Green Mountain Nursing and Rehabilitation

Colchester, VT · 73 beds · For profit - Limited Liability company

0 Trust Score
Grade: F CRITICAL Risk → Stable

Red Flags

  • 1-star health inspection rating (lowest possible)
  • 21 deficiencies — 2.1x the state average
  • 2 citation(s) at the highest severity level — immediate risk to residents
  • 1 citation(s) where residents suffered actual harm
  • $161,106 in fines over 3 years
  • 64% total nursing staff turnover

Green Flags

  • 4-star staffing rating

Quick Facts

★☆☆☆☆
CMS Overall
★☆☆☆☆
Health Inspection
21
2.1x state avg
Deficiencies
$161,106
Fines (3-yr)
★★★★☆
Staffing

Violation Timeline

June 5, 2025

3 deficiencyies
F0686 Immediate Jeopardy Scope/Severity: K

Quality of Life and Care Deficiencies

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Provide appropriate pressure ulcer care and prevent new ulcers from developing.

F0865 Immediate Jeopardy Scope/Severity: L

Administration Deficiencies

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Have a plan that describes the process for conducting QAPI and QAA activities.

F0944 Potential Harm Scope/Severity: F

Administration Deficiencies

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Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

October 21, 2024

3 deficiencyies
F0609 Potential Harm Scope/Severity: D

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

F0610 Potential Harm Scope/Severity: D

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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Respond appropriately to all alleged violations.

F0655 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

March 27, 2024

14 deficiencyies
F0584 Potential Harm Scope/Severity: E

Resident Rights Deficiencies

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Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

F0623 Potential Harm Scope/Severity: F

Resident Rights Deficiencies

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Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

F0625 No Harm Scope/Severity: C

Resident Rights Deficiencies

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Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

F0656 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

F0657 Potential Harm Scope/Severity: E

Resident Assessment and Care Planning Deficiencies

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Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

F0661 Potential Harm Scope/Severity: E

Resident Assessment and Care Planning Deficiencies

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Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

F0684 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide appropriate treatment and care according to orders, resident’s preferences and goals.

F0686 Actual Harm Scope/Severity: G

Quality of Life and Care Deficiencies

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Provide appropriate pressure ulcer care and prevent new ulcers from developing.

F0689 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F0690 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

F0692 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide enough food/fluids to maintain a resident's health.

F0693 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

F0757 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure each resident’s drug regimen must be free from unnecessary drugs.

F0758 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

See full violation history →

Staffing

0.57
RN hrs/res/day
1.68
LPN hrs/res/day
3.02
CNA hrs/res/day
4.57
Weekend hrs/res/day
64%
Total nurse turnover
50%
RN turnover

A nurse checks on each resident roughly every 4.6 hours on average.

Fines & Penalties

  • Fine Jun 5, 2025
    $128,362
  • Fine Mar 27, 2024
    $32,744
Total $161,106

Ownership

For profit - Limited Liability company Independent (not part of a chain)
  • RUBIN, ALTER

    5% OR GREATER DIRECT OWNERSHIP INTEREST

    Since since 03/01/2023

    100% Individual
  • COMBS-WILBER, JENNIFER

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 03/01/2023

    Individual
  • LUEBBERS, ROBERT

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 12/01/2023

    Individual
  • SILVER, PESI

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 03/01/2023

    Individual
  • RUBIN, ALTER

    CORPORATE OFFICER

    Since since 03/01/2023

    Individual