Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Villa Rehab during CMS and state inspections, most recent first.
An LNA verbally abused a resident after urine splashed on the LNA's face, yelling and using profanity while the resident was naked and appeared terrified. An LPN witnessed the incident, and the resident's record and the facility's investigation documented that the resident, who had dementia, was startled and terrified while the employee also made a threatening statement about wanting to punch the resident.
Failure to submit timely abuse investigation report: An LPN witnessed an LNA curse at a resident after the resident urinated in the LNA's face, and later saw the resident naked with urine on the floor and appearing terrified. The facility could not provide evidence that the required 5-day investigative report was submitted to the state agency within the required timeframe.
A resident with cognitive impairment, Alzheimer’s disease, osteoarthritis, and muscle weakness, identified as at risk for falls and dependent on staff with a mechanical lift for transfers, experienced multiple falls in the room involving a wheelchair. After an initial fall with injury, the care plan was only updated to note the fall and to follow facility policy, and a later fall led to adding a vague "monitor closely" intervention without timeframes or clear staff responsibilities. No specific interventions were implemented to address wheelchair-related falls or self-transfer attempts, and supervision was not formally increased beyond 2‑hour checks. An LPN did not know how to access the care plan and confirmed the absence of targeted fall interventions, while the DON confirmed that IDT notes were not in the record and that a sleep hygiene assessment was not incorporated into the care plan. The resident ultimately sustained bilateral displaced ankle fractures after another fall.
Two residents with identified fall risk experienced multiple falls or near-falls, including incidents from wheelchairs, from bed, and onto the floor or fall mats, yet their care plans were not updated with specific fall-prevention interventions after these events. One resident with decreased mobility, pain issues, cognitive deficits, and prior lower extremity fractures had documented falls while attempting self-transfers from a wheelchair, but the care plan only noted monitoring and lacked new interventions. Another resident with bilateral lower extremity amputation, decreased mobility/balance, and a high fall-risk score had several incidents involving self-transfer attempts, floor and fall-mat findings, and skin tears, but no additional interventions were added to the care plan despite changes in monitoring and environment. An LPN reported not knowing how to access a care plan until shown, and the DON acknowledged that the care plans did not reflect the needed updates after these recurrent falls.
The facility failed to maintain safe handwashing water temperatures, with readings between 121.1 and 124.1 degrees Fahrenheit in common areas and resident rooms. These temperatures were confirmed by the Dietary Manager and LNHA, despite logs showing no temperatures above 119 degrees Fahrenheit.
The facility failed to maintain food safety standards by not documenting freezer and refrigerator temperatures properly, serving food at incorrect temperatures, and not discarding expired items. The Dietary and Housekeeping Manager confirmed these issues, indicating a lapse in food safety protocols.
The facility's 2024 assessment failed to specify necessary staff competencies for resident care. The LNHA confirmed that while staff are evaluated during orientation and annually, the assessment did not identify specific training or competencies needed. This deficiency could impact all 20 residents.
The facility failed to administer prescribed ophthalmic medications to two residents as ordered, with multiple instances of missed doses due to medication unavailability. Despite facility policy requiring physician notification for such occurrences, there was no documentation that the physicians were informed. This involved five different nurses, including the DON, who did not follow the protocol for notifying the provider about the missed medications.
The facility did not maintain an effective training program for behavioral health or trauma-informed care, as required by the facility assessment. Despite having residents with various mental health diagnoses, 4 LNAs and 3 RNs lacked documented training. The DON confirmed the absence of training records, and only one staff member attended a 2023 training session.
The facility failed to support residents' rights to file grievances anonymously, affecting all residents. The grievance process posted in the entryway lacked details on anonymous submissions, and no grievance forms were available. Interviews with two residents revealed that grievances must be filed through the Social Services Department or the Administrator, with no anonymous option. The Administrator confirmed the absence of a process for anonymous grievance filing.
