Based on interview and record review, the facility failed to carry out critical medication level monitoring that was ordered and failed to consider whether the onset or worsening of symptoms, or a change of condition, may be related to the medication and failed to respond to the presence of adverse consequences related to the use of a high-risk medication for 1 of 3 sampled residents [Resident #1], which resulted in Resident #1's death. This citation is at the immediate jeopardy level due to the lack of an effective process to ensure medications are only administered with adequate monitoring of laboratory values, per manufacturers specifications and accepted professional standards for high risk medications, and not administered in the presence of adverse consequences which indicate the… …
F758 citations in Vermont
Psychotropic drugs · Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F758 more often than its own record predicts
2.02 times the share F758 takes of citations nationally.
Of every deficiency written in Vermont in 2025, this is the portion that was F758.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F758 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 ensure that residents were free from unnecessary psychotropic medications for 5 of 10 Residents in the sample (Resident #12, #20, #29, #54, and #61). The facility also failed to implement 14 day stop dates on prescribed as needed (PRN) psychotropic medications for 3 of the 5 residents in the sample (Residents #12, #20, #54). Findings include: 1. Per record review Resident #54 has diagnoses that include dementia with mood disturbances. Review of the Resident's Care Plan reflects that s/he was admitted to Hospice services on 8/7/2024 due to the diagnosis of congestive heart failure. A Care Plan focus initiated on 1/19/2024 states that the Resident exhibits or has the potential to exhibit physical and verbal behaviors toward others. …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2023 | 0.55% | 0.33× |
| 2024 | 3.17% | 2.13× |
| 2025 | 1.28% | 2.02× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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