Cycle 1
Health 2025-03-12 · Fire 2025-03-12
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
St. Albans, VT
Franklin County Rehab Center, LLC
5-star overall rating with 5-star inspections with 3 recent health deficiencies
110 Fairfax Road, St. Albans, VT
(802) 752-1600
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-05-01
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
1.58
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.90 · national 0.87
Aide hours / resident day
3.40
Nurse aide staffing · state 2.60 · national 2.35
Total nurse hours
5.66
All reported nurse hours · state 4.31 · national 3.89
Licensed hours
2.27
RN + LPN hours · state 1.71 · national 1.54
Weekend hours
4.46
Weekend nurse staffing · state 3.69 · national 3.43
Weekend RN hours
0.87
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.55
CMS adjusted RN staffing hours
Adjusted total hours
5.58
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 60% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,484
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.50
Composite VBP score used to determine payment impact.
Payment multiplier
1.0035
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.2
Baseline 19.97% · Performance 19.02% · Measure score 5.2 · Achievement 5.2 · Improvement 2.71
Healthcare-associated infections
4.38
Baseline 4.97% · Performance 6.53% · Measure score 4.38 · Achievement 4.38 · Improvement 0
Total nurse turnover
3.47
Baseline 61.02% · Performance 49.52% · Measure score 3.47 · Achievement 3.47 · Improvement 2.68
Adjusted total nurse staffing
6.75
Baseline 4.72 hours · Performance 5 hours · Measure score 6.75 · Achievement 6.75 · Improvement 2.15
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.8% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 207 · Observed rate 5.8% · Lower 95% interval 6.18% |
| Discharge to community | 58.55% |
50.57%
8 pts better
|
Better than the National Rate · Eligible stays 202 · Observed rate 55.94% · Lower 95% interval 52.32% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.53% |
95.27%
3.3 pts better
|
Numerator 134 · Denominator 136 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 136 |
| Discharge self-care score | 63.48% |
53.69%
9.8 pts better
|
Numerator 73 · Denominator 115 |
| Discharge mobility score | 50.43% |
50.94%
0.5 pts worse
|
Numerator 58 · Denominator 115 |
| Pressure ulcers or injuries, new or worsened | 3.68% |
2.29%
1.4 pts worse
|
Numerator 5 · Denominator 136 · Adjusted rate 4.08% |
| Healthcare-associated infections requiring hospitalization | 6.53% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 124 · Observed rate 4.84% · Lower 95% interval 3.9% |
| Staff COVID-19 vaccination coverage | 6.12% |
8.2%
2.1 pts worse
|
Numerator 6 · Denominator 98 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 65.22% |
56.45%
8.8 pts better
|
Numerator 75 · Denominator 115 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 95 · Denominator 95 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 54.55% |
25.2%
29.3 pts better
|
Numerator 36 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.4
1.3 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.5
0.3 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.4%
4.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.6%
2.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.9% |
5.9%
2 pts worse
|
3.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 8.2% · Q3 8.3% · Q4 6.5% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
10.0%
5.1 pts better
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 7.0% · Q3 2.5% · Q4 2.6% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 9.8% |
6.0%
3.8 pts worse
|
5.4%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 4.7% · Q3 15.6% · Q4 9.5% · 4Q avg 9.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.7% |
16.4%
2.3 pts worse
|
19.6%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 18.8% · Q3 25.5% · Q4 17.8% · 4Q avg 18.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.8% |
20.9%
11.1 pts better
|
16.7%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 8.3% · Q3 8.3% · Q4 8.3% · 4Q avg 9.8% · 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 | 22.7% |
19.3%
3.4 pts worse
|
16.3%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.3% |
20.3%
7 pts worse
|
14.9%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 32.6% · Q3 27.5% · Q4 32.5% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.2%
0.5 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.1% |
2.4%
2.7 pts worse
|
1.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.7% · Q3 8.7% · Q4 4.7% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.8% |
27.4%
0.6 pts better
|
19.8%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 21.2% · Q3 33.8% · Q4 29.7% · 4Q avg 26.8% |
| Percentage of long-stay residents with pressure ulcers | 11.5% |
6.1%
5.4 pts worse
|
5.1%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 11.5% · Q3 13.1% · Q4 11.8% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
84.4%
14.5 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 98.4% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.6% |
17.6%
3 pts better
|
12.0%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 13.4% · Expected 10.3% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
78.9%
16.6 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.4% |
21.5%
7.1 pts better
|
23.9%
9.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.4% · Observed 13.4% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-06 · Fire 2023-12-06
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-12-21 · Fire 2021-12-01
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-12
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 2025-04-01
D · Potential for more than minimal harm
2025-03-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-11
D · Potential for more than minimal harm
2023-12-06
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-12-22
Penalties and ownership
What sits behind the stars
$0
2024-05-06
Payment Denial
Payment Denial · denial start 2024-08-06 · 25 days
25 day denial
Ownership
Condon, Coleen
5% Or Greater Direct Ownership Interest · Individual
Condon, Coleen
Operational/Managerial Control · Individual
Gladden, Katie
Operational/Managerial Control · Individual
Strenio, Jonathan
Operational/Managerial Control · Individual
Theoria Medical
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
The Villa Rehab
St. Albans, VT
2-star overall rating with 2-star inspections with $13,380 in total fines with 13 recent health deficiencies
#2
Saint Albans Healthcare and Rehabilitation Center
Saint Albans, VT
2-star overall rating with 2-star inspections with $148,714 in total fines with 9 recent health deficiencies
#3
Champlain Valley Physicians Hosp Med Ctr S N F
Plattsburgh, NY
3-star overall rating with 4-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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