Vermont Veterans' Home

In the surveyor’s words

From the most serious findings on record at Vermont Veterans' Home, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 11, 2026

  Based on interview and record review, the facility failed to ensure a resident remained as free from accidents as possible related to the use of supplemental oxygen while smoking and failed to maintain effective supervision that would reduce the likelihood of incident or injury for 1 of 2 residents in the applicable sample (Resident #93). As a result, Resident #93 suffered a facial burn that resulted in pain, redness, and loss of skin. This is a repeat deficiency for this facility, with the violation cited during the previous re-certification survey, dated 1/29/25. […]

• No harm, potential for more than minimal, widespreadF812Mar 11, 2026

  Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety and failed to ensure freezers were maintained at the appropriate temperature. Findings include:Per observation of the kitchen freezer on 3/9/26 at 11:36 AM there was a pack of three sausages and a package of smart dogs opened in the freezer with no date or label. In the dry storage area, there was a 10-pack of instant grits with an expiration date of 11/25. There was a 13.7-ounce bag of cheese queso that had expired on 6/12/25. An interview was conducted with Kitchen Staff Member #1 on 3/9/26 at approximately 11:40 AM. The Kitchen Staff Member confirmed these items were expired. […]

• No harm, potential for more than minimal, widespreadF880Nov 2, 2022

  Based on record review and interview it was determined that the facility failed to develop and implement measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the buildings water systems. Review of the facility's Infection Control Program revealed there were no policies or educational curriculum in place to ensure the facility had a process in place that ensured an adequate water management program to prevent the growth of Legionella or other opportunistic waterborne pathogens. […]

• No harm, potential for more than minimal, patternF602Jun 9, 2026

  Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident #1 and Resident #2) remained free from misappropriation of property. Findings include: #1 Per record review, Resident #1 has diagnoses that include Parkinson's Disease, PTSD (post-traumatic stress disorder), dementia, schizoaffective disorder bipolar type, and psychotic delusions. Per an MDS (Minimum Data Set, a resident assessment tool) dated 10/2/25, Resident #1 had a BIMS (Brief Interview for Mental Status) score of 15, indicating fully intact cognition (the ability to perceive, learn, remember, reason, and problem-solve). Per review of the facility investigation, Resident #1 told the LCSW (Licensed Clinical Social Worker) that he had been giving LPN #1 money. […]

• No harm, potential for more than minimal, patternF584Mar 11, 2026

  Based on observation and interview, the facility failed to ensure a safe, clean, comfortable and homelike environment for residents who reside on one of three units of the facility. Findings include: Per observation on 3/9/26 at 1:53 PM in the bathing room on the 500 halls of the Cardinal memory care unit, the tub had chipped paint on both the seat and the tub itself. There were damaged tiles and debris in one of the two shower stalls. The toilet backrest had cracks in the padding and rust on the framing. On both the 500 and 600 halls of the Cardinal memory care unit, there were stained and damaged ceiling tiles, including outside of room [ROOM NUMBER]. […]