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. …
F585 citations in Vermont
Grievances · Resident Rights Deficiencies
Honor 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.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F585 more often than its own record predicts
1.99 times the share F585 takes of citations nationally.
Of every deficiency written in Vermont in 2025, this is the portion that was F585.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F585 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 interviews, observation, and record reviews, the facility failed to support the resident's right to file grievances anonymously for 5 out of 5 residents in the sample (Resident's #5, #26, #55, #53 and #67). This has the potential to affect all residents in the facility. Findings Include: Per interview at Resident Council (RC) on 9/11/2024 at 10:30 AM, 5 out of 5 residents revealed they did not know how to file a grievance anonymously, or at all, and had no access to forms to be able to file anonymously or independently. All five residents revealed if they had known and understood their rights to file a grievance, they would have done so. …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2023 | 2.20% | 3.60× |
| 2024 | 0.95% | 1.51× |
| 2025 | 1.28% | 1.99× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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