Based on interview and record review, the facility failed to implement a comprehensive care plan to ensure the safety and well-being of 3 of 4 residents (Residents #1, #2, and #3). For Resident #1, the facility failed to provide required hourly safety rounds. The facility failed to ensure a functioning motion sensor was used as planned for a resident at high risk of falls. Specifically, Resident #1-who had received laxatives, was non-ambulatory, and required maximal assistance for toileting-was found deceased on the floor with a detached call light and feces present, after nursing staff failed to monitor the resident according to the established fall-prevention interventions. These failures resulted in an Immediate Jeopardy due to the outcome of death for Resident #1. Findings include:1. …
F656 citations in Vermont
Comprehensive care plan · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F656 less often than its own record predicts
0.74 times the national share — cited less often here than elsewhere.
Of every deficiency written in Vermont in 2025, this is the portion that was F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F656 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.
Based on interview and record review the facility failed to implement care plan interventions related to skin and wound assessments for 1 of 15 residents in the sample (Resident #9). As a result of the failure to follow care plan interventions Resident #9's pressure ulcers worsened. Findings include. 1. Per observation on 1/22/2025 at 3:10 PM a Licensed Practical Nurse (LPN) and Director of Nursing (DON) were observed performing wound care to Resident #9's pressure ulcers. The Resident was noted to have an excoriated sacrum with two open areas that were cleansed and a new dressing was applied. The pressure ulcer on his/her right hip was also cleansed and a new dressing was applied. …
Based on observations, interviews, and record review, the facility failed to ensure that residents have a comprehensive, person-centered care plan for 2 of 20 residents (Residents #2 and #11). This is a repeat deficiency for this facility, with the violation cited during a previous partial survey, dated 7/20/26. Findings include:1. Per record review, Resident #2 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease and dependence on renal dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys cannot). …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2023 | 4.40% | 1.22× |
| 2024 | 4.76% | 1.40× |
| 2025 | 2.56% | 0.74× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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