5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Middlebury, VT
4-star overall rating with 4-star inspections with 5 recent health deficiencies
30 Porter Drive, Middlebury, VT
(802) 388-4001
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
98
Certified beds
Average residents
92
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1970-06-26
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
RN hours / resident day
1.01
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.90 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.60 · national 2.35
Total nurse hours
4.26
All reported nurse hours · state 4.31 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.71 · national 1.54
Weekend hours
3.62
Weekend nurse staffing · state 3.69 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.10
CMS adjusted RN staffing hours
Adjusted total hours
4.62
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 60% · national 46%
SNF VBP
Program rank
348
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
72.31
Composite VBP score used to determine payment impact.
Payment multiplier
1.0235
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
10
Baseline 18.09% · Performance 16.09% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
6.59
Baseline 5.73% · Performance 5.87% · Measure score 6.59 · Achievement 6.59 · Improvement 0
Total nurse turnover
3.62
Baseline 57.27% · Performance 48.87% · Measure score 3.62 · Achievement 3.62 · Improvement 2.09
Adjusted total nurse staffing
8.72
Baseline 4.83 hours · Performance 5.56 hours · Measure score 8.72 · Achievement 8.72 · Improvement 7.15
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.25% |
10.72%
2.5 pts better
|
No Different than the National Rate · Eligible stays 215 · Observed rate 5.12% · Lower 95% interval 5.62% |
| Discharge to community | 59.96% |
50.57%
9.4 pts better
|
Better than the National Rate · Eligible stays 239 · Observed rate 55.65% · Lower 95% interval 53.79% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.28% |
95.27%
4 pts better
|
Numerator 137 · Denominator 138 |
| Falls with major injury | 1.45% |
0.77%
0.7 pts worse
|
Numerator 2 · Denominator 138 |
| Discharge self-care score | 52.29% |
53.69%
1.4 pts worse
|
Numerator 57 · Denominator 109 |
| Discharge mobility score | 61.47% |
50.94%
10.5 pts better
|
Numerator 67 · Denominator 109 |
| Pressure ulcers or injuries, new or worsened | 1.45% |
2.29%
0.8 pts better
|
Numerator 2 · Denominator 138 · Adjusted rate 1.49% |
| Healthcare-associated infections requiring hospitalization | 5.87% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 94 · Observed rate 3.19% · Lower 95% interval 3.32% |
| Staff COVID-19 vaccination coverage | 11.3% |
8.2%
3.1 pts better
|
Numerator 34 · Denominator 301 |
| Staff flu vaccination coverage | 18.5% |
42%
23.5 pts worse
|
Numerator 69 · Denominator 373 |
| Discharge function score | 59.63% |
56.45%
3.2 pts better
|
Numerator 65 · Denominator 109 |
| Transfer of health information to provider | 99.06% |
95.95%
3.1 pts better
|
Numerator 105 · Denominator 106 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 64.63% |
25.2%
39.4 pts better
|
Numerator 53 · Denominator 82 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.4
0.2 pts worse
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.0 · Expected 1.3 · 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 2.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
95.4%
2.1 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 98.8% · Q3 93.8% · Q4 98.8% · 4Q avg 97.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.3% |
97.6%
1.3 pts worse
|
95.5%
0.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
5.9%
0.9 pts better
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.8% · Q3 6.2% · Q4 5.8% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.9% |
10.0%
1.1 pts better
|
11.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 7.7% · Q3 10.5% · Q4 11.1% · 4Q avg 8.9% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
6.0%
About the same
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 13.0% · Q3 4.1% · Q4 2.7% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
16.4%
0.4 pts worse
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 13.5% · Q3 22.4% · Q4 16.5% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.1% |
20.9%
0.2 pts worse
|
16.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 18.3% · Q3 24.2% · Q4 21.0% · 4Q avg 21.1% · 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 | 18.6% |
19.3%
0.7 pts better
|
16.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 33.6% · Q3 8.3% · Q4 20.2% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.5% |
20.3%
7.8 pts better
|
14.9%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 16.4% · Q3 4.8% · Q4 15.2% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.2%
0.1 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.5% · Q4 1.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
2.4%
1.5 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 4.0% · Q3 1.3% · Q4 3.7% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.6% |
27.4%
13.8 pts better
|
19.8%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 17.6% · Q3 6.8% · Q4 10.0% · 4Q avg 13.6% |
| Percentage of long-stay residents with pressure ulcers | 11.9% |
6.1%
5.8 pts worse
|
5.1%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 13.7% · Q3 12.9% · Q4 9.6% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
84.4%
6.6 pts better
|
81.7%
9.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 93.4% · Q3 87.6% · Q4 87.8% · 4Q avg 91.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.4% |
17.6%
6.2 pts better
|
12.0%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 10.1% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.9%
1.2 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
78.9%
12.8 pts better
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
21.5%
0.6 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 19.3% · Expected 22.1% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Not marked corrected
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-10
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-10-10
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-10-10
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 2025-10-10
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-20
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-07-20
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-07-20
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-20
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 2023-06-05
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-12
Penalties and ownership
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
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