Vermont Healthcare Center

In the surveyor’s words

From the most serious findings on record at Vermont Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF627Feb 6, 2026

  Based on interviews and record reviews, the facility failed to ensure a safe discharge for one of three sampled residents (Resident 1), who was a Regional Center client (a person with a developmental disability receiving care in a state-sponsored facility), with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) bipolar type (mood swings that range from the lows of depression [persistent feeling of sadness] to elevated periods of emotional highs), unspecified psychosis (mental health condition characterized by a loss of contact with reality), anxiety disorder (intense and persistent worry that is difficult to control and interferes with daily life) and seizures (sudden, uncontrolled electrical disturbance in the brain which can… […]

• Actual harm, isolatedF684Oct 30, 2025

  Based on interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Diabetic Management and Insulin Administration, which indicated the facility will ensure safe, timely, and effective monitoring of blood sugar (BS) and administration of insulin in accordance with physician orders and regulatory standards, for one of 3 sampled residents (Resident 1), who was diagnosed with diabetes mellitus type 2 ([DM], a disorder characterized by difficulty in BS control and poor wound healing). The facility failed to:1. Ensure Resident 1's primary care provider (PCP) was aware Resident 1 did not have orders for monitoring BS levels, and insulin coverage. 2. Ensure Resident 1 had orders for BS monitoring and insulin coverage as indicated. 3. […]

• Actual harm, isolatedF689May 1, 2025

  Based on interview, and record review, the facility failed to ensure the resident, who had a diagnosis of paraplegia (loss of movement and/or sensation, to some degree, of the legs), did not fall and sustain an injury during transfer from bed to a shower chair for one of three sampled residents (Resident 2). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA 4) and Restorative Nursing Assistant (RNA) 1 used a mechanical lift (a device used to safely move and transfer individuals who have limited mobility, especially those who cannot bear weight independently) to transfer Resident 2 from a bed to a shower chair as recommended by the Physical Therapy (PT) department. 2. […]

• Actual harm, isolatedF686Mar 14, 2025

  Based on observation, interview and record review, the facility failed to ensure the resident did not develop a deep tissue skin injury ([DTI] (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) on the right lateral (side) foot and the right buttock for one of four reviewed residents (Resident 154). The facility failed to: 1.Ensure Resident 154 was turned and repositioned every two hours per physician order and a care plan titled, Risk for Skin breakdown dated 1/27/25 2. Ensure Resident 154 skin assessment was done during shower days and/or bed bath (a wash that you give to someone who cannot leave their bed). 3. […]

• Actual harm, isolatedF689Feb 5, 2025

  Based on interview and record review, the facility failed to ensure the resident, who was a high risk for falls and injuries, did not fall and sustain injury for one of three sampled residents (Resident 4). The facility failed to: 1. Ensure staff implemented the fall risk prevention program for Resident 4, which included landing pads (a rectangular floor pads with inner surface made of foam or other cushiony materials used to provide a softer place for the resident to land when falling especially if the residents are falling from the bed), bed in low position, bed and chair alarm (devices that are attached to a resident's bed/wheelchair and sound an alarm when the resident gets up). 2. […]