Inspection Reports for The Pines at Rutland Center for Nursing and Rehabilitation
VT
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 17, 2025, identified deficiencies related to informed consent for psychoactive medication, notification of resident condition changes, care planning for incontinence, blood glucose monitoring, fall supervision, and trauma-informed care assessments. Earlier inspections showed a pattern of issues including medication administration errors, inadequate supervision leading to resident harm, food service sanitation problems, and infection control deficiencies. Complaint investigations substantiated a failure to provide adequate supervision that resulted in a resident injury, with corrective actions taken by the facility. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history indicates ongoing challenges in resident care and supervision, with no clear improvement trend over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
111% worse than Vermont average
Vermont average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Dec 17, 2025
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements and evaluate the quality of care provided at The Pines at Rutland Center for Nursing & Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to obtain timely informed consent for psychoactive medication, failure to notify resident representatives of changes in condition, inadequate care planning for incontinence, failure to ensure proper blood glucose monitoring for a visually impaired resident, insufficient supervision to prevent falls, and lack of trauma-informed care assessments for residents with PTSD.
Deficiencies (6)
Failed to inform a resident representative in advance of the risks and benefits of the proposed care, treatment alternatives, or other options for psychoactive medication (Resident #86).
Failed to notify a resident's representative of changes of condition (Resident #86).
Failed to create a comprehensive care plan related to incontinence care (Resident #64).
Failed to ensure quality of care in blood glucose monitoring according to physician orders and care plan for a resident with visual impairment (Resident #15).
Failed to provide adequate supervision to prevent potential injury from falls (Resident #86).
Failed to conduct a trauma informed care assessment to establish possible triggers for re-traumatization (Resident #49).
Report Facts
Falls: 20
Unwitnessed falls: 19
Falls in dining room: 4
Unwitnessed falls in dining room: 3
Unwitnessed falls in hallway: 2
Medication administrations: 7
BIMS score: 15
Blood sugar reading: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in blood glucose monitoring deficiency for Resident #15 |
| Unit Manager | Confirmed lack of informed consent documentation and inadequate supervision for Resident #86 | |
| Director of Nursing | Director of Nursing | Confirmed care planning deficiencies and lack of informed consent |
| Administrator | Facility Administrator | Confirmed lack of informed consent documentation |
| Regional Quality Specialist | Regional Quality Specialist | Confirmed lack of informed consent documentation |
| Social Worker | Social Worker | Confirmed lack of trauma informed care assessment for Resident #49 |
Inspection Report
Deficiencies: 4
Date: Nov 25, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food procurement, storage, preparation, distribution, and service standards in the kitchen area.
Findings
The facility failed to ensure kitchen staff properly air-dried or hand-dried pans prior to storage and failed to maintain a clean sanitary food service area, including wet pans stacked together, missing floor tiles with accumulated debris, grease buildup on the stove, and unclean steam table water with food particles.
Deficiencies (4)
Kitchen staff failed to properly air-dry or hand-dry pans prior to storage, resulting in wet pans being stacked.
Floor under food prep table had missing tiles with accumulated liquid and food particles and dirt and grease residue on table leg.
Gas stove top had excess food and grease buildup on and under burner grates despite daily cleaning sign-offs.
Third floor steam table water contained pieces of orzo, indicating failure to drain and clean water after dinner service.
Report Facts
Date of observation: Nov 25, 2024
Time of observation: 1405
Time of Administrator interview: 1515
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Dietary | Confirmed wet pans, grease buildup, orzo in steam table water, and provided staff education | |
| Kitchen Supervisor | Confirmed presence of orzo in steam table water | |
| facility Administrator | Confirmed kitchen observations and ongoing repairs |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Sep 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, resident care preferences, accident prevention, pharmaceutical services, medication storage, and medical record keeping.
Findings
The facility failed to assess residents for medication self-administration, honor resident care preferences, provide adequate supervision to prevent accidents resulting in harm, ensure pharmaceutical services met resident needs, properly store medications, and maintain signed and dated x-ray reports in resident records.
Deficiencies (6)
Failed to assess residents for ability to self-administer medications and initiate related care plans for 2 of 8 sampled residents.
Failed to provide activities of daily living care based on resident preference for 1 of 32 sampled residents.
Failed to provide adequate supervision to prevent accidents resulting in actual harm to one resident.
Failed to provide pharmaceutical services to meet the needs of one resident.
Failed to ensure medications were properly stored for one resident.
Failed to keep signed and dated reports of x-rays and other diagnostic services in one resident's clinical record.
Report Facts
Residents sampled for medication self-administration assessment: 8
Residents sampled for ADL care preference: 32
Residents sampled for accident supervision: 6
Residents sampled for pharmaceutical services: 32
Prescribed doses of Dantrolene not administered: 7
Prescribed doses of Finasteride not administered: 6
X-ray dates missing signed reports: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Confirmed lack of self-administration assessments and care plans for residents #82 and #92; aware of Resident #11's care preference not honored; explained lack of knowledge about x-ray report filing. | |
| Assistant Director of Nursing | ADON | Confirmed Resident #92 uses Albuterol inhaler independently but lacks self-administration assessment and locked storage. |
| Administrator | Confirmed facility lacks policy for self-administration of medications and was unaware of pharmacy medication delivery issues. | |
| Director of Nursing | DON | Interviewed regarding fall incident involving Resident #59; confirmed investigation findings and corrective actions; unaware of pharmacy medication delivery issues. |
| Licensed Nursing Assistant #1 | LNA #1 | Involved in improper transfer of Resident #59 resulting in injury. |
| Community Health Center Advanced Practice Registered Nurse | APRN | Explained receipt and review process of x-ray reports and uncertainty about filing in facility medical records. |
| Unit Manager | Explained issues with medication availability from pharmacy affecting Resident #11 and others. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 18, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision that led to an accident involving resident #59.
Complaint Details
The complaint investigation found that LNA #1 did not understand the resident's requirement for a sit to stand lift and attempted to transfer the resident alone, causing a tibial plateau fracture. The facility's investigation confirmed the LNA was not familiar with the resident's care needs and corrective actions were taken.
Findings
The facility failed to provide adequate supervision to prevent accidents, resulting in actual harm to resident #59 who suffered a tibial plateau fracture after being improperly transferred by a Licensed Nursing Assistant without the required sit to stand device and assistance of a second staff member. The facility completed corrective actions prior to the survey.
Deficiencies (1)
Failure to provide adequate supervision to prevent accidents, resulting in harm to resident #59.
Report Facts
Residents sampled: 6
Residents affected: 1
Date of incident: Aug 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LNA #1 | Licensed Nursing Assistant | Involved in improper transfer causing injury to resident #59 |
| Director of Nursing | Director of Nursing | Interviewed regarding the incident and facility investigation |
Inspection Report
Routine
Deficiencies: 9
Date: Aug 9, 2023
Visit Reason
The inspection was conducted to evaluate compliance with care plan implementation, medication administration, feeding tube management, and pharmaceutical services at The Pines at Rutland Center for Nursing & Rehabilitation.
Findings
The facility failed to implement care plan interventions regarding tube feeding and medications for Resident #59, failed to revise a comprehensive care plan for Resident #80 regarding ambulation, administered medications incorrectly for Residents #266, #6, and #59, failed to monitor weight and tube feeding as ordered for Resident #59, and did not ensure accurate medication administration documentation for Resident #31. Additionally, the pharmacist failed to identify medication scheduling errors for Resident #6.
Deficiencies (9)
Failed to implement care plan interventions regarding tube feeding and medications for Resident #59.
Failed to revise a comprehensive care plan to include interventions addressing Resident #80's goal to maintain highest practicable well-being regarding walking.
Administered wrong dose of Lidoderm Patch 5% medication 100 times for Resident #266.
Failed to administer cholestyramine per physician orders and failed to separate administration times from other medications for Resident #6.
Failed to administer Bacillus Coagulans-Inulin medication as ordered for Resident #59; medication was not delivered and documented as administered 49 times incorrectly.
Failed to ensure tube feedings were administered as ordered and weight status monitored for Resident #59.
Failed to ensure attending physician reviewed and addressed pharmacist recommendations for Residents #266 and #59.
Failed to ensure accurate medication administration documentation for Resident #31 regarding suppository administration.
Pharmacist failed to identify and report medication scheduling errors for Resident #6 regarding cholestyramine administration timing.
Report Facts
Medication not given: 51
Medication administered wrong dose: 100
Weight loss percentage: 6.6
Missed medication doses: 6
Medication documented as administered but unavailable: 49
Weight recording omissions: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unknown | Primary Nurse | Confirmed incorrect tube feeding rate for Resident #59. |
| Unknown | Administrator | Confirmed failures in care plan implementation and medication administration for Resident #59. |
| Unknown | Director of Nursing | Confirmed medication administration errors and pharmacist recommendation failures. |
| Unknown | Assistant Director of Nursing | Confirmed care plan and medication administration deficiencies. |
| Unknown | Therapy Director | Provided information on walking program for Resident #80. |
| Unknown | Licensed Practical Nurse | Described medication delivery process and confirmed notification delays. |
| Unknown | Licensed Nurse Aide | Reported documentation of ambulation task for Resident #80. |
| Unknown | Pharmacist | Stated cholestyramine administration timing and confirmed lack of recommendations. |
| Unknown | Unit Manager | Confirmed inaccurate suppository administration documentation for Resident #31. |
Inspection Report
Routine
Deficiencies: 2
Date: May 10, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, including the proper use of personal protective equipment (PPE) and reporting of communicable diseases during a COVID-19 outbreak.
Findings
The facility failed to fully implement infection prevention and control policies, including improper PPE use by staff, delayed reporting of COVID-19 positive cases to the State Health Department, and inadequate staff training on PPE. There were 82 COVID-19 positive cases identified during the outbreak, with 55 cases not reported within the required 24-hour timeframe.
Deficiencies (2)
Failure to implement infection prevention and control program policies related to proper use of personal protective equipment and reporting communicable diseases.
Failure to include mandatory training on personal protective equipment for all staff, with 2 of 5 sampled staff lacking documentation of PPE training.
Report Facts
COVID-19 positive cases: 82
COVID-19 positive cases not reported within 24 hours: 55
Direct care staff education records reviewed: 5
Staff without PPE training documentation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Infection Preventionist | Confirmed PPE requirements, lack of PPE training documentation, and delayed reporting of COVID-19 cases. | |
| Director of Nursing | Stated the facility had a COVID-19 outbreak with residents still positive. |
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