No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

The Villa Rehab

7 Forest Hill Drive, St. Albans, VT 05478 · For profit - Limited Liability company · 30 certified beds · (802) 524-3498 Medicare & Medicaid certified

Call the home — (802) 524-3498 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Special Focus candidate (CMS is watching this home)Abuse/neglect citation on record (F0600) — cited May 20261 actual-harm citation$37,040 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • CMS lists it as a Special Focus candidate — not on the watch list itself, but among the homes CMS is watching because of its recent inspection history
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $37,040 in federal fines (most recent 2026-03-05)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • nursing-staff turnover (61%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
260 Crest Rd · (802) 891-4417 · Call to confirm hours
Pharmacy
3 Crest Rd · (802) 527-6700 · Call to confirm hours
Grocery
8 S Main St · (802) 524-3769 · Call to confirm hours
Park
29 N Main St · (802) 524-1500 · Typically dawn to dusk
Place of worship

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

Overall quality measures 3 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased20.0%19.3%15.4%worse
Long-stay residents who lose too much weight2.9%6.6%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection2.9%2.4%2.0%worse
Long-stay residents with depressive symptoms1.6%13.0%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury23.9%5.9%3.3%check this — see note marked dagger below the table
Long-stay residents whose ability to walk worsened18.4%17.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication12.7%16.4%18.9%better
Long-stay residents with pressure ulcers4.9%5.3%4.7%typical
Long-stay residents with worsening bladder/bowel control26.4%26.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table8.6%19.9%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine77.8%78.5%79.4%typical
Short-stay residents rehospitalized after admission20.4%22.0%22.6%typical
Short-stay residents with an outpatient ER visit22.6%17.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.921.521.67worse
Long-stay outpatient ER visits per 1,000 resident days5.332.881.80worse

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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.

48.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 114 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.5%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
57.1%U.S. median 56.6%
Met the expected recovery
0.13U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 57.1% 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 49 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 0.13 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.5%CMS range 39.9–55.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 6.6–13.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge57.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge46.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge55.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.5%CMS range 3.0–11.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.34
RN hours/ resident / day
0.53
LPN hours/ resident / day
3.21
Aide hours/ resident / day
5.08
Total nurse hours/ resident / day
0.61
RN hoursweekends
61.0%
Total nursing turnover
64.3%
RN turnover

How full it usually is: this home is certified for 30 beds and averages 22.2 residents a day — about 74% occupied, or roughly 8 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 5.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.34 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.21 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 4.17 hrs/resident/day on weekends vs 5.45 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.64 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above the national median of 45%. 1 administrator has left in the past year.

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

9
deficiencies at the latest standard inspection (2025-07-30)
6
at the previous standard inspection (2024-07-31)

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.

ABCDEFGHIJKL

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.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2026-03-05 · 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 1 of 3 residents sampled was provided with adequate supervision and assistance devices to prevent accidents (Resident #1), by failing to systematically evaluate the effectiveness of interventions or revise care plan interventions after falls occurred. As a result, Resident #1 suffered a fall and sustained significant fractures in both ankles. This is a repeat deficiency with the violation cited during a previous complaint survey dated 7/30/25. Findings include:Per record review, Resident #1 is assessed as having cognitive impairment, with diagnoses which include Alzheimer's Disease, osteoarthritis of the knee and muscle weakness. Resident #1 is dependent on staff for activities of daily living and hygiene and requires a mechanical lift for transfers. Per record review of a Fall Risk Evaluation on 12/30/25 scores the resident as an 11 out of 32 and is at risk for falls. Per record review of a Fall Risk Evaluation on 1/13/26 scores the resident as…

