Inspection Reports for
Rutland Nursing Home

The state logged 221 complaints about this facility; 22 led to on-site inspections. 14 citations resulted from those complaints.

Across 12 inspections, 8 resulted in citations totaling 61, including 33 standard health and 28 life safety code citations. The facility had 221 complaints with 22 on-site inspections and 3 enforcement actions totaling $30,000 in fines.

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.

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 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 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.

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 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 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 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.

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.

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

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 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.