Based on observation and interview, the facility failed to ensure an effective, functioning resident call system was accessible to all 32 residents on the first floor. Specifically, the facility failed to maintain a system that effectively alerted staff when a call light was disconnected from the wall at the bedside, which occurred in Resident #1's room and was confirmed through sampling in Resident #4's room. On [DATE], Resident #1-who was at high risk for falls and was receiving laxatives-was found deceased on the floor with the call light detached and unalarmed at the nurses' station. The facility failed to implement any policies or routine testing procedures to ensure the call system's audible and visual indicators remained operational. …
F919 citations in Vermont
Call system · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F919 more often than its own record predicts
1.43 times the share F919 takes of citations nationally.
Of every deficiency written in Vermont in 2025, this is the portion that was F919.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F919 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 and interview and record review, the facility failed to ensure a call system allowing residents to call for staff assistance is accessible to residents while in their bed or other sleeping accommodations within 5 out of 6 rooms for residents Care Planned for call bell use. The facility also failed to ensure that an alternate means of communicating with staff was provided after removing the call light from the resident's room for Resident #35. Findings include: 1). …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2024 | 0.32% | 0.72× |
| 2025 | 0.64% | 1.43× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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