    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 · D2026-05-26 · 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 interview and record review, the facility failed to protect 1 of 4 residents (Resident #1) from verbal abuse by a Licensed Nursing Assistant (LNA). Findings include:Per interview on 5/26/26 at 12:48 PM with a Licensed Practical Nurse (LPN), she reported that she was the nurse on duty on 2/16/26 at approximately 1 to 2 AM, who witnessed and reported an LNA for abuse against Resident #1. The LPN stated that the LNA came up close to her when she was at the med cart and cursed saying that the LPN better go get Resident #1 and then cursed again stating Resident #1 had just urinated in their face. The LPN then walked into Resident #1's room and saw that s/he was standing there naked, with urine on the floor, and that s/he looked terrified. The LPN reported that while assisting Resident #1 with care, the LNA then came in the room and cursed at Resident #1 about how s/he urinated in the LNA's face.Per record review of Resident #1's progress notes, there is a note titled Incident Note dated 2/17/26 that states that an LNA went into Resident #1's room and cursed at the resident about…

    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 · Dcited before2026-05-26 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to submit their five-day investigative report to the Division of Licensing and Protection within the allotted time. Findings include:Per interview on 5/26/26 at 12:48 PM with a Licensed Practical Nurse (LPN), she reported that she was the nurse on duty on 2/16/26 at approximately 1 to 2 AM, who witnessed and reported a Licensed Nursing Assistant (LNA) for abuse against Resident #1. The LPN stated that the LNA came up close to her when she was at the med cart and cursed saying that the LPN better go get Resident #1 and then cursed again stating Resident #1 had just urinated in their face. The LPN then walked into Resident #1's room and saw that s/he was standing there naked, with urine on the floor, and that s/he looked terrified. The LPN reported that while assisting Resident #1 with care, the LNA then came in the room and cursed at Resident #1 about how s/he urinated in the LNA's face. Refer to F600 for more information.Per interview on 5/26/26 at 1:18 PM with the Director of Nursing and Administrator, the Administrator…

    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 · E2026-03-05 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 care plans were updated with interventions after recurrent falls for 2 of 3 sampled residents (Resident #1 and Resident #2). Findings include:1.Per review of Resident #1's care plan dated 10/17/24 and revised 2/12/26, it states, [Resident #1] is at risk for falls related to decreased mobility, pain issues and cognitive deficits, and recent falls. Most recent fall with several fractures in [his/her] bilateral lower extremities.Per review of a provider's note dated 1/16/26, it states, Primary Chief Complaint: Fall without injury. Nurse called to report a fall without injury. Pt [Patient] was attempting to self-transfer when they lost their balance and fell onto the ground. Negative LOC [Loss of Consciousness] . The resident's care plan read, 1/16/25: fall out of [his/her] wheelchair in [his/her] bedroom.Will monitor closely.Per review of a health status note dated 2/5/26, it states, This writer heard a thud from the nurses' station at 0045. Upon entering the room, found [Resident #1] sitting on the floor in front of…

    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 · F2025-07-30 · tag F0628 — widespread
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 have a system to ensure transfer notices and ombudsman notices were provided for 2 of 2 sampled residents transferred to the hospital. This has the potential to impact all residents. Findings include: 1.) Per record review, Resident #16 was admitted to the facility after a stay at the hospital for treatment of a stroke. A progress note dated 7/12/2025 reveals that Resident #16 was transferred to the hospital for evaluation of altered mental status. There is no evidence in the Resident's medical record that a bed hold, or transfer/discharge notice was provided to the Resident or their family member. Per a progress note dated 7/19/2025, Resident #16 was again transferred to the hospital for evaluation for altered mental status and aggressive behavior. The Registered Nurse who was transferring the Resident out documented Also, due to aggressive and combative behavior [her/his] bed would not be held and this was explained to the family. There is no…

    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 · F2025-07-30 · tag F0726 — failed to have competent, trained nursing staff — widespread
    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

    Based on observation, interview, and record review the facility failed to ensure that staff were competent in medication administration for 4 of 5 licensed nurses and failed to ensure that 10 of 10 direct care staff were competent in infection control measures. Findings include:Per review of the Facility Assessment, last reviewed 5/5/25, indicates that the facility offers medication management, and infection prevention and control as services and care offered to meet the residents' needs. The Facility Assessment reveals that the training program :included an orientation process and ongoing training for all new and existing staff . and is based on staff need and resident characteristics.1.) Medication administration errors were observed during survey. See F759 for more information.Per review of employee education files, 4 of 5 licensed nursing staff did not have documentation to demonstrate that they had the skill necessary to administer medication.2) Infection control deficiencies were identified with resident care during survey. See F880 for more information.Per review of employee…

