Cycle 1
Health 2024-03-28 · Fire 2024-03-28
21 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Colchester, VT
Green Mountain Nursing and Rehabilitation
1-star overall rating with 1-star inspections with Special Focus status with $161,106 in total fines with 21 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
475 Ethan Allen Avenue, Colchester, VT
(802) 655-1025
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
73
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-04-01
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
0.59
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
1.74
Licensed practical nurse staffing · state 0.90 · national 0.87
Aide hours / resident day
3.12
Nurse aide staffing · state 2.60 · national 2.35
Total nurse hours
5.46
All reported nurse hours · state 4.31 · national 3.89
Licensed hours
2.33
RN + LPN hours · state 1.71 · national 1.54
Weekend hours
4.73
Weekend nurse staffing · state 3.69 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
5.27
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 60% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,297
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.86% · Performance 22.33% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.62
Baseline 4.89% · Performance 6.16% · Measure score 5.62 · Achievement 5.62 · Improvement 0
Total nurse turnover
0
Baseline 48.33% · Performance 64.20% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.03
Baseline 4.53 hours · Performance 4.22 hours · Measure score 4.03 · Achievement 4.03 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.75% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 127 · Observed rate 4.72% · Lower 95% interval 5.94% |
| Discharge to community | 52.56% |
50.57%
2 pts better
|
No Different than the National Rate · Eligible stays 128 · Observed rate 47.66% · Lower 95% interval 46.22% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 77 · Denominator 77 |
| Falls with major injury | 2.6% |
0.77%
1.8 pts worse
|
Numerator 2 · Denominator 77 |
| Discharge self-care score | 38.3% |
53.69%
15.4 pts worse
|
Numerator 18 · Denominator 47 |
| Discharge mobility score | 53.19% |
50.94%
2.2 pts better
|
Numerator 25 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 2.6% |
2.29%
0.3 pts worse
|
Numerator 2 · Denominator 77 · Adjusted rate 3.01% |
| Healthcare-associated infections requiring hospitalization | 6.16% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 3.61% · Lower 95% interval 3.81% |
| Staff COVID-19 vaccination coverage | 10.42% |
8.2%
2.2 pts better
|
Numerator 10 · Denominator 96 |
| Staff flu vaccination coverage | 34.69% |
42%
7.3 pts worse
|
Numerator 34 · Denominator 98 |
| Discharge function score | 63.83% |
56.45%
7.4 pts better
|
Numerator 30 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 37 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 100% |
25.2%
74.8 pts better
|
Numerator 36 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.4
1 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.6 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.5
0.5 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 3.1 · 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 | 98.1% |
97.6%
0.5 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
5.9%
2.7 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.3% · Q3 2.1% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.2% |
10.0%
1.2 pts worse
|
11.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 12.2% · Q3 8.1% · Q4 6.1% · 4Q avg 11.2% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
6.0%
4.8 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.3% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.5% |
16.4%
9.9 pts better
|
19.6%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 4.8% · Q3 2.4% · Q4 7.7% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.7% |
20.9%
0.8 pts worse
|
16.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 17.9% · Q3 27.6% · Q4 23.3% · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.5% |
0.1%
0.4 pts worse
|
0.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.5% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.8% |
19.3%
10.5 pts better
|
16.3%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.3% |
20.3%
9 pts better
|
14.9%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 12.5% · Q3 15.0% · Q4 11.1% · 4Q avg 11.3% · 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 | 2.8% |
2.4%
0.4 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.2% · Q3 0.0% · Q4 7.3% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.6% |
27.4%
18.8 pts better
|
19.8%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 15.5% · Q3 4.9% · Q4 2.7% · 4Q avg 8.6% |
| Percentage of long-stay residents with pressure ulcers | 11.7% |
6.1%
5.6 pts worse
|
5.1%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 12.2% · Q3 16.5% · Q4 8.8% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
84.4%
9.2 pts better
|
81.7%
11.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 94.9% · Q3 91.9% · Q4 92.8% · 4Q avg 93.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.2% |
17.6%
6.6 pts worse
|
12.0%
12.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 23.0% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.9% |
1.9%
3 pts worse
|
1.6%
3.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 2.6% · Q3 6.2% · Q4 4.7% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.8% |
78.9%
10.9 pts better
|
79.7%
10.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
21.5%
6.9 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 24.6% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-15 · Fire 2023-03-15
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-01-26 · Fire 2022-01-26
5 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-28
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-05-11
F · Potential for more than minimal harm
2024-03-28
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-05-11
C · Minimal harm
2024-03-28
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-05-11
C · Minimal harm
2024-03-28
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-05-11
C · Minimal harm
2024-03-28
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-05-11
C · Minimal harm
2024-03-28
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-05-11
C · Minimal harm
2024-03-28
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-05-11
C · Minimal harm
2024-03-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-11
Inspection history
Recent health citations
L · Immediate jeopardy
2025-06-06
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-07-14
K · Immediate jeopardy
2025-06-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-07
F · Potential for more than minimal harm
2025-06-06
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-06-07
D · Potential for more than minimal harm
2024-10-22
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 2024-11-18
D · Potential for more than minimal harm
2024-10-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-22
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-11-18
G · Actual harm
2024-03-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-27
F · Potential for more than minimal harm
2024-03-28
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.
Corrected 2024-05-11
F · Potential for more than minimal harm
2024-03-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-11
F · Potential for more than minimal harm
2024-03-28
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-03-28
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 2024-05-11
E · Potential for more than minimal harm
2024-03-28
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 2024-07-03
E · Potential for more than minimal harm
2024-03-28
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-05-11
E · Potential for more than minimal harm
2024-03-28
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 2024-05-11
D · Potential for more than minimal harm
2024-03-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Not marked corrected
D · Potential for more than minimal harm
2024-03-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-11
D · Potential for more than minimal harm
2024-03-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-06
D · Potential for more than minimal harm
2024-03-28
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-05-11
D · Potential for more than minimal harm
2024-03-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-11
D · Potential for more than minimal harm
2024-03-28
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-05-11
D · Potential for more than minimal harm
2024-03-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-11
D · Potential for more than minimal harm
2024-03-28
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.
Not marked corrected
D · Potential for more than minimal harm
2024-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-11
C · Minimal harm
2024-03-28
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.
Corrected 2024-05-11
F · Potential for more than minimal harm
2022-01-26
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 2022-02-18
F · Potential for more than minimal harm
2022-01-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-18
D · Potential for more than minimal harm
2022-01-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-02-18
D · Potential for more than minimal harm
2022-01-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-02-18
C · Minimal harm
2022-01-26
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2022-02-18
Penalties and ownership
What sits behind the stars
$128,362
2025-06-06
Fine
Fine · fine $128,362
Fine
$32,744
2024-03-28
Fine
Fine · fine $32,744
Fine
Ownership
Rubin, Alter
5% Or Greater Direct Ownership Interest · Individual
Combs-Wilber, Jennifer
Operational/Managerial Control · Individual
Luebbers, Robert
Operational/Managerial Control · Individual
Rubin, Alter
Corporate Officer · Individual
Silver, Pesi
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Premier Rehab and Healthcare at Burlington
Burlington, VT
2-star overall rating with 2-star inspections with abuse icon flag with $85,784 in total fines with 13 recent health deficiencies
#2
Birchwood Terrace Rehab & Healthcare
Burlington, VT
3-star overall rating with 3-star inspections with $127,834 in total fines with 2 recent health deficiencies
#3
Elderwood at Burlington
Burlington, VT
1-star overall rating with 1-star inspections with Special Focus status with $252,434 in total fines with 20 recent health deficiencies
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