Based on observation, interviews and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings include: 1. Per interview and confirmed via staff interview, Resident # 7 received her medications 2.5 hours late on 2/1/21. During interview on 2/3/21, Resident # 7 that all his/her medications were late on 2/1/21, including pain medications. The resident stated that s/he was in terrible pain due to the late medications. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . …
F725 citations in Vermont
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F725 more often than its own record predicts
2.06 times the share F725 takes of citations nationally.
Of every deficiency written in Vermont in 2025, this is the portion that was F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F725 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 provide a sufficient number of Licensed Nursing Assistants (LNAs) and Registered Nurses (RN) for 8 consecutive hours a day to provide nursing services, considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. This is a repeat deficiency cited during a facility Recertification Survey on 12/11/24. Findings include:Per interview on 7/16/2025 at 12:19 PM, the Assistant Director of Nursing (ADON) revealed that she frequently works overtime to provide the facility with RN coverage. She is one of the two staff members who are trained to draw blood for labs. …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2023 | 1.65% | 2.05× |
| 2024 | 2.86% | 3.57× |
| 2025 | 1.60% | 2.06× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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