    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
  • Potential for harm · Fcited before2025-07-30 · 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 observation, interview, and record review the facility failed to ensure that food was prepared in a safe sanitary manner and environment. This has the potential to impact all residents in the facility. Findings include: Per record review of the facility's Food Safety Requirements policy [last revised 1/1/25] states, Food safety practices shall be followed throughout the facility's entire food handling process .Elements of the process include the following:.b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.6. All equipment used in the handling of food shall be cleaned, sanitized, and handled in a manner to prevent contamination.Per observation of the kitchen on 7/28/25 at 8:45 AM, there was a pool of water on the floor in front of refrigerator. The kitchen staff member stated, The sink leaks. She stated the maintenance director would be in the next day to address the water on the floor.Per observation on 7/28/25 at 8:45 AM, there was food debris under serving table including pasta 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-07-30 · tag F0838 — failed to assess facility resources and resident needs — widespread
    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.
    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 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. The IP must have the time necessary to properly assess develop implement, monitor, and manage the IPCP for the facility, address training requirements, and participate in required committees such as QAA [Quality Assessment and Assurance]. 8. The IP will physically work on site in the facility. Per review of the…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-07-30 · tag F0880 — failed to prevent and control infections — widespread
    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, interview, and record review the facility failed to ensure that a risk assessment was completed to identify areas at risk for Legionella (a bacteria found in water that can cause a serious type of pneumonia, Legionnaires' disease) could grow and spread in the facility's water system, and failed to ensure proper infection control practices were followed. Findings include: 1. Per review of the facility's water management program, it did not contain a risk assessment to identify and prevent areas in the building where Legionella could grow and spread in the facility's water system. Per review of the facility policy with a reviewed/revised date of 3/2021 states, surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems and In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies. Per interview with the…

    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 · F2025-07-30 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    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 that a infection preventionist was employed at least part time. Findings include: During an interview with the Registered Nurse (RN) identified as the Infection IP and the Director of Nursing (DON) on 7/29/25 at approximately 3:30 PM, they confirmed that the RN was covering as the IP and is an employee of another facility that is owned by the same owner. The IP stated that they are at the facility on an as-needed basis, about one day a week. When asked to describe the facilities IP Program the IP stated that she works with the Pharmacist and reviews antibiotic usage and ensures that antibiotic time outs are implemented. When asked about the facilities infection surveillance logs, updates to policies and procedures, and water management (Legionella prevention) for the facility the IP deferred to the Administrator.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…

    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 · F2025-07-30 · tag F0945 — failed to train staff on abuse prevention — widespread
    Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
    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 that staff have infection prevention and control training that covers facility policy and procedures for 10 of 10 sampled direct care staff. Findings include:Per review of employee education files, 5 of 5 licensed nursing staff and 5 of 5 LNAs did not have documentation to demonstrate that they received infection control training, including training on the facility infection prevention and control policy and procedures, other than hand hygiene.Per interview on 7/29/25 at 2:40 PM, Registered Nurse #1 explained that she is an agency nurse and the only training that the facility provided was training on the electronic medical record training and an onboarding packet.Per interview on 7/30/25 at 10:32 AM, the Director of Nursing, who is responsible for direct care staff training and competencies, described that infection control training should be done on hire and annually. She stated that there have been gaps in staff education and competency evaluation.Per interview on 7/30/25 at approximately 1:45 PM, the…

    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
Show the remaining 13 citations
  • Potential for harm · F2025-07-30 · tag F0947 — failed to train nurse aides adequately — widespread
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review the facility failed to provide the required 12 hours of in-service training for 2 of 2 applicable licensed nursing assistants (LNAs). Findings include: Education records were reviewed for 5 LNA staff. 2 of the 5 LNAs have worked at the facility for over a year; LNA #4 was hired on 6/26/17 and LNA #5 was hired on 1/18/21.LNA # 4 did not have evidence of 12 hours of in-service training within the past year. LNA #5 had a checklist from a skills fair in their file. There was no other evidence that they received any additional in-service training within the past year.Per interview on 7/30/25 10:32 AM, the Director of Nursing (DON), who is responsible for direct care staff training and competencies, explained that the 12-hour in-service training is done at a skills fair. She revealed that the in-service is documented with the same checklist that is in LNA #5's file.On 7/30/25 at 12:43 PM, the Administrator explained that the in-service training only lasts 9 hours, being held from 7:00 AM until 4 PM and does not have any way to account for the other…

    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
  • Potential for harm · E2025-07-30 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    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 medication error rate of less than %5. 2 of 26 medication administrations were observed to be in error making the error rate 7.7%. Findings include: 1.) Per record review, Resident has physician orders for 1 capsule metoprolol succinate 50 mg extended release oral capsule and 2 tablets PRN (as needed) docusate sodium 50 mg.Per observation of a medication administration for Resident #7 on 7/29/25 at 8:33 AM, Registered Nurse #1 (RN #1) administered one medication in the incorrect form and 1 medication in the incorrect dosage. RN #1 gave Resident #7 1 tablet metoprolol succinate 50 mg extended release oral tablet and 1 tablet docusate sodium. Per review of the Resident # 7's Medication Administration Record for that medication observation, RN #1 documented that Resident #7 received 1 tablet metoprolol succinate and 2 tablets of docusate sodium. RN #1 did not call a provider to notify them of the incorrect form of the metoprolol succinate or the change in dosage administered and there is no evidence in Resident #7's…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-30 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 that one of three residents (Resident #16) was free from physical restraints. During staff use of physical restraint Resident #16 became more agitated, aggressive, and resistive to redirection causing combative behavior, and threatening to hurt staff. As a result of the aggressive behaviors the facility refused to allow the Resident to return to the facility causing an extended stay in the hospital. Findings include:Per record review of progress notes between the hours of 7:00 AM and 12:00 PM Resident #16 made several attempts to exit the building throughout the morning. A progress note dated 7/19/2025 reveals that the Wander Guard alarm went off as Resident #16 went out the back door. A Licensed Nursing Assistant (LNA) went after her/him. While outside the Resident started heading to the end of the street to go through the bushes to head home. The LNA stayed with her/him for their safety. At this time, the Resident threatened to punch her if she did not remove her arm from behind her/his back. This nurse went to…

    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 · Dcited before2025-07-30 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 that an allegation of staff to resident abuse was reported to the licensing agency for one of three residents in the applicable sample (Resident #16). Findings include:Per review of a facility Internal Investigation for an incident on 7/19/2025, Resident #16 was transferred to the hospital due to increased behaviors on 7/19/2025. The hospital case manager alerted the facility Director of Nursing (DON) that while at the hospital, Resident #16 had made an allegation that staff had pushed her/him to the ground by a staff member prior to being transferred to the hospital. The internal investigation did not include evidence that the allegation had been reported to the State Licensing Agency. Per interview on 7/29/2025 at 8:45 AM with the Administrator and DON the Case Manager from the hospital had sent an email to the DON stating that she had made a report to Adult Protective Services regarding an allegation from Resident #16 that she/he had been pushed. The Administrator and DON confirmed that they had done an internal…

    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 · D2025-07-30 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    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 refused to allow a resident to return to the facility after being transferred to the hospital and inappropriately discharged the resident, for one of three residents in the applicable sample (Resident #16). Findings include:Per record review, Resident #16 was admitted to the facility after a stay at the hospital for treatment of a stroke. admission diagnoses include aphagia (a brain disorder that affects how you speak and understand language. It happens after damage to the language processing center of your brain), and cognitive communication deficit (difficulties in communication that arise from impairments in cognitive processes, such as attention, memory, and problem-solving). An admission Summary progress note dated 7/11/2025 reflects that Resident #16 was alert and oriented x 3 (person, place, and time), though has a history of forgetfulness in the evening, redirectable . Family reports sundowning [a state of confusion, agitation, and restlessness that some…

    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 · Dcited before2025-07-30 · 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 provide adequate assessment and supervision for 1 of 3 residents in the sample (Resident #16), to prevent a resident who was exit seeking to exit the facility. This resulted in staff using physical restraint in attempt to return the Resident to the facility, causing the Resident to exhibit increased agitation, resistiveness, and combativeness toward staff. Findings include:Per record review, Resident #16 was admitted to the facility after a stay at the hospital for treatment of a stroke. admission diagnoses include aphagia (a brain disorder that affects how you speak and understand language. It happens after damage to the language processing center of your brain), and cognitive communication deficit (difficulties in communication that arise from impairments in cognitive processes, such as attention, memory, and problem-solving). A hospital Discharge summary dated [DATE], reveals that the Resident had been prescribed an antipsychotic medication for…

    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 · Fcited before2024-07-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — widespread
    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 observation, interview, and record review, the facility failed to ensure that resident environments were free of accident hazards related to safe handwashing water temperatures. Findings include: During unit observations on 7/29/2024 at 2:45 PM, the hot water was assessed from a faucet in an unlocked, common area bathroom, accessible to all residents. The water was too hot to hold a hand under comfortably, so a thermometer was used to take the temperature of the water. The highest reading was 124.1 degrees Fahrenheit (F). The sample was then expanded to include other common areas sinks and resident rooms. The left hallway sink read 121.8 degrees F, a right hallway sink read 121.7 degrees F, a second common area bathroom read 121.1 degrees F. The Resident in room [ROOM NUMBER] is independent with care and uses the bathroom for toileting and bathing. The water temperature in their bathroom sink read 123.4 degrees F. The above temperatures were confirmed by the facility Dietary Manager who was accompanying…

    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 · Fcited before2024-07-31 · 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 observation, interview, and record review, the facility failed to ensure that food was stored in accordance with professional standards for food safety. The facility failed to document the temperatures of 1 of 3 freezers and the temperatures of 2 of 3 refrigerators, served food items to residents outside of the facility's standard for food temperatures, and failed to discard expired food items. Findings include: A Meat Freezer log was provided to surveyors. Per the facility's Equipment Temperature Log the accepted freezer temperature is -10 [degrees Fahrenheit] to 0 [degrees Fahrenheit]. In addition to one abnormal temperature of -12 [degrees Fahrenheit] recorded there was no month documented for the Meat Freezer log. An interview was conducted with the Dietary and Housekeeping Manager on 7/30/24 at 1:35 PM. The Dietary and Housekeeping Manager confirmed on 7/30/24 that there was no documentation identifying the month where temperature of -12 [degrees Fahrenheit] was recorded. The Dietary and Housekeeping Manager confirmed s/he did not know the month of the Meat Freezer log…

    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 · Fcited before2024-07-31 · tag F0838 — failed to assess facility resources and resident needs — widespread
    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.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to address in their facility assessment what the staff competencies that are necessary to provide the level and types of care needed for the resident population identified in the assessment. This deficient practice has the potential to affect all 20 residents residing in the facility. Findings include: Per review of the 2024 Facility Assessment does not indicate what specific competencies are necessary to provide care to the Residents who reside in the facility. The facility assessment also fails to indicate which competencies will be evaluated. Per interview on 7/31/24 at 2:37 PM with the Licensed Nursing Home Administrator (LNHA) the licensed staff are evaluated for competency during orientation and annually. Additional training is provided to staff when a skill is needed that is not something that they routinely care for. The LNHA confirmed that the facility assessment does not identify the specific training or competencies to be evaluated that are needed to provide care to the residents.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-31 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based upon interview and record review, the facility failed to provide care and services according to accepted standards of clinical practice regarding Physician Orders and notification for 2 residents [Res.#6 and #17] of 18 sampled residents. Findings include: Per review of the Lippincott Manual of Nursing, Common Departures from the Standards of Nursing Care include: failure to follow physician orders, follow appropriate nursing measures, communicate information about the patient. [Lippincott Manual of Nursing Practice-11th Edition 2018] 1.) Per record review, Physician Orders for Res.#6 include: Azithromycin Ophthalmic Solution 1 % -Instill 1 drop in both eyes two times a day for Severe Blepharitis. [According to the Mayo Clinic: Blepharitis is inflammation of the eyelids that can cause irritation, redness, crusting and stickiness. Azithromycin ophthalmic solution belongs to a group of medicines called macrolide antibiotics and works by killing the bacteria causing the infection .To help clear up your eye infection completely, keep using this medicine for the full treatment time…