Resident exposed to verbal abuse by LNA
Penalty
Summary
The facility failed to protect one resident from verbal abuse by an LNA. During the early morning hours, an LPN witnessed the LNA approach the med cart and curse at her, saying she needed to go get the resident and then cursing again that the resident had urinated in the LNA's face. The LPN then went into the resident's room and found the resident standing naked with urine on the floor and appearing terrified. While the LPN was assisting the resident with care, the LNA entered the room and cursed at the resident again about urinating in the LNA's face. The resident involved had a diagnosis of dementia. The resident's progress note documented that an LNA went into the room and cursed at the resident about urine splashing on the LNA's face, and that the resident looked startled and terrified. The facility's complaint investigation also stated that the employee was seen yelling at and using profanity at the resident after urine accidentally splashed on his face, and that the employee said he wanted to punch the resident in the face because he was so mad. The facility policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents or within their hearing distance.
Failure to Submit Timely Abuse Investigation Report
Penalty
Summary
The facility failed to submit its five-day investigative report to the Division of Licensing and Protection within the required timeframe after an allegation of abuse involving a Licensed Nursing Assistant and Resident #1. An LPN reported that while on duty, she witnessed the LNA approach her at the med cart, curse at her, and say she needed to go get Resident #1 because the resident had urinated in the LNA's face. The LPN then entered the resident's room and observed Resident #1 standing naked with urine on the floor and appearing terrified. While the LPN was assisting the resident with care, the LNA entered the room and cursed at the resident about urinating in the LNA's face. During interview, the Administrator and DON stated they could not find the five-day investigative report for the incident and were unable to provide evidence that the report had been submitted on time. The facility policy required that within 5 working days of the incident, sufficient information describing the results of the investigation and any corrective actions taken, if the allegation was verified, be reported to the state agency and other required agencies. Another facility policy stated that within 5 working days, the Social Worker, DON, and/or Administrator would complete a thorough investigation and send the investigative summary to the Division of Licensing and Protection, Adult Protective Services, and local law enforcement when used.
Failure to Revise Fall-Prevention Care Plan After Repeated Wheelchair Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and effective fall-prevention interventions for a cognitively impaired resident with Alzheimer’s disease, osteoarthritis of the knee, and muscle weakness, who was dependent on staff for ADLs and required a mechanical lift for transfers. Fall risk evaluations conducted on 12/30/25 and 1/13/26 identified the resident as at risk for falls. The facility’s fall policy required individualized fall-prevention strategies and ongoing monitoring and modification of interventions. The resident’s fall care plan included general interventions such as assessing for drugs that may cause falls, encouraging rest in bed when tired, involving the resident in activities as tolerated, and maintaining safety (call bell within reach, bed in lowest position, proper lighting, appropriate footwear). After a fall on [DATE] in which the resident was found on the floor with severe knee pain and sustained a head hematoma and large knee bruise, the only care plan update was to document the fall with injury and to “follow facility fall policy,” without adding specific new interventions. The resident experienced subsequent falls on 1/16/26, 2/5/26, and 2/8/26, all occurring in the resident’s room and involving the wheelchair, including one fall while attempting to self-transfer. After the 1/16/26 fall, the care plan was updated only to add “will monitor closely,” with no timeframes or clarification of staff responsibilities, and no new interventions were added after the 2/5/26 fall despite the emerging pattern of wheelchair-related falls. On 2/8/26, staff responded to the resident’s screams and found the resident on the floor in front of the wheelchair, in acute distress with right leg pain, leading to hospital evaluation and diagnosis of bilateral displaced severe ankle fractures. Interviews revealed that an LPN did not know how to access the resident’s care plan and confirmed there were no specific interventions to prevent falls from the wheelchair and no interventions added after the 1/16/26 or 2/5/26 falls. The DON confirmed that increased supervision was not implemented, the resident remained on 2‑hour checks without formal increase in supervision, IDT notes were not in the record, and the only additional intervention (a sleep hygiene assessment) was not reflected in the care plan.
