Cycle 1
Health 2025-02-26 · Fire 2025-02-26
4 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lyndonville, VT
Pines Rehab & Health Center
3-star overall rating with 4-star inspections with 4 recent health deficiencies
601 Red Village Road, Lyndonville, VT
(802) 626-3367
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-04-01
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
0.74
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.90 · national 0.87
Aide hours / resident day
2.79
Nurse aide staffing · state 2.60 · national 2.35
Total nurse hours
4.34
All reported nurse hours · state 4.31 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.71 · national 1.54
Weekend hours
3.47
Weekend nurse staffing · state 3.69 · national 3.43
Weekend RN hours
0.53
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
5.30
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 60% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,746
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.86
Composite VBP score used to determine payment impact.
Payment multiplier
0.9958
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
5.81
Baseline 6.23% · Performance 6.10% · Measure score 5.81 · Achievement 5.81 · Improvement 0.54
Total nurse turnover
1.65
Baseline 52.73% · Performance 56.94% · Measure score 1.65 · Achievement 1.65 · Improvement 0
Adjusted total nurse staffing
5.40
Baseline 3.81 hours · Performance 4.61 hours · Measure score 5.40 · Achievement 5.40 · Improvement 3.59
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.87% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 5.26% · Lower 95% interval 5.93% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 48 · Denominator 48 |
| Falls with major injury | 2.08% |
0.77%
1.3 pts worse
|
Numerator 1 · Denominator 48 |
| Discharge self-care score | 24.44% |
53.69%
29.2 pts worse
|
Numerator 11 · Denominator 45 |
| Discharge mobility score | 17.78% |
50.94%
33.2 pts worse
|
Numerator 8 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 2 · Denominator 48 · Adjusted rate 4.06% |
| Healthcare-associated infections requiring hospitalization | 6.1% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 0% · Lower 95% interval 3.47% |
| Staff COVID-19 vaccination coverage | 2.9% |
8.2%
5.3 pts worse
|
Numerator 2 · Denominator 69 |
| Staff flu vaccination coverage | 21.11% |
42%
20.9 pts worse
|
Numerator 19 · Denominator 90 |
| Discharge function score | 42.22% |
56.45%
14.2 pts worse
|
Numerator 19 · Denominator 45 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 51.72% |
25.2%
26.5 pts better
|
Numerator 15 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| 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 1.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.2 |
2.5
1.7 pts worse
|
1.8
2.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.2 · Observed 4.2 · 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 | 3.5% |
5.9%
2.4 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.0% · Q3 3.7% · Q4 3.8% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
10.0%
9 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
6.0%
0.4 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 8.1% · Q3 7.7% · Q4 0.0% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.1% |
16.4%
5.7 pts worse
|
19.6%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 28.2% · Q3 20.5% · Q4 16.2% · 4Q avg 22.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.7% |
20.9%
12.8 pts worse
|
16.7%
17 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 30.8% · Q3 35.6% · Q4 34.9% · 4Q avg 33.7% · 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 | 14.5% |
19.3%
4.8 pts better
|
16.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 20.8% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.1% |
20.3%
0.2 pts better
|
14.9%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 23.1% · Q3 15.4% · Q4 18.9% · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
1.2%
1.4 pts worse
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 3.5% · Q4 2.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.6% |
2.4%
2.2 pts worse
|
1.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 8.5% · Q3 3.7% · Q4 4.1% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
27.4%
4.8 pts better
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 35.5% · Q3 16.4% · Q4 24.4% · 4Q avg 22.6% |
| Percentage of long-stay residents with pressure ulcers | 9.3% |
6.1%
3.2 pts worse
|
5.1%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 11.4% · Q3 8.0% · Q4 5.4% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.6% |
84.4%
4.2 pts better
|
81.7%
6.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.8% · Q2 90.9% · 4Q avg 88.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.5% |
17.6%
3.9 pts worse
|
12.0%
9.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 25.7% · Expected 13.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.9%
0.4 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.4% |
78.9%
3.5 pts better
|
79.7%
2.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.3% |
21.5%
6.2 pts better
|
23.9%
8.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 17.1% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-15 · Fire 2023-11-15
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-30 · Fire 2022-11-30
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
B · Minimal harm
2022-11-30
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Not marked corrected
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-26
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 2025-04-12
F · Potential for more than minimal harm
2025-02-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-02-26
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 2025-04-12
D · Potential for more than minimal harm
2025-02-26
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 2025-04-12
Penalties and ownership
What sits behind the stars
Ownership
Francis E Cheney Jr Estate
5% Or Greater Direct Ownership Interest · Organization
Russell, Patricia
5% Or Greater Direct Ownership Interest · Individual
Atwood, Dale
Corporate Officer · Individual
Bergeron, Travis
Operational/Managerial Control · Individual
Bergeron, Travis
Corporate Officer · Individual
Cummings, Holly
Corporate Officer · Individual
Fatigati, Maria
Operational/Managerial Control · Individual
Rice, Warren
Corporate Officer · Individual
Russell, Patricia
General Partnership Interest · Individual
Russell, Patricia
Operational/Managerial Control · Individual
Russell, Patricia
Corporate Director · Individual
Russell, Patricia
Corporate Officer · Individual
Russell, Patricia
5% Or Greater Security Interest · Individual
Wells Fargo Bank, N.a.
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
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St. Johnsbury Health & Rehab
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1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $353,535 in total fines with 33 recent health deficiencies
#2
Union House Nursing Home
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#3
Greensboro Nursing Home
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4-star overall rating with 3-star inspections with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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