Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
16% better than Vermont average
Vermont average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 5, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged physical abuse of a resident by facility staff.
Findings
The facility failed to ensure that Resident #1 was free from physical abuse when Licensed Nursing Assistant #2 struck the resident during care on 7/20/25. The allegation was verified following interviews and record review.
Complaint Details
The complaint investigation substantiated that Licensed Nursing Assistant #2 physically abused Resident #1 by striking the resident in the face during care on 7/20/25. The facility's investigation confirmed the abuse.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to protect Resident #1 from physical abuse by staff. | Level of Harm - Actual harm |
Inspection Report
Annual Inspection
Deficiencies: 5
Jun 19, 2025
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements and ensure resident safety and care quality.
Findings
The facility was found to have multiple deficiencies including failure to prevent resident falls due to environmental hazards, improper medication storage, inadequate food safety and sanitation practices, lapses in infection control measures, and ineffective pest control. Corrective actions were implemented for the fall hazard deficiency prior to survey completion.
Severity Breakdown
Level of Harm - Actual harm: 1
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure the residents' environment remained free from accident hazards, resulting in a resident fall with a fractured hip. | Level of Harm - Actual harm |
| Failure to ensure medications were properly stored; medication left unattended at resident bedside. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store food in accordance with professional standards, including unclean equipment, uncovered and undated food items, and wet clean dishes. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program, including missed hand hygiene and lack of gown use during medication administration for a resident on enhanced barrier precautions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an effective pest control program, evidenced by presence of fruit flies and moths in food preparation and storage areas. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents surveyed: 8
Residents sampled: 7
Residents sampled: 4
Date of fall incident: Apr 29, 2025
Date of resident room transfer: Apr 28, 2025
Date of staff education completion: May 1, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Confirmed medication was left unattended at resident bedside | |
| Unit Manager | Confirmed resident room transfer and lack of nonskid strips at time of fall | |
| Business Office Manager | Provided information on resident room transfer due to pest control | |
| Admissions Coordinator | Provided information on resident room transfer due to pest control | |
| Food Service Director | Observed multiple food safety and sanitation deficiencies and confirmed pest presence | |
| Dietician | Confirmed receipt dates and labeling issues of food items | |
| Contracted Food Services District Manager | Confirmed pest presence and pest control contract | |
| RN Supervisor | Confirmed infection control requirements for enhanced barrier precautions |
Inspection Report
Annual Inspection
Deficiencies: 0
May 22, 2024
Visit Reason
This document is the annual inspection report for Rutland Healthcare & Rehabilitation Center, summarizing the findings of the survey completed on May 22, 2024.
Findings
No health deficiencies were found during this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 13, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to notify the physician about a resident's refusal of high-risk medications and failure to provide food that accommodates resident allergies and intolerances.
Findings
The facility failed to notify the physician about Resident #1's consistent refusal of insulin, violating their policy on refusal of treatment. Additionally, the facility failed to ensure that residents received food accommodating allergies and intolerances, as evidenced by Resident #1 not receiving gluten-free meals until after a complaint and Resident #2's meal ticket not reflecting wheat intolerance.
Complaint Details
The visit was complaint-related, triggered by concerns about failure to notify the physician of Resident #1's refusal of insulin and failure to provide appropriate dietary accommodations for residents with allergies and intolerances.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to consult with the resident's physician when there is a need to alter treatment significantly due to refusal of high-risk medications (Resident #1's insulin refusal). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure that each resident receives food that accommodates allergies, intolerances, and preferences (Residents #1 and #2). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 5
Residents sampled: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed no evidence of provider notification for Resident #1's insulin refusal and confirmed diet order update after complaint |
| Dietary Manager | Dietary Manager | Explained allergy/intolerance information process for meal tickets |
| Unit Manager | Unit Manager | Confirmed Resident #2's medical record allergy listing and diet status |
Inspection Report
Deficiencies: 1
Jul 25, 2023
Visit Reason
The inspection occurred to evaluate the facility's compliance with professional standards for food service safety, specifically regarding the reheating of previously cooked foods to safe temperatures.
Findings
The facility failed to reheat previously cooked foods to the required safe temperature of 165 degrees Fahrenheit, reheating leftover marinara sauce only to 115 degrees initially and then to 140 degrees, which is below the professional standard. The Dietary Manager confirmed that their training materials do not specify the 165 degrees Fahrenheit reheating requirement.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to reheat previously cooked foods to a safe temperature of 165 degrees Fahrenheit. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Temperature reading: 115
Temperature reading: 135
Temperature reading: 140
Required temperature: 165
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding reheating procedures and training materials | |
| Dietary Aide | Observed reheating and serving leftover marinara sauce |
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 22, 2023
Visit Reason
The inspection was conducted to investigate complaints related to trauma-informed care and infection prevention practices at Rutland Healthcare & Rehabilitation Center.
Findings
The facility failed to ensure trauma-informed care for residents with PTSD by not identifying or addressing trauma triggers in care plans for two residents. Additionally, the facility failed to implement proper infection prevention and control practices, including failure to don protective equipment and inadequate hand hygiene during medication administration.
Complaint Details
The complaint investigation found substantiated issues regarding trauma-informed care and infection control practices. The facility failed to identify trauma triggers for residents with PTSD and did not follow CDC and facility policies for infection prevention, including proper use of personal protective equipment and hand hygiene.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide trauma-informed care by not identifying or addressing trauma triggers for residents with PTSD. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program, including failure to don gloves and gowns when required and inadequate hand hygiene during medication administration. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 2
Residents Affected: Some
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Assistant (LNA) | Interviewed about Resident #4's trauma triggers, unable to identify them | |
| Facility Administrator | Confirmed trauma triggers were not identified in resident records | |
| Director of Nursing (DON) | Confirmed trauma triggers were not identified and agreed staff should have worn gloves and gowns when entering Resident #149's room | |
| Licensed Practical Nurse (LPN) | Observed failing to don gloves and gown as required and not performing hand hygiene properly during medication administration |
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