Failure to Update Care Plans With Fall-Prevention Interventions After Recurrent Falls
Penalty
Summary
The deficiency involves the facility’s failure to develop and update comprehensive care plans with appropriate fall-prevention interventions following recurrent falls for two residents. For Resident #1, the care plan dated 10/17/24 and revised 2/12/26 identified the resident as at risk for falls related to decreased mobility, pain issues, cognitive deficits, and recent falls, including a recent fall with several fractures in both lower extremities. A provider note dated 1/16/26 documented a fall without injury when the resident attempted to self-transfer and lost balance, and the care plan entry for that date only stated the resident fell out of the wheelchair in the bedroom and would be monitored closely. A subsequent health status note on 2/5/26 described staff hearing a thud and finding the resident on the floor in front of the wheelchair, denying head injury, with pain consistent with baseline and stable vital and neuro checks. Despite these recurrent falls from the wheelchair on 1/16/26 and 2/5/26, review of Resident #1’s care plan showed no added interventions specifically addressing prevention of falls from the wheelchair. This was inconsistent with the facility’s Comprehensive Care Plans policy, which requires measurable objectives, time frames, and documentation of alternative interventions as needed, as well as notification of qualified staff when changes are made. During interview, an LPN stated she did not know how to access the resident’s care plan until shown and confirmed there were no interventions implemented in the care plan to prevent the resident from falling from the wheelchair and no fall interventions added after the falls on 1/16/26 and 2/5/26. The DON confirmed that Resident #1’s care plan should have been updated with interventions for falls out of the wheelchair for those dates. For Resident #2, the care plan dated 8/27/25 and revised 1/23/26 identified the resident as at risk for falls related to bilateral left knee amputation, decreased mobility/balance, and a history of falls, with a fall risk assessment score of 17/32 indicating fall risk. An incident note dated 1/11/26 documented the resident found on the floor, covered in feces, sitting on the bottom with back against the wall near the wheelchair, unable to give a credible account of the fall, with the fall mat undisturbed; the care plan noted the resident was found on the floor after attempting to self-transfer with no injury. Another incident note on 1/23/26 documented the resident found on the floor mat beside the bed, and a 2/3/26 note described the resident found sitting on the fall mat after reporting a fall scenario, with no known injuries. A 2/1/26 note documented an attempted self-transfer from bed to get a remote, during which an LNA intervened to prevent a head-first fall, resulting in two skin tears treated and neurovitals within normal limits. Review of Resident #2’s care plan showed no additional documented interventions added for the falls that occurred on 1/11/26 and 1/23/26, and the DON confirmed that interventions such as room change, rehab referral, and frequent checks were not reflected in the care plan.
Unsafe Water Temperatures in Resident Areas
Penalty
Summary
The facility failed to ensure that resident environments were free of accident hazards related to safe handwashing water temperatures. During observations, the hot water from a faucet in an unlocked, common area bathroom was found to be too hot to hold a hand under comfortably, with a thermometer reading of 124.1 degrees Fahrenheit. Further assessments revealed similar high temperatures in other common area sinks and resident rooms, with readings ranging from 121.1 to 123.4 degrees Fahrenheit. These temperatures were confirmed by the facility's Dietary Manager and the Licensed Nursing Home Administrator (LNHA), who maintained a water temperature monitoring log that did not document temperatures above 119 degrees Fahrenheit. However, rechecks of the water temperatures by the surveyor and the LNHA confirmed the elevated temperatures, indicating a discrepancy in the monitoring process.
Food Safety and Temperature Documentation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by improper storage and temperature documentation of food items. Specifically, the facility did not document the temperatures of one out of three freezers and two out of three refrigerators. An abnormal temperature of -12 degrees Fahrenheit was recorded for the Meat Freezer without a documented month, and the Dietary and Housekeeping Manager was unable to confirm the month of the log. Additionally, the milk refrigerator and milk cooler had several recorded temperatures outside the facility's accepted range, with no documented corrective actions. Furthermore, the facility served food items to residents at temperatures below the facility's standards. Ground entrees were recorded at temperatures lower than the required 170 degrees Fahrenheit, and other entrees and vegetables were below the accepted 160 degrees Fahrenheit. Additionally, during a kitchen assessment, expired Magic Cup ice cream cups were found in one of the basement freezers, which should have been discarded but were not. These findings indicate a failure to maintain proper food safety protocols, potentially compromising the quality of care provided to residents.
