Premier Rehab and Healthcare at Burlington

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

58.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 164 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 52.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 159 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 164 beds and averages 129.3 residents a day — about 79% occupied, or roughly 35 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.16 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.80 hrs/resident/day on weekends vs 4.30 on weekdays — 12% thinner on weekends. RN hours go from 0.59 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 70% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

34 citations, most serious first. The 16 most serious are shown; the remaining 18 are one tap away and print in full.

• Actual harm · Gcited before2026-03-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate supervision and the implementation of care planned interventions for 1 of 3 sampled residents (Resident #1). The facility did not ensure staff followed the resident's individualized transfer requirements, including the use of a Hoyer lift with two staff members as outlined in the care plan and facility policy. A Licensed Nursing Assistant (LNA) independently conducted a manual transfer of Resident #1 and as a result, Resident #1 experienced pain and subsequently sustained a fractured scapula (shoulder blade). Findings include:Per record review, Resident #1 was admitted to the facility on [DATE] and has diagnoses that include Osteogenesis Imperfecta (a genetic disorder causing fragile bones that break easily due to defective or insufficient collagen) and Osteoporosis (bone disease where decreased bone mass and density make bones weak, brittle, and prone to fractures). The facility reported incident was reviewed, which described a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-12-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. As a result, Resident #14 developed an infection requiring hospitalization and two surgical interventions. Findings include:Per record review, Resident #14 was admitted to the facility on [DATE] for rehabilitation services after a left hip replacement. A Transition of Care report from the sending hospital…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-12-17 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide necessary education and ensure staff were competent 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) for 3 of 3 sampled licensed nurses providing care to Resident #14 . As a result, Resident #14 developed an infection requiring hospitalization and two surgical interventions. Findings include:Per record review, Resident #14 was admitted to the facility on [DATE] for rehabilitation services after a left hip replacement. Resident #14's cognition was assessed on 11/29/25 with a BIMS (Brief Interview for Mental Status) score of 15 indicating cognitive intactness.Per interview on 12/16/25 at 8:55 AM, Resident #14 explained that s/he really wants to go back home and is very frustrated that s/he can't because s/he has to go back for another revision to his/her hip due to an infection. S/he explained that s/he had a wound…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to protect the resident's right to be free from neglect for one applicable resident (Resident #1) by neglecting to provide services that are necessary to avoid physical harm and emotional distress related to providing care to a port (port-a-cath; a device, typically implanted in the chest, used to access the central vein to deliver medications or obtain blood samples) for 1 applicable resident (Resident #1). As a result, Resident #1's port became infected and had to be removed which delayed Resident #1's chemotherapy. Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] and has diagnoses that include ovarian cancer, congestive heart failure, and depression. A 4/3/24 facility nurse Practitioner note indicates that Resident #1 was admitted for sub-acute rehabilitation from the hospital following 3 rounds of chemotherapy and surgery to remove her uterus, ovaries, and tumors related to ovarian cancer. The note indicates…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2024-05-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care to a port [A port protects your veins during cancer treatment. An implanted port is a type of central venous catheter .[that] lets the medication go into your bloodstream through your vein. It can be used to give you medication for several days in a row.1.] for 1 applicable resident (Resident #1) as evidenced by staff not conducting comprehensive skin assessments, obtaining and implementing orders for port care, and care planning for the care of a port. As a result, Resident #1's port became infected and had to be removed which delayed Resident #1's chemotherapy. Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] for sub-acute rehabilitation following abdominal surgery and has diagnoses that include ovarian cancer, congestive heart failure, and depression. A 4/3/2024 facility nurse practitioner note indicates that Resident #1 was admitted for sub-acute rehabilitation from the hospital following three…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2023-10-13 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for three applicable residents (Resident #1, #3, and #5). Findings include: 1. Record review reveals that Resident #1 has diagnoses that include personality disorder, depression, and dementia. On 7/11/23, Resident #1 is assessed to have a BIMS of 4 (brief interview for mental status; a cognitive assessment score indicating severe cognitive impairment). Resident #2 has diagnoses that include schizophrenia, depression, and post-traumatic stress disorder. On 8/14/23, Resident #2 is assessed to have a BIMS of 14 (indicating cognitive intactness). Review of facility resident to resident incident reports dated 9/15/23 for Residents #1 and #2 reveal that Resident #1 was found by nursing staff on the floor in the dining room at approximately 4:30 PM complaining of left arm and hand pain. Resident #2 was standing over Resident #1. A 9/15/23 progress note reveals that Resident #1 was sent to the emergency room after the incident and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-12-17 · tag F0801 — widespread
  Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
  What the surveyor found here — the official record, unedited, may be distressing

