Based on interview and record review the facility failed to ensure that the facility assessment provided adequate information related to competencies and training and failed to address needed positions. Findings include: 1. Per review of the facility Infection Preventionist job description implemented on 5/1/2025 section 6. states The IP must be employed at least part-time and the amount of time should be determined by the facility assessment, to determine the resources it needs for its IPCP [Infection Prevention Control Program]. Designated IP hours per week may vary based on the facility and its resident population. Section 7. States The facility based on the facility assessment will determine if the individual functioning as the IP should be dedicated solely to the IPCP. …
F838 citations in Vermont
Facility assessment · Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Vermont cites F838 more often than its own record predicts
2.53 times the share F838 takes of citations nationally.
Of every deficiency written in Vermont in 2025, this is the portion that was F838.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F838 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 staff interview and record review, the facility failed to ensure that the complete facility-wide assessment was reviewed annually determining what resources are necessary to care for residents during both day-to-day operations and emergencies. The findings include the following: Per review of the facility-wide assessment dated [DATE] and Orientation and Competencies dated 05/22/18, identifies that the facility has not conducted an annual review. Confirmation was made by the facility administrator on 10/16/19 at 8:15 AM, that the facility wide assessment has not been reviewed annually and began an update on 10/15/19, twenty-four hours after the recertification survey began.
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2024 | 0.95% | 4.89× |
| 2025 | 0.64% | 2.53× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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