Based on interview and record review, the facility failed to ensure a resident was not administered psychotropic medications without implementation of person-centered, non-pharmacological approaches to manage behavioral expressions of distress for one of two residents in the sample (Resident #3). Findings include:Per record review Resident #3 has diagnoses that include anxiety, depression, and dementia with behavioral disturbances. Further review of the record revealed that the Resident had been having behavioral expressions of distress when receiving care including refusals, resistive, and combativeness with care. On 6 different occasions nursing staff documented that Resident #3 was refusing and resistive to care, at times becoming combative, hitting staff and yelling out. …
F605 citations in Vermont
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F605 more often than its own record predicts
1.81 times the share F605 takes of citations nationally.
Of every deficiency written in Vermont in 2025, this is the portion that was F605.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F605 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.
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2023 | 0.55% | 55.78× |
| 2025 | 1.28% | 1.81× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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