  Per interview and record review, the facility failed to have a qualified food service director or a full-time qualified dietician. This has the potential to impact all residents. Findings include:Per interview on 12/16/25 at 8:14 AM, the Kitchen Manager explained that he was new to the position and does not have his certification as a dietary manager or food service manager yet.Per interview on 12/17/25 at 12:15 PM, the Administrator explained that the Registered Dietician (RD) works full time between two facilities. Per review of the RD's timecard for the previous week, the RD worked 25 hours at the facility.Per interview on 12/17/25 at 12:32 PM, the RD explained that she works at the facility 3 times a week and confirmed that she does not work full-time at this facility.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-12-17 · tag F0809 — failed to serve meals on a reasonable schedule — widespread
  Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, observations, and interviews, the facility failed to provide substantial snacks at bedtime when there is more than14 hours between a substantial evening meal and breakfast the following day. This has the potential to impact all residents. Findings include: 1. Per review of the medical record for Resident #106, it revealed the resident has medical diagnosis that include end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, anemia in chronic kidney disease, pulmonary hypertension, generalized edema, chronic obstructive pulmonary disease, insomnia, and chronic diastolic heart failure. Per review of Resident #106's physician orders, the resident is scheduled for dialysis treatments on Tuesdays, Thursdays, and Saturdays. Per record review of Resident #106's meal intake, from the dates of 11/1/25 through 12/17/25, there are six dates where Resident #106 either had no documentation for their dinner consumption, or the documentation stated RX resident not available. Per interview with Resident #106 on 12/15/25 at 3:18 PM, s/he revealed that…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-12-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and interviews, the facility failed to store food in a safe, sanitary condition. This has the potential to impact all residents. Findings include: 1. On 12/15/2025 at 10:55 AM, a tour of the kitchen as conducted with the Kitchen Manager (KM) and Registered Dietician. The following observation was made: The walk-in freezer had multiple boxes stacked directly on the floor of the cooler, blocking access to most of the food on the shelves. The KM explained that the boxes should be put on crates and should not be on the freezer floor directly.Per observation on 12/16/2025 at 8:12 AM, the walk-in freezer had multiple boxes stacked directly on the floor of the cooler.Per interview on 12/16/2025 at 8:14 AM, the Kitchen Manager stated that the freezer was organized yesterday after our initial observation and boxes shouldn't be on the freezer floor.2. On 12/15/25, starting at 11:27 AM, the following observations were made of all four unit kitchenettes:Second floor The microwave was covered in a large white smear; The cabinets were lined with what looked like cracker…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-17 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to implement infection control practices designed to provide a safe and sanitary environment for 1 of 4 units (Second floor) and ensure infection control measures were followed to prevent the transmission of diseases and infections for one randomly sampled resident (Resident #14). Findings include: 1. Per observation on 12/15/2025 at approximately 2:10 PM, a white/grey powder like substance was on the code cart, wound care/treatment cart, and the precaution supply carts. Per interview on 12/15/2025 at approximately 2:30 PM with the LPN on the Second floor, they confirmed the code cart, wound care cart, and precaution supply carts were dusty with white/grey powder and needed to be cleaned. Per interview with 12/15/2025 at 3:09 PM with the Director of Nursing (DON), she confirmed there was dust on the code cart, suction machine, precaution supply carts, and treatment cart containing construction dust and that they all needed to be cleaned.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-17 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment regarding construction debris and resident room equipment maintenance and repair on 1 of 4 units (Second Floor).Findings include:1. Per observation on 12/15/2025 at approximately 2:10 PM, a white/grey powder like substance was on the code cart, wound care/treatment cart, and the precaution supply carts. Per interview on 12/15/2025 at approximately 2:30 PM with the LPN on the Second floor, they confirmed the code cart, wound care cart, and precaution supply carts were dusty with white/grey powder and needed to be cleaned. Per interview with 12/15/2025 at 3:09 PM with the Director of Nursing (DON), she confirmed there was dust on the code cart, suction machine, precaution supply carts, and treatment cart containing construction dust and that they all needed to be cleaned. During observation of the Second floor on 12/17/25 at 9:41 AM, Hoyer lifts, a mechanical device used to lift and transfer…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-17 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview the facility failed to put effective measures in place to ensure that further potential abuse does not occur while investigating an allegation of abuse for one of three sampled residents (Resident #73). Findings include:Per review of Resident #73's medical record, s/he had a BIMS [Brief Interview of Mental Status] score of 13 as of 9/26/25, indicating s/he is not cognitively impaired. S/he has medical diagnoses of COPD [Chronic Obstructive Pulmonary Disease], anxiety disorder, MDD [Major Depressive Disorder], and Wernicke's encephalopathy [a disease that is caused from a low level of thiamine]. Resident #73 is independent with ADLs [Activities of Daily Living] and hygiene.Per record review of a progress note written on 10/21/25 at 2:39 PM states, Resident is being monitor on accusation of abuse from staff. No interaction with accused staff noted in this shift. Resident is pleasant to work with today. No c/o [complaints of] of accusation from staff reported today. POC [plan of care] continued.Per record review, the alleged incident occurred on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-17 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure a resident who required dialysis received services consistent with professional standards of practice for one of two residents (Resident #106). Findings include:Facility policy titled Hemodialysis revised on 9/25, states The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility . ongoing assessment and oversight of the resident before, during and after dialysis treatments . Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Per review of the medical record for Resident #106, it revealed the resident has medical diagnosis that include end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, anemia in chronic kidney disease, pulmonary hypertension, generalized…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-17 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on interview, record review, and observation, the facility failed to safely store locked medications for 1 of 7 medication carts. Findings include: During observations on the second floor on 12/15/25 at 10:54 AM till 11:04 AM, the medication treatment cart was observed to be unlocked. There was one Resident walking up and down the hallway. Per interview with a nurse on 12/15/25 at 11:04 AM, she confirmed that the medication treatment cart should be locked and then locked the cart. Per review of the facility's Medication Storage policy reviewed 9/24, it states . All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms).

