Based on record review and interview, the facility failed to provide care to an existing non-pressure related injury for 2 of 2 sampled residents [Residents #2 and #8] and preventative skin care to residents at risk for development of non-pressure related injuries for 5 of 6 sampled residents [Residents #1, #2, #3, #6, and #8] consistent with facility policy and professional standards of practice. Findings include: Record review and interview reveal the facility had multiple systemic failures in its prevention and management of non-pressure injuries in accordance with facility policy and professional standard of practice. …
F684 citations in Vermont
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F684 less often than its own record predicts
0.45 times the national share — cited less often here than elsewhere.
Of every deficiency written in Vermont in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F684 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 record review and interview, the facility failed to provide care to a resident with a wound vac (wound vacuum; a negative pressure pump that helps a wound heal faster by removing fluid and infection-causing bacteria with suction) in accordance with their facility policy for 1 of 1 sampled residents (Resident #14). The facility did not have a care plan or physician orders and evidence of monitoring in accordance with facility policy for the wound vac until 11/27/25, 22 days later, did not maintain a wound vac or following wound treatment orders after wound vac was removed on 11/13/25, and did not provide necessary education and ensure staff were competent to provide care to a resident with a wound vac. …
Based on observation, interview and record review the facility failed to provide quality care to 1 of 3 sampled residents (Resident #3) related to skin assessment, and non-pressure wound care. Findings include:1.) Resident #3 is a long term resident of the facility with diagnoses including lymphedema (swelling caused by fluid build up), chronic venous insufficiency (veins in the legs do not work well resulting in blood buildup), diabetes, chronic pain, depression and anxiety. Per interview with Resident #3 on 6/24/2026 at 10:45 AM, s/he stated that his/her legs have been unwrapped for days. S/he reported that the bandages were removed earlier in the week before his/her shower and that they have not been replaced. …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2023 | 2.20% | 0.61× |
| 2024 | 2.54% | 0.64× |
| 2025 | 1.92% | 0.45× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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