Based on observation, interview, and record review, the facility failed to maintain a critical fall-prevention intervention for 1 of 3 sampled residents (Resident #1), who was at high risk due to severe cognitive impairment and repeated falls. Despite a care plan and motion detector alarm system, the device was unplugged and non-operational during the fatal fall. Leadership admitted that an active monitor could have prevented the incident, which resulted in death. Findings include:Per record review, Resident #1 had a Brief Interview for Mental Status (BIMS) of 4 (a cognitive assessment score demonstrating level of impairment), indicating severe cognitive impairment; diagnoses include Alzheimer's disease, dementia, muscle weakness, cognitive communication deficit, anxiety, depression, and… …
F689 citations in Vermont
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F689 more often than its own record predicts
1.21 times the share F689 takes of citations nationally.
Of every deficiency written in Vermont in 2025, this is the portion that was F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F689 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 the interview and record review, the facility failed to implement safe mechanical lift procedures to prevent an avoidable accident for 1 of 5 sampled residents (Resident #1). The facility did not ensure that staff operating the mechanical lift were competent in the task per the facility policy. During transfer, Resident #1 sustained multiple skin tears and fractures to their body, including a fracture of the right femur (thigh bone) and a fracture to the left humerus (upper arm bone). This is a repeat violation previously cited in a partial survey dated 9/9/25. …
Based on observation, record review, and interview, the facility failed to ensure that resident environments were free of accident hazards related to safe handwashing water temperatures for 2 of 3 units (Units A and B). Findings include:During observations of residents' bathrooms on the memory care unit on 9/14/26 at 2:05 PM, the water temperature in the bathroom sink in room [ROOM NUMBER] was so hot that 2 surveyors could not keep their hands under the water for more than 5 seconds. After this discovery, surveyors randomly verified other bathroom sinks in residents' rooms throughout the facility and noted excessive water temperatures above 120 degrees Fahrenheit (F) on 2 of the 3 units observed. …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2023 | 4.40% | 0.89× |
| 2024 | 5.08% | 0.94× |
| 2025 | 6.71% | 1.21× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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