Facility Assessment Lacks Specific Staff Competencies
Penalty
Summary
The facility failed to adequately address staff competencies in their facility-wide assessment, which is necessary to provide the level and types of care needed for the resident population. The 2024 Facility Assessment did not specify the competencies required to care for the residents, nor did it indicate which competencies would be evaluated. During an interview, the Licensed Nursing Home Administrator (LNHA) stated that licensed staff are evaluated for competency during orientation and annually, with additional training provided as needed. However, the LNHA confirmed that the facility assessment did not identify the specific training or competencies needed to provide care to the residents. This deficiency has the potential to affect all 20 residents residing in the facility.
Failure to Administer Medications and Notify Physicians
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice regarding physician orders and notification for two residents. Resident #6 had physician orders for Azithromycin Ophthalmic Solution to be administered twice daily for severe blepharitis, but the medication was not given as ordered seven times over nine days. Nursing notes indicated that the medication was unavailable and on order, but there was no documentation that the physician was notified about the missed doses. An RN confirmed that the protocol is to notify the provider if medication is unavailable, but this was not done. Similarly, Resident #17 had physician orders for Erythromycin Ophthalmic Ointment to be administered twice daily for blepharitis, but the medication was not administered as ordered nine times over eighteen days. Nursing notes again cited medication unavailability, but there was no documentation of physician notification. The DON confirmed that the facility's policy requires contacting the resident's provider for missed or unavailable medications, but this was not followed. The records showed that five different nurses, including the DON, failed to administer medications as ordered and did not notify the physician as required.
Deficiency in Behavioral Health Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program related to behavioral health or trauma-informed care and services, as determined by resident needs and the facility assessment. The 2024 Facility Assessment revealed that the facility had residents diagnosed with anxiety disorder, depression, manic depression, psychiatric disorder, and Post Traumatic Stress Disorder. However, a review of employee training and competency files showed that 4 Licensed Nursing Assistants and 3 Registered Nurses had no documented evidence of receiving behavioral health and trauma-informed care training upon hire or annually for 2024. During an interview, the Director of Nursing confirmed the absence of documented evidence of such training for the staff. Although the facility Administrator provided a training log for behavioral health and trauma completed in 2023, only one of the sampled staff members had attended the training.
Failure to Support Anonymous Grievance Filing
Penalty
Summary
The facility failed to support residents' rights to file grievances anonymously, which has the potential to affect all residents. Observations revealed that the facility's entryway bulletin board displayed the grievance process, including the grievance officer's contact information, but lacked details on filing grievances anonymously. There was no evidence of grievance forms or information on submitting grievances anonymously. The facility's policy, revised on 2/2/24, mentioned that grievances could be filed anonymously but did not provide a process for doing so. Interviews with two residents indicated that grievances must be filed through the Social Services Department or the Administrator, with no system in place for anonymous submissions. One resident expressed a desire for the option to file grievances anonymously. The Administrator confirmed that the facility no longer provides grievance forms in common rooms and acknowledged the absence of a process for anonymous grievance filing.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 38 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near St. Albans
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Franklin County Rehab Center, Llc | 0.5 mi | ★★★★★ | 10 | 0 |
| Saint Albans Healthcare And Rehabilitation Center | 1.2 mi | ★★★★★ | 3 | 0 |
| Champlain Valley Physicians Hosp Med Ctr S N F | 20.7 mi | ★★★★★ | 0 | 0 |
| Clinton County Nursing Home | 20.8 mi | ★★★★★ | 0 | 0 |
| Plattsburgh Rehabilitation And Nursing Center | 20.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Villa Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.