F835 in Vermont. Pick another state for the same tag.
Against expectation — 2025
Vermont cites F835 more often than its own record predicts
Versus expected share2.17×
2.17 times the share F835 takes of citations nationally.
Share of Vermont citations0.64%
Of every deficiency written in Vermont in 2025, this is the portion that was F835.
Vermont0.64%
National0.29%
Share of all citations that were F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F835 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.
L · Immediate jeopardy, widespreadMarch 3, 2025
Based on observation, interview, and record review, the facility was not administered in a manner that enables it to maintain the physical well-being of each resident, whereby actions and decisions by the facility's leadership team directly contributed to multiple deficiencies that resulted in harm and immediate jeopardy by failing to ensure that the physician was notified of changes, residents were free from abuse, care plans were implemented, pressure ulcer care and prevention was provided, adequate supervision of residents, residents' care is supervised by a physician, the responsibilities of the Medical Director were met, implement an effective infection prevention program, and have a qualified infection preventionist. …
Based on interview and record review, the facility was not administered in a manner that enables it to maintain the physical well-being of each resident, whereby actions and decisions by the facility's leadership team directly contributed to deficient practices at F684 and F686.
Findings include:
Findings of deficient practices at F684 and F686 establish that 5 of 6 sampled residents were not provided effective care to promote optimal skin health, prevent pressure injuries and non-pressure injury skin impairments, and promote healing. As a result, these 5 residents were put at increased risk for developing pressure ulcer and non-pressure ulcer skin impairments. …
F · No harm, potential for more than minimal, widespreadJuly 24, 2025
Based on observation, interview, and record review, it was determined that the facility was not administered in a manner that enables it to maintain the physical well-being of each resident, whereby actions and decisions by the facility's leadership team directly contributed to deficiencies that resulted in immediate jeopardy (F600 and F841). In addition, there are several repeat deficiencies. The identified failures by the lack of administrative oversight for a large amount of regulatory requirements in multiple areas of compliance put all residents at risk for more than minimal harm. …
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