Based on observation, record review, and interview the facility failed to ensure medication error rates were less than 5% or greater. There were 31 medication administration opportunities, 29 were observed to be given and 2 were omitted, resulting in errors for 2 of 6 sampled residents (Resident #14 and Resident #16). The total error rate for all observations was calculated at 6.45%. Findings include:During a medication administration observation on 02/24/2026 at 9:50 AM, the Registered Nurse (RN) administered medications to Resident #16 and stated, That's all for [Resident #16].Per record review of the Medication Administration Record (MAR) it was noted that one prescribed medication (docusate sodium, stool softener) was documented as administered by the RN but was not observed to be… …
F759 citations in Vermont
Medication error rate · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F759 more often than its own record predicts
1.18 times the share F759 takes of citations nationally.
Of every deficiency written in Vermont in 2025, this is the portion that was F759.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F759 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 | 1.10% | 0.90× |
| 2024 | 0.32% | 0.30× |
| 2025 | 1.28% | 1.18× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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