Inspection Reports for Rutland Nursing Home

Two standard health citations related to administration and safe/clean/comfortable/homelike environment with level 2 severity; no immediate jeopardy but minor discomfort and potential for more than minimal harm.

Two standard health citations related to administration and safe/clean/comfortable/homelike environment with level 2 severity; no immediate jeopardy but minor discomfort and potential for more than minimal harm.

The inspection was conducted in response to complaints submitted regarding high temperatures throughout the facility, including a specific complaint about loss of air conditioning on the sixth floor.

The facility failed to maintain safe and comfortable temperature levels in resident rooms and common areas, with temperatures exceeding federal and state requirements. The facility's air conditioning system was inadequate, leading to discomfort among residents and staff, and the facility ordered portable air conditioning units to address the issue.

The visit was complaint-related based on Complaint NY00384371. Complaints included loss of air conditioning on the sixth floor and high temperatures throughout the facility affecting all residents. The complaints were substantiated by observations and interviews.

One standard health citation for free from abuse and neglect with level 3 severity indicating actual harm; isolated scope; no systemic quality of care problems.

One standard health citation for free from abuse and neglect with level 3 severity indicating actual harm; isolated scope; no systemic quality of care problems.

Multiple standard health citations (14) and life safety code citations (2) mostly level 1 and 2 severity; deficiencies corrected as of May 30, 2025; issues included assessments, care plans, medication review, food sanitation, environment, and life safety electrical systems and exit signage.

Multiple standard health citations (14) and life safety code citations (2) mostly level 1 and 2 severity; deficiencies corrected as of May 30, 2025; issues included assessments, care plans, medication review, food sanitation, environment, and life safety electrical systems and exit signage.

The inspection was conducted as a Recertification survey from 03/24/2025 to 03/31/2025 to assess compliance with regulatory requirements for nursing home operations and resident care.

The facility was found deficient in multiple areas including failure to provide timely and accurate Medicare Part A benefit termination notices, inadequate maintenance of a clean and homelike environment, delayed discharge notifications to the Ombudsman, late submission and inaccuracies in Minimum Data Set assessments, incomplete baseline care plans, lack of comprehensive and updated care plans, failure to provide recommended nursing rehabilitation services, improper respiratory care, failure to act on pharmacist medication regimen review recommendations, inappropriate use of psychotropic medications, and food safety violations related to staff not wearing beard restraints.

The inspection was conducted as a Recertification and Complaint Survey from 03/24/2025 to 03/31/2025 to investigate allegations related to inadequate supervision and assistance devices leading to resident accidents.

The facility failed to ensure adequate supervision and proper use of assistance devices for residents, resulting in two residents (#108 and #260) sustaining injuries from falls. Resident #108 fell from a Hoyer lift due to improper sling placement and poor transfer technique by Certified Nursing Assistants. Resident #260, a highly active resident requiring harness restraints, fell after being removed from their wheelchair and placed in an armchair by a teacher, leading to subsequent medical complications.

The complaint investigation found that Resident #108 fell and sustained an acute fracture of the left orbit due to poor transferring technique and improper use of the Hoyer lift sling by Certified Nursing Assistants. Resident #260 fell from an armchair after being removed from their wheelchair by a teacher, despite requiring constant supervision and harness restraints due to high activity level. The fall did not contribute to later increased intracranial pressure requiring shunt revision, as concluded by the Pediatric Medical Doctor.

One standard health citation for respect, dignity/right to have personal property with level 2 severity; isolated scope; deficiency corrected as of May 23, 2025.

One standard health citation for respect, dignity/right to have personal property with level 2 severity; isolated scope; deficiency corrected as of May 23, 2025.

The abbreviated survey was conducted to investigate allegations of emotional and verbal abuse by a Certified Nursing Assistant towards Resident #6, following reports of disrespectful treatment and failure to provide care in a manner that promotes resident dignity.

