Based on interview and record review, the facility failed to ensure 1 [Resident #1] of 3 sampled residents received care and services according to accepted standards of clinical practice. Resident #1 suffered serious harm that rose to the immediate jeopardy level due to the facility's failure to provide care in accordance with professional standards, As a result, Resident #1 experienced symptoms related to very high, unsafe blood sugar and psychosocial harm. Findings include: According to the American Nurses Association: Scope and Standards of Practice (http://www.Nursingworld.org © 2010 American Nurses Association) The Standards of Professional Nursing Practice are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are… …
F658 citations in Vermont
Professional standards of care · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F658 less often than its own record predicts
0.90 times the national share — cited less often here than elsewhere.
Of every deficiency written in Vermont in 2025, this is the portion that was F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F658 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 upon observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality regarding resident medications administered as ordered, treatments administered as ordered, and assessments completed as ordered for 1 resident [Res.# 10] of 12 sampled residents. Findings include: Review of the American Nurses Association's Standards of Professional Nursing Practice (Nursing: Scope and Standards of Practice (wordpress.com)) reveals: The Standards of Professional Nursing Practice are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. Under 'Standard 5. …
Based on observation, interview, and record review the facility failed to ensure that physicians orders related to vital sign parameters were followed prior to medication administration for 1 of 3 sampled residents (Resident #86). Findings include:Per record review, Resident #86 has a Physicians order with a start date on 6/5/2026 for lisinopril (prescribed to lower high blood pressure) 50 mg at bedtime including parameters to hold for systolic blood pressure less than 110. Review of the Resident's medication administration record (MAR) from 6/6/2026- 8/4/2026 revealed that they received the lisinopril each day. Further review reveals that there are no documented blood pressure results recorded in the MAR. …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2023 | 3.30% | 2.06× |
| 2024 | 3.17% | 1.94× |
| 2025 | 1.60% | 0.90× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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