Mountain View Center: Accident Harm Cited - VT
The July 26 incident at Mountain View Center Genesis Healthcare sent the resident to the hospital with a broken left hip and multiple pelvic fractures. The resident reported severe pain in their right hip, back, and head after hitting the floor.
Resident #1 has multiple serious medical conditions including epilepsy, normal pressure hydrocephalus, and is legally blind with an artificial eye. Previous pelvic radiation treatments have left them with impaired movement on one side of their upper body and both sides of their lower body.
The resident's care plan, established in May 2023, specifically required two staff members to assist with all activities of daily living due to limited mobility and blindness. The plan remained in effect at the time of the fall.
Despite these clear safety requirements, the nursing assistant attempted to provide evening care alone on July 26. When changing the resident's bed linens, the assistant needed to tuck in the sheets and rolled the resident to one side of the bed without help from a second staff member.
The resident fell onto the floor.
Hospital records show the resident was admitted for management of severe hip pain. Doctors diagnosed fractures to the left femoral neck and both the inferior and superior pubic rami in the pelvis. The resident became non-weight-bearing and required complete care following the injuries.
The nursing assistant confirmed during a September 9 interview with state inspectors that they had been working alone when the incident occurred. The assistant acknowledged attempting to complete the linen change without assistance, directly violating the facility's established care protocols.
The Unit Manager told inspectors that Resident #1 "needs 2 people to assist with ADL care as mobility is limited." She confirmed that the care plan included this two-person intervention and that staff were expected to follow it for safety reasons.
"The resident would not have fallen had the interventions been followed," the Unit Manager stated.
The facility's incident report, filed the day after the fall, documented that the resident had been receiving care from the nursing assistant when the witnessed fall occurred. A five-day summary report submitted to state regulators noted the resident's baseline condition before the fall and the extent of injuries sustained.
Federal inspectors determined that Mountain View Center Genesis Healthcare failed to implement proper interventions to keep residents free from accidents. The violation resulted in actual harm to the resident, who suffered preventable injuries requiring hospitalization and ongoing pain management.
The resident's medical complexity made the safety protocols particularly crucial. Normal pressure hydrocephalus involves abnormal accumulation of cerebrospinal fluid in the brain, affecting movement and balance. Combined with legal blindness and radiation-related mobility limitations, the resident was especially vulnerable to falls.
The nursing assistant's decision to work alone during bed care directly contradicted established safety measures designed to protect residents with significant physical limitations. The two-person assistance requirement had been in place for more than two years before the incident.
Mountain View Center Genesis Healthcare operates as part of Genesis Healthcare, one of the nation's largest nursing home chains. The facility's failure to ensure staff compliance with basic safety protocols resulted in serious injuries that could have been prevented through proper supervision and adherence to care plans.
The resident now faces ongoing complications from multiple fractures and requires complete care assistance, representing a significant decline from their previous functional status.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mountain View Center Genesis Healthcare from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Mountain View Center Genesis Healthcare in Rutland, VT was cited for violations during a health inspection on September 9, 2025.
The July 26 incident at Mountain View Center Genesis Healthcare sent the resident to the hospital with a broken left hip and multiple pelvic fractures.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.