    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 · E2024-07-31 · tag F0949 — failed to train staff on dementia and abuse — pattern
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program related to behavioral health or trauma informed care and services, as determined by resident needs and the facility assessment for 7 of 8 sampled staff. Review of the 2024 Facility Assessment indicates that the facility has had 27 residents with the diagnosis of anxiety disorder, 37 residents with depression, 2 residents with manic depression, 2 residents with psychiatric disorder, and 1 resident with Post Traumatic Stress Disorder. Review of employee training and competency files revealed that 4 Licensed Nursing Assistants and 3 Registered Nurses had no documented evidence that they received behavioral health and trauma informed care training on hire or annually for 2024. During an interview on 7/31/24 at 12:31 PM the Director of Nursing (DON) confirmed that there was no documented evidence that staff had received behavior health or trauma informed care training. The facility Administrator was able to produce a training log for behavioral health and trauma…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-07 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 that one of five applicable residents of the sampled 16 residents (Resident #14) was free from any significant medication errors. Findings include: Per record review, Resident #14 was administered an incorrect dose of an ordered medication daily from 5/14/23-5/22/23. On 5/14/23 Resident #14 was admitted to the facility following a hospital stay for weakness/falls, additional diagnosis include myasthenia gravis (a neuromuscular disease) and congestive heart failure (weakened heart muscle). On 5/22/23 Resident #14 was acutely sent to the emergency room with swelling in the right hip and thigh and shortness of breath at rest as well as with exertion. Per hospitalist Discharge summary dated [DATE] although he had an exacerbation of this congestive heart failure on this dose of diuretics (medication to reduce fluid excess), suspect his prednisone may be contributing to fluid retention and may improve as prednisone is tapered. University of [NAME]…

    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.

    Pharmacy Service Deficiencies · Past Non-Compliance
  • No harm found · C2024-07-31 · tag F0585 — failed to handle grievances — widespread
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews, the facility failed to support the resident's right to file grievances anonymously. This has the potential to affect all residents in the facility. Findings Include: Per observation, the facility's entryway on the first floor has a bulletin board with the grievance process posted on it. The process includes who the grievance officer is and the contact information, but it does not give details on anonymously filing a grievance. There is no evidence of grievance forms or information on submitting a grievance anonymously. A review of the facility policy, titled Resident and Family Grievances, revised on 2/2/24, #9. A grievance may be filed anonymously, but it does not address a process to do it. Per interview on 7/30/2024 at approximately 1:30 PM with two residents, it was revealed by Resident #5 that if a resident wants to file a grievance, they must contact the Social Services Department or the Administrator. S/he does not know of a system within the facility that allows the resident to file the grievance without revealing the writer's…

    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

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$37,040 in federal fines across 2 penalties.

  • $23,660 — penalty dated 2026-03-05
  • $13,380 — penalty dated 2024-07-31

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.

Who owns this facility

Owner / managerTypeRoleShareSince
CONDON, COLEENIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/11/2022
THEORIA MEDICALOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
MATTISON, DEANAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
STRENIO, JONATHANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025

CMS files one row per role, so the 7 rows in the source record cover these 4 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.

$3.2M
Net patient revenuemost recent cost report
-10.4%
Operating marginrevenue minus expenses
$77K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 30%Other / private 70%

This home reported $77K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$509per resident / day
operating cost
$15,481per month
≈ monthly operating cost
$461per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Vermont Medicaid page.

Typical monthly cost in Vermont
$14,113/mo
Nursing home (semi-private)
$15,528/mo
Nursing home (private)
$8,597/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 475055. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

What to do next