F657 in Vermont. Pick another state for the same tag.
Against expectation — 2025
Vermont cites F657 more often than its own record predicts
Versus expected share1.54×
1.54 times the share F657 takes of citations nationally.
Share of Vermont citations2.88%
Of every deficiency written in Vermont in 2025, this is the portion that was F657.
Vermont2.88%
National1.87%
Share of all citations that were F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F657 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, isolatedApril 1, 2026
Based on interview and record review, the facility failed to ensure care plans were updated with a new intervention for 1 of 3 residents sampled (Resident #1). As a result, the resident sustained a necrotic ulcer on his/her right foot related to improper application of an Unna boot (compression dressing impregnated with healing agents) requiring admission to the hospital which later resulted in a below the knee amputation. Findings include: Per record review, Resident #1 had a BIMS (Brief Interview of Mental Status) of 14, indicating no cognitive impairment. …
D · No harm, potential for more than minimal, isolatedAugust 19, 2026
Based on interview and record review the facility failed to revise the person-centered care plan for 1 of 3 sampled residents (Resident #3) to address the risks of wandering behavior and resident-to-resident altercations. The findings include: Record review shows that Resident #3 has diagnoses that include dementia and generalized anxiety. Resident #3 has an MDS (Minimum Data Set, a resident assessment tool) dated 1/27/26, showing a BIMS (Brief Interview for Mental Status) result of 1 on a scale of 1 to 15, indicating severe cognitive impairment (the ability to perceive, learn, remember, reason, and problem-solve). …
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