F865 in Vermont. Pick another state for the same tag.
Against expectation — 2025
Vermont cites F865 more often than its own record predicts
Versus expected share2.68×
2.68 times the share F865 takes of citations nationally.
Share of Vermont citations0.64%
Of every deficiency written in Vermont in 2025, this is the portion that was F865.
Vermont0.64%
National0.24%
Share of all citations that were F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Vermont surveyors wrote
F865 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, widespreadNovember 13, 2025
Based on interview, record review of the facility's Quality Assurance and Performance Improvement Program (QAPI), and facility policy review, the facility failed to address all systems of care in a comprehensive manner by identifying problems and opportunities for improvement in the areas of infection control, environment, and Medical Director. As a result, GAS (group A strep) spread through the facility and 12 residents developed symptoms of GAS. 2 of 3 sampled residents with symptoms of GAS were hospitalized with sepsis due to cellulitis (Residents #1 and #2). This citation is at the immediate jeopardy level as these failures put all residents at risk for serious harm and/or death. …
F · No harm, potential for more than minimal, widespreadJuly 24, 2025
Based on record review and interview of the facility's Quality Assurance and Performance Improvement Program (QAPI), the facility failed to address all systems of care in a comprehensive manner by identifying problems and opportunities for improvement in the areas of treatment/services specific to meeting required regulatory visits; appropriate staffing levels: ensuring there was an RN in the building for 8 consecutive hours 7 days/week; residents care supervised by a physician to include required regulatory visits; laboratory orders were performed timely; neglect (cited at immediate jeopardy level); administration; and Medical Director (cited at immediate jeopardy level). …
C · No harm, potential for minimal, widespreadApril 5, 2023
Based on interview and review of limited Quality Assurance and Performance Improvement (QAPI) program documentation, the facility failed to address all systems of care in a comprehensive manner by identifying problems and opportunities for improvement.
Findings include:
On 04/05/23 at 10:30 am an interview with the administrator of [NAME] Air Center, reveals verbal confirmation that the facility tried to hold regular monthly Virtual QAPI meetings over the past year as it has been difficult to have in person meetings, due to COVID, staffing issues and changes with medical directors. The nurse practitioner, physician and pharmacist do not always attend, but does report monthly. …
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