Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rutland Nursing Home, Inc during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and NG-tube dependence received enteral feedings and medications without consistent verification or documentation of NG tube placement, despite facility policy and MD orders requiring checks before feedings and medications. During evening care, an RN removed the soiled dressing securing the NG tube, had a CNA hold the tube while the RN left to obtain tape, then re-secured the tube and resumed feeding without confirming placement by aspirating gastric contents or documenting any check. Later, another RN responded to a pump error, changed the feeding bottle and tubing, aspirated residual without checking the external mark, and did not document the verification. The resident subsequently developed tachypnea, tachycardia, fever, and respiratory distress, and hospital evaluation confirmed respiratory failure and aspiration pneumonitis due to a malpositioned NG tube in the left lung.
The facility did not maintain required temperature levels, with 22 out of 34 sampled rooms on six floors exceeding regulatory limits, resulting in widespread resident discomfort. Staff and residents reported hot conditions, and temperature logs confirmed persistent high temperatures above the acceptable range. The facility's air conditioning system was not functioning adequately, and the emergency plan was not effective in preventing the deficiency.
The facility did not ensure effective temperature control during a period of extreme heat, resulting in indoor temperatures exceeding policy limits. Despite the air conditioning system functioning, it was inadequate to maintain comfort, and portable AC units were not installed until after complaints and a Department of Health visit. Residents and staff reported discomfort due to the heat, and the DON confirmed that medical conditions were being monitored during the incident.
A resident with a history of aggressive behavior was involved in two altercations with another resident, the first in an elevator and the second in their room. After the initial incident, staff failed to promptly implement required close monitoring or 1:1 supervision, allowing a second unwitnessed altercation to occur. The resident sustained an acute rib fracture as a result of the second incident, demonstrating a failure to protect from abuse.
Two residents in an LTC facility experienced falls due to inadequate supervision and improper use of assistance devices. One resident, with severe cognitive impairment, fell during a Hoyer lift transfer due to improper securing, resulting in fractures. Another active resident fell from a chair after being removed from a wheelchair with a harness by a teacher, contrary to their care plan. These incidents highlight failures in training and adherence to safety protocols.
A resident with a history of stroke and diabetes, who was cognitively intact, was emotionally distressed after a CNA made inappropriate and unprofessional remarks, including stating that none of the staff liked the resident and refusing to acknowledge the resident's pain during care. The CNA admitted to "telling off" the resident and did not follow protocol to address the resident's complaints, resulting in a finding of emotional abuse and a failure to uphold the resident's dignity.
Failure to Verify Nasogastric Tube Placement and Monitor Enteral Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving enteral nutrition via a nasogastric (NG) tube received appropriate care and monitoring for complications, including verification of tube placement as required by facility policy and physician orders. The resident was an infant with prematurity, chronic respiratory failure, ventilator dependence, and NG-tube dependence, with severely impaired cognition. Facility policy required verification of tube placement before feedings and medication administration, including checking exit length in centimeters and aspirating gastric contents, and the resident’s care plan and physician orders specifically directed staff to check NG tube placement before and after medications and feedings. However, the Treatment Administration Record and Medication Administration Record from admission through the date of the incident contained no documented evidence that nursing staff verified NG tube placement at any time, despite standing orders to do so. On the evening of the incident, video surveillance and staff interviews showed that a CNA entered the resident’s room and paused the feeding pump to provide care, noting that the dressing securing the NG tube was soiled and lifted. The CNA called an RN, who removed the soiled dressing and instructed the CNA to hold the NG tube at the resident’s nose while the RN left the room to obtain tape, leaving the NG tube stabilized only by the CNA. The RN then returned, applied new tape, assisted with the resident’s care, and resumed the feeding. The CNA reported that the RN did not use a syringe to aspirate stomach contents before restarting the feeding, and the RN acknowledged not calling another nurse for assistance and not verifying tube placement after the dressing change. The facility’s investigation later concluded that this dressing change, during which the NG tube was manipulated and not re-verified, was the only major manipulation that could have caused tube dislodgement. Later that same evening, another RN, who was not assigned to the resident, responded to a feeding pump error and changed the feeding bottle and giving set. This RN stated they checked NG placement by aspirating gastric residual but did not check the external mark on the tube and did not document the verification because they were not the assigned nurse. Around this time, the resident developed tachypnea, tachycardia, fever, and respiratory distress, prompting involvement of multiple nurses, a respiratory therapist, and a nurse practitioner, and eventual transfer to the hospital. Hospital records documented that the resident was admitted with respiratory failure due to aspiration pneumonitis/pneumonia caused by a misplaced NG tube in the left lung, with imaging confirming malposition of the NG tube into the left mainstem bronchus. The facility’s investigation and leadership interviews acknowledged that the NG tube exit length had not been documented on the Enteral Tube Placement Form and that nurses were required, but failed, to consistently verify and document NG tube placement before feedings and medications, including after the dressing change on the night of the incident. The Medical Director, Attending Physician, Clinical Manager RN, Senior Director of Pediatrics, and DON all confirmed in interviews that facility practice and physician orders required verification of NG tube placement by checking the external mark and aspirating gastric contents before feedings and medications, and that this verification should have been documented in the resident’s records. The Clinical Manager RN stated that it was not the facility’s practice to document NG placement checks on the Treatment Administration Record, despite the written orders. The Attending Physician noted that the measurement at the skin exit site should have been recorded on the Enteral Tube Placement Form but was not. The Senior Director of Pediatrics and DON both indicated that the NG tube could have been dislodged during the dressing change when the RN left the CNA holding the tube and did not verify placement before resuming the feeding. These combined failures to follow policy and orders for NG tube verification and documentation, particularly surrounding the dressing change and continuation of feeding without confirmed placement, led to the resident receiving enteral feeding through a malpositioned NG tube, resulting in respiratory failure and aspiration pneumonitis.
Failure to Maintain Safe and Comfortable Temperature Levels
Penalty
Summary
The facility failed to maintain safe and comfortable temperature levels for residents, as required by federal and state regulations. On six of seven resident floors, 22 out of 34 sampled rooms had temperatures above the acceptable range of 71°F to 81°F, with some rooms reaching as high as 86.9°F. The issue was first reported by a resident who complained about the loss of air conditioning on one floor, and subsequent complaints were made regarding high temperatures throughout the facility. Facility temperature logs and direct observations confirmed that room and corridor temperatures exceeded regulatory limits over several days. The facility's own policy required activation of an emergency plan when temperatures reached 78°F, but temperatures continued to rise above this threshold in multiple areas. Interviews with staff revealed that the air conditioning equipment was old and not functioning adequately, resulting in weak airflow and poor circulation. The DON stated that the energy company had reduced power voltage, but claimed no residents were affected, while the Medical Director indicated that residents' vital signs were being monitored and hydration was being provided. Residents and staff reported discomfort due to the heat, with fans blowing warm air and complaints of hot conditions. The facility documented that all residents were affected by the elevated temperatures, and staff took measures such as moving residents to cooler areas and providing water, but the deficiency persisted during the survey period.
Failure to Maintain Safe and Comfortable Temperatures During Extreme Heat
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels in residents' rooms and common areas, as required by its Extreme Heat Emergency policy. During a period of high temperatures, the inside temperature on various units ranged from 82.2°F to 87.6°F, exceeding the policy's threshold of 78°F for activating the emergency plan. Despite the air conditioning system being operational, it was not sufficient to keep the rooms cool, and the facility did not take timely action to address the rising temperatures before complaints were made. Multiple interviews confirmed the uncomfortable conditions: a resident reported that the facility was hot and the fan was blowing warm air, while a CNA stated that both residents and staff were complaining about the heat. The DON acknowledged that the energy company had reduced power voltage, and residents' medical conditions were being monitored. The Administrator received a complaint about the heat and recognized the difficulty in maintaining cool temperatures, but portable air conditioning units were not installed until after the Department of Health's onsite visit.
Failure to Protect Resident from Repeat Abuse Resulting in Harm
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from resident-to-resident abuse, resulting in actual harm. The incident began when a resident with a history of impulsive and aggressive behavior, as well as prior altercations, was involved in a physical altercation with another resident in the elevator. The first resident initiated the altercation by hitting the second resident, who then retaliated. Staff intervened and separated the residents, and both were assessed with no immediate injuries found. However, there was a delay in implementing close visual monitoring or 1:1 supervision for the resident identified as high risk for abuse, despite this being an intervention in their care plan. Following the initial altercation, the resident who was at high risk for abuse returned to their room. Later, the same day, the second resident entered the first resident's room, and another unwitnessed altercation occurred. The first resident subsequently complained of chest pain and was transferred to the emergency department, where they were diagnosed with an acute rib fracture. Documentation and interviews revealed that staff had not yet implemented the required close visual monitoring or 1:1 supervision at the time of the second incident, despite instructions to do so after the first altercation. The facility's failure to promptly implement safety measures and monitoring after the initial incident allowed for a second altercation to occur, resulting in actual physical harm to the resident. The care plan for the resident at high risk for abuse included interventions such as close monitoring, but there was no documented evidence that these were put in place in a timely manner. This lapse in protection and supervision directly contributed to the resident sustaining a serious injury.
Inadequate Supervision and Improper Use of Assistance Devices Lead to Resident Falls
Penalty
Summary
The facility failed to ensure adequate supervision and proper use of assistance devices, leading to accidents involving two residents. Resident #108, who had severe cognitive impairment and was dependent on staff for all activities of daily living, fell and sustained a significant injury while being transferred using a Hoyer lift. The incident occurred because the Certified Nursing Assistants did not properly secure the resident in the sling, resulting in the resident sliding to the floor and sustaining fractures. Interviews with staff revealed inconsistencies in training and understanding of the proper use of the Hoyer lift, contributing to the accident. Resident #260, who was severely cognitively impaired and required constant supervision, fell from a chair after being removed from a wheelchair with a harness. The resident was known to be very active and required a harness for safety. The teacher, who was not authorized to transfer residents, moved the resident to an armchair without securing them, leading to the fall. The incident highlighted a lack of adherence to the care plan, which specified the need for a harness and supervision. Both incidents demonstrate a failure in the facility's responsibility to provide a safe environment and adequate supervision to prevent accidents. The deficiencies were attributed to improper training and execution of transfer techniques, as well as a lack of adherence to established care plans for residents with high fall risks.
Resident Subjected to Emotional Abuse and Lack of Dignity by CNA
Penalty
Summary
A deficiency occurred when a resident with a history of cerebrovascular accident with right hemiplegia and diabetes mellitus, and who was cognitively intact, was not treated with respect and dignity by a Certified Nursing Assistant (CNA). The resident reported to a Licensed Practical Nurse (LPN) that the CNA told them that none of the staff liked them and made other inappropriate and unprofessional statements, including that the CNA would not take criticism from residents. The resident became visibly upset, began crying, and required emotional support. A neuropsychology progress note documented that the resident was distressed by the CNA's behavior and needed assistance to calm down. The facility's investigation found that the CNA admitted to "telling off" the resident, stating that the resident was verbally abusive and that the CNA would accept suspension for their actions. The CNA also failed to recognize the resident's complaint of pain during care and did not follow protocol to stop care and alert a nurse. The investigation concluded that emotional abuse had occurred, as the CNA's statements and actions did not promote the resident's dignity or recognize their individuality. Multiple staff interviews and documentation confirmed the resident's account of the incident, including statements from the LPN, the Registered Nursing Supervisor, and the Director of Nursing. The resident reported feeling better after the CNA did not return, and there were no physical injuries observed. The facility's policy requires staff to treat residents with respect and dignity, but this was not upheld in this instance, resulting in a violation of the resident's rights.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brooklyn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dr Susan Smith Mckinney Nursing And Rehabilitation | 0.3 mi | ★★★★★ | 0 | 0 |
| Crown Heights Center For Nursing And Rehabilitatio | 0.9 mi | ★★★★★ | 5 | 0 |
| Brooklyn Center For Rehabilitation And Residential | 1.1 mi | ★★★★★ | 9 | 0 |
| Schulman And Schachne Inst For Nursing & Rehab | 1.1 mi | ★★★★★ | 0 | 0 |
| The Monarch At Brooklyn Rehab And Nursing Center | 1.1 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.