Cycle 1
Health 2024-06-20 · Fire 2023-04-19
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Windsor, VT
Cedar Hill Health Care Center
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
49 Cedar Hill Drive, Windsor, VT
(802) 674-6609
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
39
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.85
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.90 · national 0.87
Aide hours / resident day
3.02
Nurse aide staffing · state 2.60 · national 2.35
Total nurse hours
4.87
All reported nurse hours · state 4.31 · national 3.89
Licensed hours
1.84
RN + LPN hours · state 1.71 · national 1.54
Weekend hours
4.07
Weekend nurse staffing · state 3.69 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
5.17
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 60% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,383
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9931
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.11
Performance 19.99% · Measure score 3.11 · Achievement 3.11 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.97
Baseline 5.69% · Performance 6.65% · Measure score 3.97 · Achievement 3.97 · Improvement 0
Total nurse turnover
2.44
Performance 53.70% · Measure score 2.44 · Achievement 2.44 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.55
Baseline 4.66 hours · Performance 4.94 hours · Measure score 6.55 · Achievement 6.55 · Improvement 1.99
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.8% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 3.92% · Lower 95% interval 6.35% |
| Discharge to community | 33.57% |
50.57%
17 pts worse
|
Worse than the National Rate · Eligible stays 60 · Observed rate 25% · Lower 95% interval 23.83% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 85% |
95.27%
10.3 pts worse
|
Numerator 34 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 52.94% |
53.69%
0.8 pts worse
|
Numerator 18 · Denominator 34 |
| Discharge mobility score | 47.06% |
50.94%
3.9 pts worse
|
Numerator 16 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 2 · Denominator 40 · Adjusted rate 5.3% |
| Healthcare-associated infections requiring hospitalization | 6.65% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 4.55% · Lower 95% interval 3.41% |
| Staff COVID-19 vaccination coverage | 11.43% |
8.2%
3.2 pts better
|
Numerator 8 · Denominator 70 |
| Staff flu vaccination coverage | 38.75% |
42%
3.2 pts worse
|
Numerator 31 · Denominator 80 |
| Discharge function score | 52.94% |
56.45%
3.5 pts worse
|
Numerator 18 · Denominator 34 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 65% |
25.2%
39.8 pts better
|
Numerator 13 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.4
0.1 pts worse
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.9 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.5
1.1 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
95.4%
1.9 pts worse
|
93.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 96.9% · Q3 93.3% · Q4 90.6% · 4Q avg 93.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
97.6%
0.4 pts worse
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
5.9%
1.8 pts better
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.1% · Q3 3.3% · Q4 6.2% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
10.0%
10 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 9.3% |
6.0%
3.3 pts worse
|
5.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 7.1% · Q3 19.2% · Q4 7.1% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.6% |
16.4%
13.8 pts better
|
19.6%
17 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 6.7% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.6% |
20.9%
6.3 pts better
|
16.7%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 15.0% · Q3 11.5% · Q4 9.5% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.9% |
19.3%
7.6 pts worse
|
16.3%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.0% |
20.3%
5.7 pts worse
|
14.9%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.5% · Q2 19.2% · Q3 25.0% · Q4 21.4% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.2%
1.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
2.4%
1 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.7% · Q3 3.6% · Q4 3.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.7% |
27.4%
5.3 pts worse
|
19.8%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.1% · Q2 20.9% · Q3 48.9% · Q4 26.3% · 4Q avg 32.7% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
6.1%
0.1 pts better
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 0.0% · Q3 16.0% · Q4 4.3% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.1% |
84.4%
10.3 pts worse
|
81.7%
7.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 70.8% · Q4 55.0% · 4Q avg 74.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.6% |
17.6%
13 pts better
|
12.0%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.6% · Observed 4.2% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.1% |
21.5%
5.6 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 25.0% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-19 · Fire 2022-04-20
4 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-04-20 · Fire 2019-12-03
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
C · Minimal harm
2023-04-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Not marked corrected
C · Minimal harm
2022-04-20
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-07-01
C · Minimal harm
2022-04-20
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Not marked corrected
D · Potential for more than minimal harm
2019-12-03
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2020-02-10
D · Potential for more than minimal harm
2019-12-03
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2020-02-07
D · Potential for more than minimal harm
2019-12-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-02-13
D · Potential for more than minimal harm
2019-12-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-02-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-06-20
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-06-20
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-06-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-06-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-06-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-05
B · Minimal harm
2023-04-19
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Not marked corrected
B · Minimal harm
2023-04-19
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Not marked corrected
B · Minimal harm
2023-04-19
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Not marked corrected
B · Minimal harm
2023-04-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Not marked corrected
E · Potential for more than minimal harm
2022-04-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-06-04
E · Potential for more than minimal harm
2022-04-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-06-04
E · Potential for more than minimal harm
2022-04-20
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-06-04
D · Potential for more than minimal harm
2022-04-20
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-06-04
Penalties and ownership
What sits behind the stars
Ownership
The Mary Louise Sayles Revocable Trust
5% Or Greater Direct Ownership Interest · Organization
Horn, Patricia
5% Or Greater Direct Ownership Interest · Individual
Horn, Patricia
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Elm Wood Center At Claremont
Claremont, NH
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Sullivan County Health Care
Unity, NH
1-star overall rating with 2-star inspections with $16,153 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Springfield Health & Rehab
Springfield, VT
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $637,467 in total fines with 41 recent health deficiencies
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