F655 in Vermont. Pick another state for the same tag.
Against expectation — 2025
Vermont cites F655 more often than its own record predicts
Versus expected share1.46×
1.46 times the share F655 takes of citations nationally.
Share of Vermont citations0.96%
Of every deficiency written in Vermont in 2025, this is the portion that was F655.
Vermont0.96%
National0.66%
Share of all citations that were F655.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F655 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.
G · Actual harm, isolatedNovember 21, 2023
Based on interview and record review, the facility failed to develop and revise a baseline care plan, specific to the person-centered care related to elopement for 1 applicable resident (Resident #1), who left the facility undetected, was found on the road by a local citizen and brought to the Emergency Department with multiple lacerations. Findings include:
Record review reveals that Resident #1 was admitted to the facility on [DATE] with diagnoses that include Wernicke's encephalopathy (a neurological disorder that presents with confusion, muscle movement coordination disorder, and vision problems), dementia, orthostatic hypotension (low blood pressure after standing that can cause dizziness or lightheadedness), and history of falling. …
D · No harm, potential for more than minimal, isolatedMarch 11, 2026
Based on interview and record review, the facility failed to develop a baseline care plan that addressed the smoking needs of 1 of 2 residents in the applicable sample (Resident #93). Findings include:Per a record review, Resident #93 was admitted to the facility on [DATE] with diagnoses that included nicotine dependence and respiratory failure.A smoking assessment dated [DATE] states that Resident #93 is capable of holding his/her own cigarette and smoking unsupervised. The assessment also states that his/her lighter would need to be secured by nursing and would be available as needed.A nursing progress note dated 2/12/26 states that Resident #93 went to smoke several times that day and had to be reminded repeatedly to wear O2 (oxygen). …
B · No harm, potential for minimal, patternApril 18, 2018
Based on interview and record review the facility failed to provide the resident and/or resident's representative with a summary of the baseline care plan for 2 of 16 residents in the applicable sample (Resident #35 and Resident #55). Findings include:
1. Per record review Resident #35, who was admitted on [DATE] had a baseline care plan initiated on 1/31/18. There was no evidence in the record that a summary of the baseline care plan was provided to the resident and/or resident's representative. Per interview on 4/17/18 at 3:29 PM with a Licensed Practical Nurse (LPN), s/he confirmed that there was no indication in the record that a summary of the baseline care plan was provided to the resident and/or resident's representative.
2. Per record review Resident #55 was admitted on [DATE]. …
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