Cycle 1
Health 2025-07-30 · Fire 2022-05-25
13 health deficiencies
Top issue: Infection Control (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
St. Albans, VT
The Villa Rehab
2-star overall rating with 2-star inspections with $13,380 in total fines with 13 recent health deficiencies
7 Forest Hill Drive, St. Albans, VT
(802) 524-3498
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
30
Certified beds
Average residents
20
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-04-01
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
1.23
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 0.90 · national 0.87
Aide hours / resident day
3.26
Nurse aide staffing · state 2.60 · national 2.35
Total nurse hours
5.61
All reported nurse hours · state 4.31 · national 3.89
Licensed hours
2.36
RN + LPN hours · state 1.71 · national 1.54
Weekend hours
4.51
Weekend nurse staffing · state 3.69 · national 3.43
Weekend RN hours
0.70
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
1.21
CMS adjusted RN staffing hours
Adjusted total hours
5.54
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 60% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,692
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9961
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.24
Baseline 18.87% · Performance 19.00% · Measure score 5.24 · Achievement 5.24 · Improvement 0
Healthcare-associated infections
7.69
Baseline 5.44% · Performance 5.54% · Measure score 7.69 · Achievement 7.69 · Improvement 0
Total nurse turnover
0
Baseline 54.84% · Performance 65.79% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.71% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 6.25% · Lower 95% interval 6.59% |
| Discharge to community | 48.48% |
50.57%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 114 · Observed rate 44.74% · Lower 95% interval 39.89% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 75 · Denominator 75 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 75 |
| Discharge self-care score | 53.97% |
53.69%
0.3 pts better
|
Numerator 34 · Denominator 63 |
| Discharge mobility score | 50.79% |
50.94%
0.1 pts worse
|
Numerator 32 · Denominator 63 |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 3 · Denominator 75 · Adjusted rate 5.24% |
| Healthcare-associated infections requiring hospitalization | 5.54% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 0% · Lower 95% interval 2.96% |
| Staff COVID-19 vaccination coverage | 65.38% |
8.2%
57.2 pts better
|
Numerator 17 · Denominator 26 |
| Staff flu vaccination coverage | 50% |
42%
8 pts better
|
Numerator 14 · Denominator 28 |
| Discharge function score | 58.73% |
56.45%
2.3 pts better
|
Numerator 37 · Denominator 63 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 45 · Denominator 45 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 47.37% |
25.2%
22.2 pts better
|
Numerator 18 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.4% |
5.9%
4.5 pts worse
|
3.3%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
10.0%
8.4 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
6.0%
6 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.9% |
16.4%
4.5 pts better
|
19.6%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.3% |
20.9%
10.6 pts better
|
16.7%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.3% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.0% |
19.3%
1.7 pts worse
|
16.3%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.4% |
20.3%
0.1 pts worse
|
14.9%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.4% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.4%
0.8 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.5% |
27.4%
4.9 pts better
|
19.8%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.5% |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
6.1%
1 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
84.4%
13.7 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 100.0% · Q3 100.0% · Q4 95.2% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 29.9% |
17.6%
12.3 pts worse
|
12.0%
17.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.9% · Observed 30.4% · Expected 11.4% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.8% |
78.9%
1.1 pts worse
|
79.7%
1.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.1% |
21.5%
6.4 pts better
|
23.9%
8.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 15.2% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-31 · Fire 2019-11-20
6 health deficiencies
Top issue: Administration (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-06-07 · Fire 2018-11-28
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
B · Minimal harm
2019-11-20
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
B · Minimal harm
2019-11-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
B · Minimal harm
2019-11-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Not marked corrected
B · Minimal harm
2019-11-20
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Not marked corrected
B · Minimal harm
2019-11-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Not marked corrected
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-30
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-05
F · Potential for more than minimal harm
2025-07-30
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 2025-09-09
F · Potential for more than minimal harm
2025-07-30
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 2025-08-29
F · Potential for more than minimal harm
2025-07-30
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-08-29
F · Potential for more than minimal harm
2025-07-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-05
F · Potential for more than minimal harm
2025-07-30
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-08-29
F · Potential for more than minimal harm
2025-07-30
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-09-09
F · Potential for more than minimal harm
2025-07-30
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 2025-09-04
E · Potential for more than minimal harm
2025-07-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-07-30
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-30
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 2025-08-29
D · Potential for more than minimal harm
2025-07-30
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-30
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 2025-09-05
F · Potential for more than minimal harm
2024-07-31
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 2024-07-31
F · Potential for more than minimal harm
2024-07-31
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 2024-08-06
F · Potential for more than minimal harm
2024-07-31
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-07-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-07-31
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-09-03
C · Minimal harm
2024-07-31
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-08-05
D · Potential for more than minimal harm
2023-06-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-06
Penalties and ownership
What sits behind the stars
$13,380
2024-07-31
Fine
Fine · fine $13,380
Fine
Ownership
Condon, Coleen
5% Or Greater Direct Ownership Interest · Individual
Mattison, Deana
Operational/Managerial Control · Individual
Strenio, Jonathan
Operational/Managerial Control · Individual
Theoria Medical
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Franklin County Rehab Center, LLC
St. Albans, VT
5-star overall rating with 5-star inspections with 3 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
Jump out