The facility failed to ensure Resident #6 was treated with respect and dignity, as evidenced by verbal abuse from Certified Nursing Assistant #1. The investigation confirmed emotional abuse occurred, with the staff member admitting to telling the resident off and not following protocol to stop care when the resident complained of pain. Resident #6 was assessed by medical and psychological staff and provided emotional support.

The visit was complaint-related, triggered by allegations of verbal and emotional abuse by Certified Nursing Assistant #1 towards Resident #6. The complaint was substantiated based on interviews, progress notes, and facility investigation.

The abbreviated survey was conducted due to an incident involving resident-to-resident abuse between two residents, Resident #1 and Resident #2, including an altercation in the elevator and a subsequent assault in Resident #1's room resulting in injury.

The facility failed to ensure Resident #1 was free from resident-to-resident abuse, resulting in an acute fracture to Resident #1's left fourth rib. The facility did not implement timely safety measures such as close visual monitoring after the initial incident. Resident #2 was removed from the facility following law enforcement involvement and an order of protection was issued.

One deficiency related to abuse reporting documentation.

One deficiency related to abuse reporting documentation.

The inspection was conducted as a Recertification and Complaint Survey from 10/16/2023 to 10/23/2023 to investigate complaints related to resident care planning and supervision.

The facility failed to ensure a comprehensive person-centered care plan was reviewed and revised after a resident-to-resident physical abuse incident. Additionally, the facility did not provide adequate supervision to prevent a resident from eloping, resulting in the resident leaving the unit undetected and being found later at their parent's home.

The complaint investigation focused on incidents involving Resident #212's care plan not being updated after a physical abuse event on 7/20/23, and Resident #592 eloping from the facility on 9/3/23 without adequate supervision. The abuse allegation was substantiated with findings that care plans were not updated. The elopement was confirmed with documentation of the resident leaving the unit undetected and being found at their parent's home.

Two standard health citations related to reporting of alleged violations and requirements before submitting a request with level 2 severity; isolated and pattern scopes; deficiencies corrected as of December 15, 2023.

Two standard health citations related to reporting of alleged violations and requirements before submitting a request with level 2 severity; isolated and pattern scopes; deficiencies corrected as of December 15, 2023.

The visit was conducted as an abbreviated survey to investigate the facility's failure to timely report an alleged abuse incident involving Resident #1, as required by federal and state regulations.

The facility failed to report an alleged abuse incident involving a Behavioral Health Associate (BHA) grabbing a resident's phone and bumping the resident's forehead within the required two-hour timeframe to the New York State Department of Health. The incident was investigated internally, no visible injury or psychological harm was found, and the facility did not save the camera footage. The Director of Nursing and Administrator acknowledged the reporting requirement but did not report the incident due to lack of observed abuse on video.

The inspection was conducted as a recertification survey from 10/16/2023 to 10/23/2023, including complaint investigation NY00315981, to assess compliance with food safety and pest control standards.

The facility failed to ensure proper food handling and hygiene practices by dietary staff, leading to potential cross-contamination risks. Additionally, the facility did not maintain an effective pest control program, with live mice observed on two units and documented multiple pest sightings.

The inspection included complaint NY00315981 regarding pest control issues, which was substantiated by observations of live mice and multiple pest sightings documented in the facility.

One standard health citation for reporting - national health safety network with level 2 severity; widespread scope; no correction noted.

One standard health citation for reporting - national health safety network with level 2 severity; widespread scope; no correction noted.

The inspection was conducted as part of the recertification survey to assess compliance with regulatory requirements including resident rights, use of restraints, accuracy of assessments, care planning, and medication management.

The facility was found deficient in honoring resident bathing preferences, improper use of physical restraints (four side rails raised), inaccurate Minimum Data Set (MDS) assessments regarding oxygen use, untimely revision of care plans, and use of unnecessary psychotropic medication without documented behavioral justification.