Rutland Healthcare & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Rutland Healthcare & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 5, 2025

  Based on interview and record review, the facility failed to ensure 1 of 3 residents sampled [Resident #1] was free from physical abuse by facility staff. A reasonable person has the expectation that they will be safe in their home and can trust and rely on staff to keep them safe. In this case, a reasonable person would suffer psychosocial harm of fear and or anxiety related to being abused by a staff member. Findings include:Per record review, Resident #1 was admitted to the facility with diagnoses that include dementia, major depressive disorder, anxiety, hallucinations, dissociate conversion disorder, and has a BIMS [brief interview for mental status] score of 7 indicating severe cognitive impairment.Review of the facility's Abuse, Neglect, and Exploitation Prevention policy [effective… […]

• Actual harm, isolatedF689Jun 19, 2025

  Based on interviews and record reviews, the facility failed to ensure the residents' environment remained as free from accident hazards as is possible for 1 of 8 residents surveyed (Resident #29). Findings include: Per interview on 6/17/25 at 11:30 AM with Resident #29's Family Member, s/he stated that her/his parent was transferred to another room due to pest control issues. While the resident was in her/his new room, s/he got up during the night to use the bathroom and fell. S/he stated that s/he thinks the resident fell because there were no nonskid strips on the floor like there were in his/her previous room. S/he also stated his/her mother went to the hospital because s/he had a fractured hip from the fall. […]

• Actual harm, isolatedF600Sep 1, 2021

  Based on interview and record review the facility failed to ensure that one of three residents in the sample were free from physical abuse on three occasions, (Resident #2). Findings include: Per record review Resident #1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . S/he has a history of anxiety, aggression, and being resistive to care. Resident #1's care plan reflects a risk for resident-to-resident altercation due to cognitive deficit and wandering, and the potential to exhibit physical behaviors related to cognitive loss/dementia. Progress Notes indicate Resident #1 was becoming aggressive with other residents and staff who attempt to redirect her/him. 1. On 7/3/2021 at approximately 8:30 PM Resident #1 hit Resident #2 in the face, leaving a red mark on her/his cheek. […]

• No harm, potential for more than minimal, widespreadF812Jun 19, 2025

  Based on observation, interview and policy review, it was determined that the facility failed to store food in accordance with professional standards for food service safety. This deficiency has the potential to impact all residents in the facility. Findings include: During observation with the Food Service Director on 6/16/25 at approximately 11:00 AM, the initial tour of the kitchen revealed a dry storage room, with a covered [NAME] mixer that was noted to have a dried yellow substance on the front of the mixer and a powdery substance on the base of the mixer. The Food Service Director stated that the mixer was ready for use in its current state and that the item is cleaned between uses. […]

• No harm, potential for more than minimal, widespreadF925Jun 19, 2025

  Based on observation and interview, it was determined that the facility failed to maintain an effective pest control program that ensures the facility is free of pests. This deficiency has the potential to impact all residents. Findings include: Per observation on 6/16/25 at approximately 11:00 AM during the initial tour of the facility kitchen area many fruit flies were observed in the dry storage room around a stainless-steel table. Across the room on top of a rack was noted to be a box of over ripe bananas with fruit flies. The Food Service Director confirmed that the fruit flies may be coming from the overripe bananas. Observation on 6/16/25 at approximately 11:15 AM revealed a large-sized moth flying and landing on clean dishes in the dishwashing room. […]