Inspection Report Summary
The most recent inspection on September 9, 2025, identified deficiencies related to inadequate supervision and accident prevention that resulted in a resident fall and hospitalization. Earlier inspections showed a pattern of deficiencies involving resident care issues such as failure to protect residents from abuse, dignity and respect concerns, incomplete care planning, staffing shortages, medication management, and infection control. Complaint investigations substantiated cases of verbal abuse and inadequate supervision, but fines or enforcement actions were not listed in the available reports. Prior reports also noted issues with timely reporting of incidents and refund processing. The inspection history indicates ongoing challenges in resident safety and care, with no clear improvement trend over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
100% worse than Vermont average
Vermont average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident fall incident where the facility allegedly failed to implement interventions to prevent accidents.
Complaint Details
The complaint investigation found that Resident #1 fell while receiving care from a Licensed Nursing Assistant without the required two-person assistance, leading to serious injury. The complaint was substantiated by interviews and record review.
Findings
The facility failed to ensure adequate supervision and accident prevention for Resident #1, who required two-person assistance for ADL care but was provided care by a single staff member, resulting in a fall that caused a fractured hip and required hospitalization.
Deficiencies (1)
Failure to implement interventions to ensure residents were free of accidents for 1 of 3 residents, resulting in a fall with hospitalization.
Report Facts
Residents affected: 3
Date of fall incident: Jul 26, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Assistant | Provided care to Resident #1 without assistance during the fall incident | |
| Unit Manager | Interviewed regarding care plan and supervision requirements for Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 4, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged verbal abuse of a resident by a Licensed Nursing Assistant (LNA) at the facility.
Complaint Details
The complaint investigation substantiated verbal abuse against Resident #281 by LNA #1, confirmed by the facility's internal investigation and the Administrator's interview.
Findings
The facility failed to protect one resident from verbal abuse by an LNA, confirmed through interviews, record reviews, and the facility's internal investigation. The Administrator acknowledged that the resident was not free from abuse.
Deficiencies (1)
Failure to protect a resident from verbal abuse by a Licensed Nursing Assistant.
Report Facts
Residents sampled: 10
BIMS score: 13
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 11, 2024
Visit Reason
The inspection was conducted due to complaints regarding undignified and disrespectful treatment of residents and failure to report an alleged resident-to-resident altercation.
Complaint Details
The complaint investigation found substantiated issues including undignified treatment of Resident #66 and failure to assist Resident #99 with meals, as well as failure to report a resident-to-resident verbal abuse incident involving Resident #66 to the State Survey Agency.
Findings
The facility failed to ensure that two residents were treated with dignity and respect during meal assistance and staff interactions, and failed to timely report a resident-to-resident verbal abuse incident to the State Survey Agency.
Deficiencies (2)
Failed to ensure that 2 of 36 sampled residents were treated with dignity and respect, including undignified staff interaction and lack of meal assistance.
Failed to timely report an alleged resident-to-resident altercation resulting in potential verbal abuse to the State Survey Agency.
Report Facts
Sampled residents: 36
Residents affected: 2
Residents affected: 1
Meal intake variation: 50
Meal intake variation: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Assistant (LNA) | Named in undignified interaction with Resident #66 and failure to assist Resident #99 | |
| Unit Manager (UM) | Wrote nursing note reflecting Resident #99's weight loss | |
| Dietary Manager | Checked food temperature and removed unpalatable meal for Resident #99 | |
| Licensed Practical Nurse (LPN) | Assisted Resident #99 with meal and confirmed need for assistance | |
| Administrator | Confirmed undignified behavior by LNA and failure to report resident-to-resident altercation |
Inspection Report
Routine
Census: 36
Deficiencies: 13
Date: Apr 11, 2024
Visit Reason
The inspection was a routine recertification survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, provision of a homelike environment, timely reporting of abuse, comprehensive care planning, professional nursing standards, adequate staffing, medication management, wound care, activities programming, food service, and safe food storage.
Deficiencies (13)
Failed to ensure 2 of 36 residents were treated with dignity and respect related to staff interaction and meal assistance.
Failed to provide a homelike environment on 1 of 4 units due to continuous loud alarms.
Failed to timely report an alleged resident-to-resident verbal abuse incident to the State Survey Agency.
Failed to develop and implement a complete person-centered care plan for 3 of 36 residents.
Failed to ensure services met professional standards by not following physician orders for PRN anti-anxiety medication and non-pharmacological interventions for 1 of 36 residents.
Failed to provide care and assistance for activities of daily living including shaving, nail care, and range of motion exercises for 4 of 36 residents.
Failed to provide an activities program that meets the needs of 5 of 9 sampled residents, including lack of engagement and individualized activities.
