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| Deficiency Category | Inspection Date: 12/4/24 Complaint Reporting Period: 5/1/24 - 4/30/25 | Inspection Date: 9/13/23 Complaint Reporting Period: 5/1/23 - 4/30/24 | Inspection Date: 3/29/23 Complaint Reporting Period: 5/1/22 - 4/30/23 |
|---|---|---|---|
| Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
| Quality of Life and Care Deficiencies | |||
| Infection Control Deficiencies | |||
| Resident Assessment and Care Planning Deficiencies | |||
| Nursing and Physician Services Deficiencies | |||
| Resident Rights Deficiencies | |||
| Nutrition and Dietary Deficiencies | |||
| Pharmacy Service Deficiencies | |||
| Environmental Deficiencies | |||
| Administration Deficiencies |
| Date of last standard health inspection: | 12/4/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 5/1/24 - 4/30/25 | 7/17/24Read the full report (PDF) 6/12/24Read the full report (PDF) 5/29/24Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 5/1/24 - 4/30/25 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Vermont: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 5/29/24 | 5/29/24 | 3 - Actual harm | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 7/17/24 | 9/3/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide care and assistance to perform activities of daily living for any resident who is unable. | 12/4/24 | 1/18/25 | 2 - Minimal harm or potential for actual harm | Some |
Provide activities to meet all resident's needs. | 12/4/24 | 1/18/25 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 12/4/24 | 1/18/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/29/24 | 5/15/24 | 3 - Actual harm | Few |
| No Infection Control Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 6/12/24 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 12/4/24 | 1/18/25 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 12/4/24 | 1/18/25 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 12/4/24 | 1/18/25 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 7/17/24 | 9/3/24 | 2 - Minimal harm or potential for actual harm | Many |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | 12/4/24 | 1/18/25 | 1 - Potential for minimal harm | Some |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | 7/17/24 | 9/3/24 | 2 - Minimal harm or potential for actual harm | Many |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | 7/17/24 | 9/3/24 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | 12/4/24 | 1/18/25 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 7/17/24 | 9/3/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Environmental Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | 7/17/24 | 9/3/24 | 2 - Minimal harm or potential for actual harm | Few |
| Date of last standard health inspection: | 9/13/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 5/1/23 - 4/30/24 | 10/13/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 5/1/23 - 4/30/24 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Vermont: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 10/13/23 | 11/4/23 | 2 - Minimal harm or potential for actual harm | Some |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 10/13/23 | 11/4/23 | 3 - Actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide activities to meet all resident's needs. | 9/13/23 | 9/29/23 | 2 - Minimal harm or potential for actual harm | Few |
| No Infection Control Deficiencies were found during this inspection period. |
| No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| No Resident Rights Deficiencies were found during this inspection period. |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| No Pharmacy Service Deficiencies were found during this inspection period. |
| No Environmental Deficiencies were found during this inspection period. |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 3/29/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 5/1/22 - 4/30/23 | 2/14/23Read the full report (PDF) 1/19/23Read the full report (PDF) 12/13/22Read the full report (PDF) 11/15/22Read the full report (PDF) 10/11/22Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 5/1/22 - 4/30/23 | 11/22/22Read the full report (PDF) |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Vermont: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 2/14/23 | 2/14/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 12/13/22 | 12/13/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 1/19/23 | 3/3/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Provide enough food/fluids to maintain a resident's health. | 3/29/23 | 5/2/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 1/19/23 | 3/3/23 | 4 - Immediate jeopardy to resident health or safety | Some |
| No Infection Control Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 11/15/22 | 12/6/22 | 2 - Minimal harm or potential for actual harm | Few |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 3/29/23 | 5/2/23 | 2 - Minimal harm or potential for actual harm | Some |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 10/11/22 | 10/21/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | 1/19/23 | 3/3/23 | 4 - Immediate jeopardy to resident health or safety | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | 3/29/23 | 5/2/23 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | 2/14/23 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Few |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 2/14/23 | 2/22/23 | 2 - Minimal harm or potential for actual harm | Few |
| No Environmental Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | 1/19/23 | 3/3/23 | 1 - Potential for minimal harm | Many |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | 1/19/23 | 3/3/23 | 2 - Minimal harm or potential for actual harm | Many |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 1/19/23 | 3/3/23 | 3 - Actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 5/29/24 | 5/29/24 | 3 - Actual harm | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 7/17/24 | 9/3/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/29/24 | 5/15/24 | 3 - Actual harm | Few |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 6/12/24 | 2 - Minimal harm or potential for actual harm | Some | |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 7/17/24 | 9/3/24 | 2 - Minimal harm or potential for actual harm | Many |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | 7/17/24 | 9/3/24 | 2 - Minimal harm or potential for actual harm | Many |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | 7/17/24 | 9/3/24 | 2 - Minimal harm or potential for actual harm | Many |
Ensure that residents are free from significant medication errors. | 7/17/24 | 9/3/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | 7/17/24 | 9/3/24 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 10/13/23 | 11/4/23 | 2 - Minimal harm or potential for actual harm | Some |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 10/13/23 | 11/4/23 | 3 - Actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 2/14/23 | 2/14/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 12/13/22 | 12/13/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 1/19/23 | 3/3/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 1/19/23 | 3/3/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 11/15/22 | 12/6/22 | 2 - Minimal harm or potential for actual harm | Few |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 10/11/22 | 10/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | 1/19/23 | 3/3/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | 2/14/23 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 2/14/23 | 2/22/23 | 2 - Minimal harm or potential for actual harm | Few |
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | 1/19/23 | 3/3/23 | 1 - Potential for minimal harm | Many |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | 1/19/23 | 3/3/23 | 2 - Minimal harm or potential for actual harm | Many |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 1/19/23 | 3/3/23 | 3 - Actual harm | Some |
| This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years. |