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-12 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to create and implement a baseline care plan for 2 of 3 sampled residents related to communication (Residents #1 and #2). Findings include:1. Per record review, Resident #1 was admitted to the facility on [DATE]. Per his/her MDS dated [DATE], his/her preferred language is not English, and s/he needs an interpreter to communicate with doctors and health care staff.Per phone interview on 9/23/25 at 2:05 PM, Resident #1's Representative explained that the facility was unable to get Resident # an interpreter so the facility made a communication board in English, which s/he could not understand. As a result, staff were not able to meet his/her needs. Once the staff gave Resident # pain medication when s/he was trying to let staff know s/he was cold.Per record review, Resident #1 did not have a baseline care plan for communication or interventions for interpreter services within 48 hours of admission. A care plan was created on 9/6/25, with a focus that…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to assure that 2 of 4 residents reviewed were free from physical abuse (Resident #1 and Resident #3). 1. Per record review, Resident #1 was the victim of a physical assault on 5/18/25 at 9:30 AM. A progress note dated 5/18/25 says, Resident noted to have verbal altercation with [Resident #2], resulting in [Resident #2] hitting resident on the side of the face. Per interview with Resident #1 on 5/20/25 at 11:43 AM, s/he reported that Resident #2 was touching his/her belongings and when s/he tried to get Resident #2 to stop, it resulted in him/her getting hit in the head by Resident #2. A review of the facilities policy titled Abuse, Neglect and Exploitation dated 4/2025 states Abuse means the willful infliction of injury .with resulting physical harm, pain, or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Per interview with the [NAME] President of Clinical Operations, the Administrator, and the Assistant Director of Nursing…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$137,679 in federal fines across 4 penalties.

• $19,135 — penalty dated 2026-03-17
• $32,760 — penalty dated 2025-12-12
• $12,529 — penalty dated 2024-05-29
• $73,255 — penalty dated 2023-10-11

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to STELLAR HEALTH GROUP — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 12 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $7.2M paid to related parties — landlords or management companies under common ownership — equal to about 56% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in VT