Based on record review and staff interview, the facility failed to ensure that dietary staff and support personnel had the appropriate competencies and skills to safely carry out food service functions for one applicable resident (Resident #1). Findings include: Per record review, Resident #1 was prescribed a mechanically altered (Dysphagia Advanced) diet with ground meat by the physician, as well as the same diet as recommended by the Speech Language Pathologist after evaluating the resident. At the lunch meal on 5/20/18, Resident #1 was served meat that had not been ground, and subsequently choked and required hospitalization and intubation as a result. …
F802 citations in Vermont
Nutrition and Dietary Deficiencies
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F802 more often than its own record predicts
2.07 times the share F802 takes of citations nationally.
Of every deficiency written in Vermont in 2025, this is the portion that was F802.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F802 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 observation, interview, and record review the facility failed to ensure the contracting food service department employed sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. This deficiency has the potential to impact all residents. Findings include: During observations of the facility kitchen on 7/15/2025 at 8:50 AM there were several concerns with kitchen cleanliness, food storage, safety, and sanitization noted. Review of the facility Grievance Log and actual grievances from April 2025 - July 2025 revealed 5 grievances dated 4/7, 4/21, 4/25, 6/10, and 6/12 related to food quality, temperature, raw meats, over and under cooked foods including chicken, pork, and hamburger. …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2024 | 0.32% | 1.59× |
| 2025 | 0.32% | 2.07× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction