Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 Mountain View Center Genesis Healthcare during CMS and state inspections, most recent first.
Expired meds were found in a medication cart and a med room, including Mirtazapine 15 mg for one resident and two OTC Bisacodyl 5 mg bottles. In addition, an RN left a med cart unlocked in a common area on a memory care unit while residents were present, and she confirmed the cart should have remained locked when unattended.
Failure to provide privacy during wound care. An LPN assessed and applied a dressing to a resident while the resident was eating lunch, with the room door open and the privacy curtain not pulled. The interaction was visible from the hallway, and the LPN and Unit Manager confirmed privacy should have been provided and that dressing care should not occur during mealtime.
Failure to care plan positioning and hearing needs. One resident was observed leaning to the right in a wheelchair with wedges and other positioning devices, and staff confirmed the resident frequently leans right and needs position changes, but positioning and wheelchair devices were not on the care plan. Another resident reported a broken hearing aid and staff said the hearing aids were being replaced by ENT, yet the care plan initially had no documentation for hearing, communication needs, or hearing aid use; those items were added later.
A resident with anxiety, major depressive disorder, and dementia had intact cognition on MDS but showed an escalating pattern of verbal and physical aggression toward staff and other residents, including swearing, name-calling, threats, and striking another resident. The resident’s care plan for potential verbal and physical behaviors was not revised with newer interventions despite repeated incidents, and the DON confirmed there was no evidence of updated care plan interventions.
A resident with rheumatoid arthritis, DJD, osteoporosis, and contractures, care planned for two-person Hoyer lift transfers, was being moved from bed to wheelchair when two LNAs reported the resident began leaning and sliding in the sling, with the lift striking bed mechanics and the resident not appearing properly supported. The resident slipped from the sling at about 12 inches above the bed, sustaining multiple skin tears on the right arm and leg, later documented as total and partial flap loss, and subsequently reported left shoulder and right hip pain. An ED evaluation identified right femur and left humerus fractures, along with skin tears and bruising. Staff accounts noted the resident contacted parts of the lift, including the arm and piston, while sliding, and the MD attributed the injuries to the described fall and shearing against the sling. The DON confirmed that one LNA had not demonstrated competency in Hoyer lift use prior to the incident, despite facility policy requiring staff training and demonstrated competency in safe resident handling equipment.
A contracted LNA was allowed to provide care, including operating a Hoyer lift, without the facility verifying clinical competencies such as Safe Resident Handling. The facility relied on a "Mandatory Training Participation Guide" packet, which lacked documented competency assessments and was not confirmed as an agency document. While a contracted LNA was transferring a resident with a Hoyer lift, the resident—who was care planned for two-person Hoyer transfers due to mobility issues—fell and sustained fractures of the right femur and left humerus, multiple skin tears, and bruising. Record review showed this LNA had worked 11 shifts without competency verification, and that dozens of other contracted staff had also worked without documented competency checks by the facility.
A resident with severe mobility limitations and legal blindness, who required two-person assistance for ADL care, was left in the care of a single LNA. While the LNA attempted to change bed linens and reposition the resident alone, the resident fell from the bed, resulting in hospitalization for a fractured hip and pelvic injuries. The care plan's requirement for two-person assistance was not followed, as confirmed by staff interviews.
A resident with multiple medical conditions and intact cognition was verbally abused by an LNA after an incontinence episode. The LNA made disparaging remarks about the resident's continence, which were confirmed by the resident, a roommate, and another staff member. The facility's investigation substantiated the verbal abuse.
The facility failed to maintain a homelike environment on Unit D due to continuous loud call bell alarms affecting approximately 50 residents. Observations during a survey revealed alarms going off for extended periods during meals, louder than the TV volume. Residents and staff confirmed the disruptive nature of the alarms, with the Administrator acknowledging the issue.
The facility failed to create comprehensive care plans for three residents, leading to unmet needs. A resident experienced significant weight loss without updated nutritional assessments or care plan interventions. Another resident's preference for bi-weekly shaving was not documented, and staff were unaware of this need. A third resident with Parkinson's disease did not have a care plan addressing her need for hand exercises to manage contractures.
The facility failed to provide adequate personal hygiene and nail care for residents unable to perform activities of daily living. One resident had long, dirty fingernails and facial hair, while another was not shaved according to their preference due to staff being too busy. A third resident had excessively long toenails, and a resident with a pressure ulcer had worsening nail conditions due to lack of podiatry services. The facility lacked a system to track residents needing podiatry care.
The facility failed to meet the activity needs of several residents, including those with cognitive impairments and mobility limitations. Residents reported a lack of engagement and variety in activities, with some expressing a desire for more in-room activities and opportunities to go outside. Activity logs and care plans were outdated or incomplete, and there was no formal process for determining or documenting one-on-one visits.
The facility failed to provide adequate nursing staff, resulting in delayed assistance for residents' basic needs and personal care. Residents reported long waits for help with toileting, walking, and personal grooming. Staff confirmed the difficulty in managing care with insufficient aides, especially on weekends. Additionally, a resident at risk for malnutrition did not receive timely meal assistance, highlighting the impact of staffing shortages on resident care.
A facility failed to monitor behaviors and side effects in residents using psychotropic drugs. One resident with anxiety and depression was given Hydroxyzine without behavior documentation. Another resident with schizophrenia and bipolar disorder was not monitored for behaviors despite being on Paroxetine and Risperidone. A third resident with dementia received Seroquel and Trazadone without monitoring for adverse effects, despite frequent sleepiness. The DON and LPN confirmed the lack of monitoring.
The facility failed to serve meals that were palatable and timely to three residents. A resident with Alzheimer's and other conditions did not receive a meal for 40 minutes, resulting in non-palatable food. Additionally, two residents were left without meals while another resident at their table was served, due to late food cart arrival.
The facility failed to maintain safe refrigerated food temperatures in the Cherry Tree Country Kitchen. A refrigerator storing resident drinks and snacks was found open, with temperatures recorded at 56 degrees, despite logs showing 41 degrees. An LNA noted the refrigerator had been broken for some time, and the Dietary Manager confirmed the issue. The administrator was unaware of the ongoing problem with the refrigerator seal.
A facility failed to consistently follow physician orders for a resident with anxiety and major depressive disorder. The resident's care plan required non-pharmacological interventions before administering PRN Hydroxyzine, but these were documented only 5 out of 22 times. The DON confirmed the oversight, highlighting a lapse in adhering to professional standards of care.
The facility failed to conduct and document weekly skin and wound assessments for two residents, leading to unaddressed and worsening skin conditions. One resident with morbid obesity and diabetes had a bleeding wound on the thigh, with no assessments since February, despite a care plan and treatment order. Another resident with venous insufficiency had a coccyx wound treated without a care plan or physician order until days later, and inaccurate documentation of skin status. The DON confirmed the lack of required assessments.
A facility failed to follow pharmacy recommendations for monitoring heart rate before administering digoxin to a resident with atrial fibrillation. The pharmacy review required checking the apical pulse and withholding the medication if the pulse was below 60 bpm. However, these instructions were not documented in the medication order, and there was no evidence that the pulse was checked before administration, as confirmed by the Unit Manager.
Two residents were not treated with dignity and respect in a facility. A resident with dementia was distressed after an LNA forcefully cut their food and ignored their inquiry. Another resident, at risk for malnutrition, was left without meal assistance while others were served. The resident attempted to eat without help, and their food was found unpalatable after being left out. An LPN confirmed the resident required assistance.
A facility failed to report a resident-to-resident altercation involving potential verbal abuse to the State Survey Agency. The incident occurred when a resident exhibited aggressive behavior towards their roommate due to frustration over bathroom usage, leading to incontinence. Staff intervened to prevent further escalation, but the incident was not reported as required by the facility's Abuse Prohibition policy.
Expired Medications Found and Medication Cart Left Unlocked
Penalty
Summary
Drugs and biologicals were not maintained in accordance with accepted storage principles because expired medications were found in both a medication cart and a medication room. On the Beach unit medication cart, Mirtazapine 15 mg for one resident was observed expired on 5/23/26, and the nurse confirmed it was expired. In the Beach unit medication room, two over-the-counter bottles of Bisacodyl 5 mg were observed expired in 4/2026, and nurses on the unit confirmed both bottles were expired. Medication carts were also not kept locked when unattended. On the Cherrytree memory care unit, an unlocked medication cart was observed in the common area while several residents were present, and no staff member was seen at or near the cart. During interview, the RN assigned to the cart confirmed it should have remained locked when unattended and stated she failed to lock it. The facility policy stated that medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by authorized persons.
Failure to Provide Privacy During Wound Care
Penalty
Summary
Privacy during wound care was not provided for one sampled resident. During observation on 6/1/26 at 12:16 PM on the Dogwood unit, an LPN was preparing supplies from a wound care cart outside Resident #93's room while the resident sat on the side of the bed eating lunch. The LPN rolled up the resident's right shirt sleeve and began assessing the area where a bandage would be applied while the resident continued eating salad and the LPN documented and labeled the dressing. When ready to apply the dressing, the LPN asked the resident to put the salad down. The interaction was observed from the hallway with the door open and no privacy curtain pulled, and five people were seen walking by the room. The LPN later confirmed the door and privacy curtain were open and should have been closed for privacy during wound care. The Unit Manager also confirmed that it is never appropriate for a dressing to be applied or removed during mealtime and that privacy should always be provided for wound care.
Failure to Care Plan Positioning and Hearing Needs
Penalty
Summary
The facility failed to care plan two sampled residents for identified needs related to positioning and hearing/communication. Resident #11 was observed sitting in a wheelchair and leaning over the right arm rest, with a high-back wheelchair, head rest, leg rests, a cushioned foot board, and two cushioned wedge devices positioned at the right hip. An LPN stated that Resident #11 leans to the right frequently and requires position changes as needed, and also noted the resident had recently received a new high-back wheelchair to assist with positioning. Record review showed Resident #11 was not care planned for positioning or for the use of additional positioning devices while in the wheelchair, and the Unit Manager confirmed this was not care planned and should have been. Resident #63 stated that one hearing aid had broken and was waiting for a replacement, and the Unit Manager stated the resident's hearing aids were being replaced by ENT. Record review of the care plan showed no documentation concerning hearing, communication needs, or use of hearing aids. The facility's OPS416 Person-Centered Care Plan policy states the interdisciplinary team will establish goals and outcomes of care and other factors related to the effectiveness of the plan of care. The DON later presented a care plan showing Resident #63 was care planned for hearing, but the hearing area and interventions had been added the same day as the interview, and the DON confirmed they were not added until that date.
Failure to Revise Care Plan for Escalating Aggressive Behaviors
Penalty
Summary
The facility failed to revise and implement a person-centered care plan for one resident with diagnoses including anxiety disorder, major depressive disorder, and dementia. The resident’s MDS assessments documented a BIMS score of 15, indicating fully intact cognition. Despite this, the record shows an escalating pattern of verbal and physical aggression toward others, including swearing at the Social Worker after being told that others felt the resident was putting them down or telling them what they could and could not do, yelling and being accusatory toward others, and calling the Social Worker names and using profanity. Additional records showed continued behavioral incidents involving another resident, including swatting that resident after a dispute over coloring paper, slapping that resident on the back, and later entering the dining room calling that resident a derogatory name and telling the nurse to f-off when redirected. Another note documented the resident threatening the same resident, stating there was no problem fighting and using profanity while leaving the room. The Social Worker confirmed the resident became jealous and possessive of belongings and seating and had acted out verbally and physically toward other residents. Although the care plan had a focus related to potential verbal and physical behaviors and was last revised earlier, there were no newer interventions documented to address the continuing escalating behaviors, and the DON confirmed there was no evidence of new care plan interventions.
Injury During Hoyer Lift Transfer Due to Inadequate Staff Competency and Unsafe Technique
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift procedures and staff competency in operating a Hoyer lift during transfers, resulting in an avoidable accident. A resident with rheumatoid arthritis, degenerative joint disease, and osteoporosis, who was care planned for two-person Hoyer lift transfers due to mobility issues, was being transferred from bed to wheelchair when they began leaning to the left and slipping in the sling. During this transfer, the Hoyer lift repeatedly hit the mechanics of the bed, the resident did not appear properly “scooped” in the sling, and staff described the situation as chaotic as they attempted to maneuver the lift back under the bed. Both LNAs involved reported that the resident slid in the sling and ultimately slipped out toward the footboard when approximately 12 inches above the bed. Following this aborted transfer, the resident was returned to bed and assessed, with findings of left shoulder pain and multiple skin tears on the right arm and right leg. The skin tears included total flap loss on the right anterior elbow and right inner forearm, and partial flap loss on the right leg, attributed by staff and the MD to shearing from the resident’s fragile, “paper-like” skin rubbing against the Hoyer sling as the resident slid. The resident, who had contractures but had previously been transferred with the Hoyer lift without incident, later reported right hip pain and swelling after another transfer from chair to bed the same day, prompting transfer to the hospital. Emergency Department documentation identified a fracture of the right femur, a fracture of the left humerus, and skin tears and bruising consistent with the earlier descriptions. Interviews and internal statements revealed inconsistent accounts but consistently described the resident sliding in the sling, contacting parts of the lift (including the arm and piston) and landing on the lower portion of the bed from a height of about 12 inches. The MD confirmed that the injuries could have resulted from a fall from that height and that the skin tears were most likely due to shearing while sliding in contact with the sling. The Unit Manager confirmed the resident’s contractures and stiffness during the attempted move, while the PT confirmed that the resident’s size and contractures were appropriate for Hoyer lift use and that there had been no prior slippage incidents. The DON confirmed that LNA #1’s competency in proper Hoyer lift use had not been demonstrated before the incident, despite facility policy requiring staff to complete training and demonstrate competency in safe resident handling and transfer equipment, indicating that staff operating the mechanical lift were not ensured to be competent as required by facility policy.
Failure to Verify Competencies of Contracted Staff Operating Mechanical Lift
Penalty
Summary
The facility failed to ensure that a contracted Licensed Nursing Assistant (LNA) had the specific competencies required to safely operate a mechanical lift and provide care in accordance with resident assessments and care plans. Review of three LNA education files showed that one contracted LNA from Clipboard Health had no documented assessment of clinical competencies, including Safe Resident Handling, prior to being assigned to resident care. The facility relied on a packet titled "Genesis Mandatory Training Participation Guide" and the employee’s signature on it as evidence of competency, although this packet did not contain documented competency assessments. The DON stated he believed Clipboard Health verified competencies and that the packet represented the agency’s assessment, despite the packet bearing the Genesis heading and not being a Clipboard Health document. On the date of the incident, this contracted LNA was transferring a resident using a Hoyer lift from bed to wheelchair when the resident fell from the lift. The resident had a care plan requiring two staff members and use of a Hoyer lift for transfers due to mobility issues. Following the fall, the resident initially complained of left shoulder pain and an X-ray was ordered; later that day, due to additional pain, the resident was transferred to the hospital. Emergency Department documentation showed the resident sustained a right femur fracture, a left humerus fracture, skin tears to the right arm and right lower leg, and bruising of the right foot. Further review revealed that this LNA had worked 11 shifts without any facility verification of competencies, and that over the past 12 months, 59 Clipboard Health employees had been scheduled at the facility with no documented competency verification by the facility for any of these contracted staff.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with significant mobility impairments, legal blindness, and a history of chronic conditions including epilepsy and normal pressure hydrocephalus, was not provided the required level of assistance during activities of daily living (ADL) care. The resident's care plan specified the need for two-person assistance for ADL care due to limited mobility and other health conditions. Despite this, a Licensed Nursing Assistant (LNA) provided care alone, attempting to change bed linens and reposition the resident without additional help. During this unsupervised care, the LNA rolled the resident to the side of the bed, resulting in the resident falling to the floor. The incident led to the resident experiencing pain and being hospitalized for a fractured hip and pelvic injuries. Interviews confirmed that the care plan intervention requiring two-person assistance was not followed at the time of the incident, and the unit manager acknowledged that adherence to the care plan would have prevented the fall.
Resident Subjected to Verbal Abuse by LNA Following Incontinence Episode
Penalty
Summary
A deficiency occurred when a resident with diagnoses of acute respiratory failure with hypoxia, congestive heart failure, and chronic kidney disease, who was cognitively intact and independent with activities of daily living, was subjected to verbal abuse by a Licensed Nursing Assistant (LNA). The incident took place after the resident experienced an episode of incontinence. The LNA entered the resident's room and made disparaging remarks, questioning why the resident was incontinent in the facility and whether they soiled themselves at home. These statements were confirmed by both the resident and their roommate during interviews conducted as part of the facility's internal investigation. Further documentation from the internal investigation included an admission from the LNA that she raised her voice and made comments about the resident's incontinence not being helpful in the rehabilitation setting. Another LNA reported that the staff member was visibly upset after cleaning the resident and expressed her displeasure to colleagues, using inappropriate language regarding the resident's condition. The facility's internal investigation confirmed the occurrence of verbal abuse, and the administrator acknowledged that the resident was not free from abuse.
Continuous Loud Alarms Disrupt Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment on Unit D, where approximately 50 residents reside, due to continuous loud call bell alarms. During the recertification survey conducted from April 9 to April 11, 2024, it was observed that call bell alarms were repeatedly going off for extended periods, ranging from 10 to 40 minutes, during meal times. The alarms were loud enough to be heard over the surveyors' speaking voices and louder than the television volume in the common area, which serves as both a living and dining area. Interviews with residents and staff confirmed the disruptive nature of the alarms. One resident expressed that the alarms were bothersome, while another stated they hated the loudness of the call bells. Staff, including a Licensed Nurse Aide and a Licensed Practical Nurse, acknowledged that the alarms were going off non-stop throughout the day. The facility's Administrator also confirmed the loudness of the alarms in an area frequently used by residents, indicating a failure to maintain a comfortable and homelike environment.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for three residents, leading to deficiencies in addressing their specific needs. Resident #72 experienced significant weight loss, dropping from 175.2 pounds to 139.0 pounds, yet the care plan did not include goals or interventions to address nutritional needs. The nutritional assessment was outdated, based on a weight from 2022, and did not reflect the resident's current risk for malnutrition. The Director of Nursing confirmed the care plan's inadequacy in addressing nutrition and weight loss risk. Resident #3 expressed dissatisfaction with not having his face shaved for three weeks, despite his preference for bi-weekly shaving due to his inability to perform this task independently. The care plan lacked specific interventions to accommodate this preference, and staff were unaware of where such preferences were documented. Similarly, Resident #83, who has contractures due to Parkinson's disease, did not have a care plan addressing her need for assistance with hand exercises to maintain function. The care plan failed to include interventions for her contractures, despite her expressed importance of maintaining independence.
Failure to Provide Adequate Personal Hygiene and Nail Care
Penalty
Summary
The facility failed to provide necessary services for residents unable to perform activities of daily living, resulting in poor hygiene and unmet personal care needs. Resident #102 was observed with long, dirty fingernails and facial hair, despite their care plan indicating a need for extensive assistance with personal hygiene. The Unit Manager confirmed the expectation for staff to maintain residents' nail and facial hair care, which was not met in this case. Resident #3 expressed dissatisfaction with not having their face shaved for three weeks, although their preference was to be shaved twice a week. The care plan did not reflect this preference, and staff cited being too busy due to short staffing as the reason for not fulfilling this need. An LNA confirmed the workload prevented them from completing the shaving task, leading to Resident #3's distress. Resident #83 had excessively long toenails, with no interventions in their care plan addressing nail care, despite being dependent on staff for personal hygiene. Additionally, a resident with a pressure ulcer on their right great toe had progressively worsening nail conditions due to the lack of podiatry services. The facility did not have a podiatrist available, and there was no system in place to track residents needing podiatry care, as confirmed by an LPN and RN.
Deficiency in Resident Activities Program
Penalty
Summary
The facility failed to ensure that the activities program met the needs of each resident, as evidenced by the lack of engagement and stimulation for several residents. Resident #91, who has Parkinson's Disease and Dementia, was observed spending days in their room with no activities other than watching TV. Despite having a care plan that emphasized the importance of engaging in favorite activities, there was no record of activity participation, and the resident's family was not involved in discussions about their care preferences. The activities assistant and director confirmed that there was no formal process for determining which residents should receive one-on-one visits, and these visits were not documented. Resident #19, who is unable to leave their room due to poor upper body strength, reported having no activities provided in their room and expressed a desire for more engagement. Their activity logs showed limited participation in independent activities, and their care plan did not reflect any recent updates to address their preferences for in-room activities. Similarly, Resident #95 expressed a desire for more varied activities beyond watching TV and playing bingo, but their care plan had not been updated since 2022, and their activity logs showed minimal engagement. Residents #72 and #15 also reported dissatisfaction with the available activities, noting a lack of variety and opportunities to go outside. Resident #72's care plan had not been revised since 2020, and their activity logs showed no participation in activities for several months. Resident #15's care plan emphasized the importance of engaging in meaningful activities, but their logs indicated only receiving newsletters, with no record of additional engagement. The facility's failure to provide adequate activities and engagement for these residents highlights a significant deficiency in meeting their individual needs and preferences.
Staffing Shortages Lead to Delayed Care and Meal Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, impacting two of four units. Multiple residents expressed frustration over the lack of staff, leading to delays in receiving assistance for basic needs. One resident reported waiting 45 minutes for help to get off the toilet, while another could not receive assistance to walk daily, resulting in prolonged periods in a wheelchair. Residents also reported unmet personal care needs, such as nail cutting, hand exercises, and shaving, due to staff shortages. Staff interviews corroborated the residents' concerns, with Licensed Nurse Aides (LNAs) stating that it is challenging to complete all patient care tasks with insufficient staffing levels. On weekends, the number of aides often drops to three or four, making it difficult to manage the workload. The constant ringing of call bells further indicates the high demand for assistance that the current staffing levels cannot meet. Additionally, the facility failed to provide timely meal assistance to a resident at risk for malnutrition. The resident, who requires help with meals, was left without a dining tray while others were served, and their meal was placed out of reach. It took 50 minutes for staff to address the situation, during which the resident attempted to eat a pear handed by another resident. The delay in meal service and lack of attention to the resident's needs highlight the staffing inadequacies affecting resident care.
Failure to Monitor Psychotropic Drug Use in Residents
Penalty
Summary
The facility failed to ensure proper monitoring of residents using psychotropic drugs, leading to deficiencies in care for three residents. Resident #15, diagnosed with anxiety disorder and major depressive disorder, was administered Hydroxyzine for anxiety on multiple occasions without any documentation of behaviors or monitoring orders. The care plan lacked interventions to monitor behaviors, and there was no evidence of behavior monitoring in the Medication Administration Record (MAR), Treatment Administration Record (TAR), or the point of care system. Resident #10, with diagnoses including schizophrenia, bipolar disorder, major depressive disorder, and anxiety, was prescribed Paroxetine and Risperidone. Despite the care plan's directive to complete a behavior monitoring flow sheet, there was no documentation of behavior monitoring in the MAR, TAR, or point of care system. The Director of Nursing confirmed that behavior monitoring was not conducted for this resident, despite the expectation to monitor behaviors three times a day for residents on psychotropic medications. Resident #98, admitted with dementia and behavioral disturbances, was prescribed Seroquel and Trazadone. The resident received all scheduled doses of these medications without any documented monitoring for behaviors or adverse effects, despite the care plan's requirement to monitor for changes in mental status and functional level. Observations noted the resident frequently sleeping through meals, and the LPN Unit Manager confirmed an increase in sleepiness, potentially due to pneumonia, but acknowledged the lack of monitoring for adverse effects or increased behaviors related to the psychotropic medications.
Failure to Serve Palatable and Timely Meals
Penalty
Summary
The facility failed to serve food that was palatable and at an appetizing temperature to three residents. Resident #99, who was admitted with Alzheimer's dementia, stroke with aphasia, and heart failure, was observed sitting at a table without being offered a meal or beverage while other residents received their trays. The meal intended for Resident #99 was left uncovered for 40 minutes, and upon checking, the food temperature was found to be non-palatable. The Dietary Manager confirmed that the meal should not be served and replaced it with a new plate. In another instance, residents #11 and #12 were observed sitting at a table with Resident #17, who was eating their dinner while the other two residents had not received their meals. The RN/Unit Manager, upon noticing the situation, instructed an LNA to serve the meals to residents #11 and #12. An LNA later explained that the food carts had arrived late, which disrupted the usual dining process where all residents at a table are served simultaneously.
Refrigerator Temperature Maintenance Failure
Penalty
Summary
The facility failed to maintain refrigerated food temperatures at a safe level in the Cherry Tree Country Kitchen. On observation, the refrigerator used to store resident drinks and snacks was found to be open approximately 2 inches, with no items obstructing the door. The temperature monitoring log indicated temperatures of 41 degrees from April 1 to April 9, but at the time of observation, the temperature was 56 degrees. A Licensed Nursing Assistant (LNA) mentioned that the refrigerator had been broken for some time, but was unsure if anyone was aware of the issue, and believed it was the kitchen's responsibility to monitor the temperature. The Dietary Manager confirmed the refrigerator was broken and the temperature inside was 58 degrees. The administrator acknowledged that the refrigerator had ongoing issues with the seal, which had been replaced several times, but was unaware of the current problem. The administrator confirmed that a new refrigerator was being purchased to replace the broken one in the Cherry Tree Country Kitchen.
Failure to Follow Physician Orders for Anxiety Management
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not consistently following physician orders for a resident with anxiety and major depressive disorder. The resident had physician orders for the administration of Hydroxyzine, an antianxiety medication, with specific instructions to attempt non-pharmacological interventions before administering the medication. However, the Medication Administration Record (MAR) revealed that these non-pharmacological interventions were documented only 5 out of 22 times when the PRN Hydroxyzine was administered. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that non-pharmacological interventions should have been attempted and documented prior to administering PRN medications. This oversight occurred despite the resident's care plan, which included a range of non-pharmacological strategies to be used before resorting to medication. The failure to adhere to these orders indicates a lapse in following professional standards of care for the resident.
Failure to Conduct Weekly Skin and Wound Assessments
Penalty
Summary
The facility failed to provide safe and effective skin and wound care for two residents by not performing and documenting weekly skin checks and wound evaluations as per professional standards and facility policy. Resident #94, who has conditions including morbid obesity, type 2 diabetes, and mixed urinary incontinence, was found with a bleeding wound on the right thigh and redness on both thighs. Despite having a care plan indicating a risk for skin breakdown and a physician order for topical treatment, the last documented skin assessment was on 2/22/2024, with no subsequent weekly assessments or wound evaluations conducted. Interviews with staff confirmed the lack of adherence to the facility's policy for weekly wound assessments. Resident #125, diagnosed with venous insufficiency and type 2 diabetes, was noted to have a dressing applied to the coccyx on 4/1/2024, yet there was no care plan, wound evaluation, or physician orders for this wound at that time. The care plan was only updated on 4/2/2024, and a physician order for treatment was initiated on 4/5/2024. However, a skin check on 4/5/2024 inaccurately reported no skin injuries or wounds. As of 4/10/2024, there were still no wound assessments for the coccyx wound. The Director of Nursing confirmed the absence of initial or weekly wound assessments for Resident #125.
Failure to Monitor Heart Rate Before Digoxin Administration
Penalty
Summary
The facility failed to adhere to pharmacy recommendations regarding the monitoring of heart rate prior to the administration of digoxin for a resident diagnosed with cerebral vascular accident and atrial fibrillation. The resident was prescribed digoxin to manage atrial fibrillation, which requires careful monitoring due to the risk of cardiac arrhythmias. The pharmacy review, signed by the provider, explicitly stated that the apical pulse should be checked before administering digoxin, and the medication should be withheld if the pulse is less than 60 beats per minute. However, there was no evidence in the resident's records that these instructions were included in the medication order or that the pulse was checked before administering the medication. During an interview, the Unit Manager confirmed that the medication parameters, including the requirement to check the pulse, were not documented in the digoxin order. The Unit Manager acknowledged that the absence of these parameters meant that nurses were not aware of the need to check the pulse before administering the medication. This oversight resulted in a failure to follow the necessary protocol for administering digoxin, as there was no documentation of the pulse being checked on the medication administration record.
Failure to Ensure Dignity and Meal Assistance
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect. Resident #66, who has dementia, was observed in the dining room expressing difficulty with eating. A Licensed Nursing Assistant (LNA) responded in a loud and forceful manner, cutting the resident's food without consent and ignoring the resident's inquiry about their drink. This interaction left the resident visibly distressed, with their head resting on the table. The LNA later acknowledged that their approach was undignified and disrespectful. Resident #99, diagnosed with Alzheimer's dementia, stroke with aphasia, and heart failure, was not provided assistance with meals despite being at risk for malnutrition. During meal service, Resident #99 was left without a tray or beverage while other residents at the table were served. The resident attempted to eat a pear handed by another resident and later tried to consume condensation from the food cover. Staff did not assist or notice the resident's actions for an extended period. When the Dietary Manager was alerted, the food was found to be unpalatable due to prolonged exposure, and a new meal was eventually provided. The LPN confirmed that Resident #99 required assistance and should have been served alongside others.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report an alleged incident of resident-to-resident altercation, which potentially involved verbal abuse, to the State Survey Agency. The incident involved a resident who exhibited verbal and aggressive behavior towards their roommate due to frustration over bathroom usage, which led to incontinence. The resident attempted to throw themselves out of bed while shouting threats and obscenities. Staff intervened to prevent a fall and further escalation by assisting the resident back into bed and redirecting the roommate. The facility's policy on Abuse Prohibition requires any witnessed incident of suspected abuse to be reported immediately to a supervisor and subsequently to the Administrator or designee, as well as other officials in accordance with state law. However, during an interview, the Administrator revealed that the incident was not reported to them or the State Agency, indicating a failure to adhere to the facility's reporting policy.
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 12 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 Rutland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pines At Rutland Center For Nursing & Rehabili | 0.3 mi | ★★★★★ | 6 | 0 |
| Rutland Healthcare & Rehabilitation Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Gill Odd Fellows Home Of Vermont | 19 mi | ★★★★★ | 6 | 0 |
| Granville Center For Rehabilitation And Nursing | 20.3 mi | ★★★★★ | 0 | 0 |
| Slate Valley Center For Rehabilitation And Nursing | 22.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.