Based on resident representative and staff interviews and record review, the facility failed to create and implement an individualized person-centered plan to render trauma-informed care to a resident with a personal history of trauma, related to witnessing a relative drown, for 1 of 20 residents sampled (Resident #30). Findings include: Record review reveals that Resident #30 was admitted in April 2021 with diagnoses including Alzheimer's disease, muscle weakness, and major depressive disorder. On 10/9/23 at approximately 12:20 PM, Resident #30's Representative noted that at times Resident #30 does not appear to have been bathed and at other times they receive reports that Resident #30 has assaultive behaviors that occur during bathing. …
F699 citations in Vermont
Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F699 more often than its own record predicts
6.79 times the share F699 takes of citations nationally.
Of every deficiency written in Vermont in 2025, this is the portion that was F699.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F699 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 interview and record review the facility failed to provide culturally competent and trauma-informed care by failing to ensure a care plan identified triggers of past trauma and provided interventions for those triggers for 1 applicable resident in the sample (Resident #8). Findings include:Per review of the facility policy Trauma-informed Care and culturally Competent Care revised 8/22, it states: Resident Care Planning, 2). Identify and decrease exposure to triggers that may re-traumatize the resident. Per record review, Resident #8 has a diagnosis of post-traumatic stress disorder. His/her care plan with a review date of 01/08/26, lists several traumatic events. …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2023 | 1.10% | 4.85× |
| 2024 | 1.90% | 5.93× |
| 2025 | 2.24% | 6.79× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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