level. Upon further observation, the odor was concentrated in and around room [ROOM NUMBER]. Carpeting in the room was noted to have several large dark spots, one beside the bed closest to the door and three beside the bed closest to the window. …
F584 citations in Vermont
Safe, clean, homelike environment · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F584 more often than its own record predicts
1.37 times the share F584 takes of citations nationally.
Of every deficiency written in Vermont in 2025, this is the portion that was F584.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F584 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.
Per observation and staff interview the facility failed to ensure that the resident shower and tub rooms in the special care unit were kept orderly and sanitary. Findings include: Per observations made throughout survey between 6/12- 6/14/23 the Resident tub room was noted to be cluttered with a floor scale, tub, a mechanical lift, several wheelchairs, 2 shower chairs, and 1 shower bed. A shower chair and the shower bed were piled on top of the tub and another shower chair was stacked on top of the wheelchairs giving it a storage room type of appearance. The floor scale was located in the entrance of the tub room. The flooring between and inside the two shower rooms were noted to have large areas of chipped peeling paint. …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2023 | 3.30% | 1.48× |
| 2024 | 1.59% | 0.74× |
| 2025 | 2.88% | 1.37× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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