The Pines at Rutland Center for Nursing & Rehabili

In the surveyor’s words

From the most serious findings on record at The Pines at Rutland Center for Nursing & Rehabili, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 18, 2024

  Based upon interview and record review, the facility failed to provide adequate supervision to prevent accidents resulting in harm to one resident [Res.#59] of 6 sampled residents. Findings include: Per review of Res.#59's medical record, the resident was admitted to the facility with diagnoses that included generalized muscle weakness, cerebral infarction [stroke], seizures, and dementia. Review of Res.#59's Care Plan reveals the resident was identified as at risk for falls related to a history of falls, dementia, hemiplegia [one-sided paralysis], anxiety, depression, and medications associated with increased fall risk. […]

• No harm, potential for more than minimal, widespreadF812Aug 31, 2022

  Based on observation and staff interview, the facility failed to ensure foods were stored and/or prepared under sanitary conditions. Findings include: The following observations were made during the initial tour of of the kitchen with the Interim Food Services Director (IFSD) on 8/29/22 at 9:56 AM: 1. The meat slicer was observed sitting under a prep table. Much of the slicer was coated in a sticky white film. The IFSD stated that staff did use the slicer. 2. The vent hood over the main stove was soiled with grease and dust. The IFSD stated that the hood is cleaned every 180 days and is due in September 2022. 3. The steam table is heavily soiled with stuck on dripped food, grease and dust. 4. A microwave on a kitchen shelf is heavily soiled with spilled foodstuffs. […]

• No harm, potential for more than minimal, patternF812Nov 25, 2024

  Based on observation, and staff interview, 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. Findings include: During an observation on 11/25/24 at 2:05 PM, there was a baking sheet that was stacked on other baking sheets that was noted to be wet. The baking sheet was placed on the counter by this surveyor and the steam table pans were inspected. There was a wet small steam table pan that had been stacked on others. At this time the Director of Dietary was shown the small steam table pan and when this surveyor was attempting to show her/him the baking sheet it had been removed from the counter and placed back on top of the stacked sheets. […]

• No harm, potential for more than minimal, patternF554Sep 18, 2024

  Based on observations, interview, and record review, the facility failed to assess a resident for the ability to self-administer medications and initiate a care plan related to self-administration of medications for 2 of 8 sampled residents (Residents #82 and #92). Findings include: 1. Per interview on 9/16/24 at approximately 11:30 AM, Resident #92 was observed to have two medications in her/his room, the first called Mannitol Supplement (the label indicates it is a supplement that is useful to prevent urinary tract infections) and and the second was an Albuterol Inhaler (used to treat difficulty breathing) on the windowsill. When s/he was asked what the medications were, s/he explained that family members bring in the Mannitol supplement as s/he has a history of urinary tract infections. […]

• No harm, potential for more than minimal, patternF658Aug 9, 2023

  Based on observations, interviews, and record reviews the facility failed to ensure services provided met professional standards of quality regarding resident medications administered as ordered for 3 of 35 sampled residents (Resident #266, #6, & #59) and regarding tube feeding and weight monitoring for 1 resident [Resident #59]. Findings include: Review of The National Library of Medicine Nursing Rights of Medication Administration (ncbi.[NAME].nih.gov) notes the nurse is frequently the final person to ensure medication is correctly prescribed and dispensed before administration. […]