Failed to provide safe and effective skin and wound care for 2 of 36 residents by not performing and documenting weekly skin and wound assessments.
Failed to provide enough nursing staff to meet resident needs and have a licensed nurse in charge on each shift, impacting 2 of 4 units.
Failed to ensure a licensed pharmacist performed monthly drug regimen review including monitoring of heart rate prior to digoxin administration for 1 of 6 residents.
Failed to accurately monitor residents on psychotropic medications for behaviors and side effects for 3 of 6 residents.
Failed to serve food that is palatable and at a safe and appetizing temperature to 3 of 36 residents.
Failed to maintain refrigerated food temperatures at safe levels in the unit refrigerator used for resident drinks and snacks.
Report Facts
Residents sampled: 36
Residents affected by dignity deficiency: 2
Residents affected by homelike environment deficiency: 50
Residents affected by abuse reporting deficiency: 1
Residents affected by care plan deficiency: 3
Residents affected by professional standards deficiency: 1
Residents affected by ADL care deficiency: 4
Residents affected by activities deficiency: 5
Residents affected by wound care deficiency: 2
Units impacted by staffing deficiency: 2
Residents affected by pharmacist review deficiency: 1
Residents affected by psychotropic monitoring deficiency: 3
Residents affected by food service deficiency: 3
Refrigerator temperature: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LNA | Licensed Nursing Assistant | Named in undignified interaction with Resident #66 and meal assistance issues with Resident #99 |
| Administrator | Facility Administrator | Confirmed undignified behavior by LNA and loud alarms on Unit D |
| Unit Manager | Unit Manager | Wrote nursing note on Resident #99's weight loss and confirmed long fingernails and shaving expectations |
| Director of Nursing | Director of Nursing | Confirmed care plan deficiencies, medication administration issues, wound care deficiencies, and staffing concerns |
| Dietary Manager | Dietary Manager | Checked food temperature for Resident #99 and confirmed food was not palatable |
| Kitchen Manager | Kitchen Manager | Provided replacement meal for Resident #99 after original meal was discarded |
| LPN | Licensed Practical Nurse | Assisted Resident #99 with meal and confirmed meal assistance needs |
| Activities Assistant | Activities Assistant | Described activities program and resident engagement |
| Activities Director | Activities Director | Confirmed lack of formal activities assessment and one-on-one visits |
| Unit LPN | Licensed Practical Nurse | Confirmed long toenails and lack of podiatry services |
| Unit Manager | Unit Manager | Confirmed lack of pulse monitoring prior to digoxin administration and psychotropic medication monitoring |
Inspection Report
Deficiencies: 1
Date: Jan 31, 2024
Visit Reason
The inspection was conducted due to an active COVID-19 outbreak in the facility and to assess the facility's infection prevention and control program, specifically regarding adherence to testing protocols for staff to prevent the spread of COVID-19.
Findings
The facility failed to implement an infection prevention and control program that follows accepted national standards, as evidenced by not following recommended broad-based COVID-19 testing guidance for staff during an outbreak. The facility only conducted limited staff testing on 12/19/23 and 12/21/23 and did not perform facility-wide testing as recommended by the Vermont Department of Health (VDH) and CDC guidelines.
Deficiencies (1)
Failure to implement a system for controlling infections that follows accepted national standards, specifically not following accepted guidance for testing of staff to prevent the spread of COVID-19.
Report Facts
Date of positive COVID-19 staff case: Nov 16, 2023
Dates of staff testing: 2
Recommended testing frequency: 2
Recommended testing days: 3
Inspection Report
Deficiencies: 1
Date: Sep 18, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding refunding residents for charges paid for days they did not reside in the facility, specifically related to Resident #1's discharge and refund process.
Findings
The facility failed to ensure that Resident #1 was refunded charges already paid for days not residing in the facility within 30 days of discharge. The refund was delayed due to unresolved payment issues with a secondary insurance provider and unclear reimbursement processes within the facility.
Deficiencies (1)
Failed to ensure that each resident is refunded charges already paid for days the resident did not reside in the facility within 30 days of discharge for Resident #1.
Report Facts
Refund amount: 6970
Outstanding balance: -6790
Date of discharge: Mar 15, 2023
Refund submission date: Apr 11, 2023
Regulatory timeframe: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed insurance payment issues and refund process | |
| Corporate Business Office employee | Confirmed managed care provider payment issues and documentation follow-up responsibility | |
| Business Office Manager (BOM) | Stated instructions from Corporate Office regarding refund issuance and communication with Resident #1's representative |
Inspection Report
Deficiencies: 9
Date: Apr 5, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication administration, activities, and vaccination status at Mountain View Center Genesis Healthcare.
Findings
The facility was found deficient in multiple areas including failure to develop timely and comprehensive care plans, inadequate activity programming, improper wheelchair positioning, failure to follow bowel management protocols, unsafe environmental conditions, medication administration errors, and failure to update pneumococcal vaccinations for eligible residents.
Deficiencies (9)
Failure to develop baseline care plans within 48 hours of admission for 6 of 37 sampled residents.
Failure to develop and implement comprehensive care plans meeting all resident needs for 6 residents including dialysis and bowel management.
Failure to provide activities based on resident preferences for 2 residents, resulting in lack of socialization and participation.
Failure to provide appropriate treatment and care including proper wheelchair positioning and bowel management, resulting in rehospitalization and discomfort for 2 residents.
Unsafe environmental conditions including loose toilet safety bars in multiple rooms and a heating register with dangerously high temperature.
Failure to update fall care plans with new interventions after falls for 3 residents.
Failure to provide appropriate care and interventions for residents with dementia-related behaviors for 2 residents.
Medication administration errors with a 19.35% error rate due to late administration of medications.
Failure to ensure pneumococcal vaccinations were administered to 4 eligible residents despite consent.
Report Facts
Medication errors: 6
Medication error rate: 19.35
Temperature: 146
Temperature: 143
Days delayed: 42
Days delayed: 144
Days delayed: 9
Days delayed: 10
Days delayed: 5
Days delayed: 277
Days delayed: 14
Falls: 5
Falls: 1
Falls: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Confirmed baseline care plans should include diagnoses, medications, ADLs, skin integrity, falls, and pain; confirmed lack of specific behavior triggers in care plans. | |
| Director of Nursing | Confirmed baseline care plans should include care needs including catheter care, ADLs, and falls; confirmed care plans not updated after falls; confirmed medication administration errors. | |
| Licensed Nursing Assistant | Reported knowledge of resident assistance needs for ADLs by asking nurse or reviewing documentation. | |
| Licensed Practical Nurse Unit Manager | Confirmed bowel management protocol and lack of care plan for bowel management for Resident #58. | |
| Activity Director | Reviewed activity participation records and confirmed lack of documentation for activity participation or refusal. | |
| Administrator | Confirmed lack of documentation for activity participation; confirmed unsafe environmental conditions; confirmed wheelchair armrests not obtained for Resident #87. | |
| Physical Therapy/Occupational Therapy Assistant | Reported lack of follow-up on wheelchair armrests and poor positioning for Resident #87. | |
| Director of Environmental Services | Confirmed heating register temperature was above safe range and took immediate action. | |
| Infection Preventionist | Confirmed residents were not up to date with pneumococcal vaccines. |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Apr 13, 2022
Visit Reason
The inspection was conducted as part of the annual survey of Mountain View Center Genesis Healthcare to assess compliance with regulatory requirements and quality of care standards.
Findings
The facility was found deficient in several areas including failure to ensure accurate advanced directives documentation, improper use of physical restraints without physician orders, failure to conduct significant change assessments, incomplete care plans, failure to implement medication administration as ordered, inadequate fall prevention interventions, and failure to provide proper education and documentation regarding influenza vaccinations.
Deficiencies (7)
Failed to ensure the resident's right to formulate an accurate advanced directive in the medical record for one resident.
Failed to assess, care plan, and obtain a physician's order prior to the use of a physical restraint for one resident.
Failed to comprehensively assess a resident experiencing a significant change using the CMS-specified Resident Assessment Instrument process.
Failed to implement care plan interventions regarding administering medications as ordered for one resident.
Failed to revise the plan of care to reflect necessary care and services for three residents.
Failed to ensure services provided met professional standards of quality regarding resident medications administered as ordered for one resident.
Failed to develop and implement policies and procedures for flu and pneumonia vaccinations including education and documentation for residents or their representatives.
Report Facts
Residents sampled: 32
Days medication not administered: 4
Falls: 2
Falls: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN | Interviewed regarding code status referencing physician orders | |
| Nurse Manager | Interviewed regarding nurses' expectations for CPR orders and restraint use | |
| RN | Interviewed regarding use of COLST form and electronic health record for code status | |
| Director of Nursing | Confirmed COLST and electronic orders should match and physician updates | |
| Unit Manager | Interviewed regarding restraint use and medication administration issues | |
| MDS Coordinator | Confirmed significant change assessment should have been completed | |
| Unit Manager | Interviewed regarding fall prevention procedures and care plan updates | |
| Infection Preventionist | Interviewed regarding flu vaccine consent and education process | |
| Director of Nursing | Confirmed flu vaccine consent and education policies |
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