F635 in Vermont. Pick another state for the same tag.
Against expectation — 2025
Vermont cites F635 more often than its own record predicts
Versus expected share11.54×
11.54 times the share F635 takes of citations nationally.
Share of Vermont citations0.64%
Of every deficiency written in Vermont in 2025, this is the portion that was F635.
Vermont0.64%
National0.06%
Share of all citations that were F635.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F635 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.
K · Immediate jeopardy, patternNovember 19, 2025
Based on interview and record review, the facility failed to accurately reconcile physician orders needed to provide necessary care and services on admission, once the facility identified an issue with the admission orders, they failed to review the rest of the discharge summary for other potential missed orders for 1 of 3 residents in the sample (Resident #1). All residents admitting or readmitting to the facility are at risk for serious injury or death as a result of noncompliance. …
Based on staff interview and record review, the facility failed to obtain accurate physician orders to provide necessary care and services on admission for 3 of 3 applicable residents (Residents #1, #2, and #3). Findings include:
Facility policy Standards and Procedures for All Licensed Independent Practitioners, revised 9/17/21, states,
Upon the admission of a patient, the attending physician or advanced practice provider (APP) is required to: Enter appropriate admission orders on the day of admission. …
D · No harm, potential for more than minimal, isolatedMarch 27, 2025
Based on staff interview and record review, the facility failed to obtain accurate physician orders to provide necessary care and services on admission for 1 of 27 sampled residents (Resident #322). Findings include:
1). Per record review, Resident #322 was admitted on [DATE] after acute hospitalization, related to a fractured right hip, that was repaired on 3/13/25. Per his/her discharge summary and orders written by the hospital Physician on 3/20/25, Resident #322 was being admitted to rehabilitation for therapy, and pain control. Per further review of the discharge summary, Resident #322 had been receiving oral dilaudid for pain 4 times a day in addition to acetaminophen. …
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction