Based on document review and interview, it was determined that the facility failed to ensure the Medical Director duties per the Medical Director Agreement and Medical Director facility policy were performed, including ensuring resident care policies were implemented and coordination of care was provided to ensure resident care and services were provided to all resident that were consistent with current professional standards of practice for 2 of 2 units. On 7/18/25 the facility was notified of non-compliance at the immediate jeopardy (IJ) level for Medical Director. This is a repeat deficiency for this facility, with the violation cited during the previous complaint survey, dated 4/8/25. On 7/23/25 the facility's IJ plan of correction was accepted. …
F841 citations in Vermont
Nursing and Physician Services Deficiencies
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F841 more often than its own record predicts
57.72 times the share F841 takes of citations nationally.
Of every deficiency written in Vermont in 2025, this is the portion that was F841.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F841 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 the medical director fulfilled her responsibilities to effectively implement resident care policies and coordinate medical care for residents in the facility regarding the surveillance of, and development of policies that reflect current professional standards of practice to prevent the spread of potential COVID-19 infection, and coordinate care of residents. This deficient practice resulted in ineffective COVID-19 mitigation, death of a resident from COVID-19, and resident abuse with injury. 1. Per review of the facility documented COVID-19 outbreak line list revealed that 11 Residents and 15 staff members tested positive for COVID-19 between [DATE] and [DATE]. …
Based on interview and record review, the facility failed to ensure that the Medical Director fulfilled his/her responsibility to coordinate medical care with facility providers and assist the facility with the development and implementation of resident care policies. This deficient practice has the potential to affect all residents residing in the facility.Findings include:Per review of the facility's Medical Director Services policy [policy undated] on 11/13/25, the scope of services for the Medical Director will include:-Ensuring that each resident's responsible physician attends to the resident's medical needs--Periodic review and development of medical care policies and procedures as required to ensure compliance with Federal, State, and local laws, rules, and regulations.An interview… …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2023 | 0.55% | 31.87× |
| 2024 | 0.95% | 33.13× |
| 2025 | 1.92% | 57.72× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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