Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 The Pines At Rutland Center For Nursing & Rehabili during CMS and state inspections, most recent first.
A resident's responsible party was not informed in advance about the risks, benefits, or alternatives to a newly prescribed psychoactive medication for insomnia. The medication was administered multiple times before any documented consent was obtained, contrary to facility policy requiring prior written consent and discussion. Staff confirmed that informed consent was not documented until weeks after the medication was first given.
A resident sustained a bruise to the right foot and toes after a footboard fell off the bed, but the resident's representative was not notified of this injury. The Unit Manager was unaware of the injury and could not provide details about its occurrence or duration. The representative only learned of the injury during a surveyor interview and had previously expressed concerns about falls and new medication.
A resident with paraplegia, cognitive communication deficit, and anoxic brain injury was consistently documented as always incontinent of bowel function, yet did not have a care plan addressing bowel incontinence. Staff interviews confirmed the absence of a care plan despite chronic incontinence being recorded, and the DON acknowledged that such a care plan was required.
A resident with type 1 diabetes and diabetic retinopathy was allowed to self-report blood glucose readings without staff verification, contrary to physician orders and care plan instructions. Staff relied on the resident's verbal report and did not observe or verify the glucometer reading, despite the resident's visual impairment and the requirement to use the facility's glucometer.
A resident with Parkinson's, dementia, and a history of frequent unwitnessed falls was not provided with adequate supervision or care plan interventions to address wandering and safety concerns. Despite multiple falls and visible injuries, the care plan lacked measures for increased supervision, and staff confirmed the resident's ongoing wandering and falls.
A resident with PTSD was not assessed for trauma or possible triggers, and their care plan lacked interventions to manage PTSD or prevent re-traumatization. Staff and the social worker confirmed that no trauma assessment or trigger evaluation had been completed, and the care plan did not address these needs.
The facility failed to maintain proper sanitation and drying procedures in the kitchen. Wet baking sheets and steam table pans were improperly stacked, and the floor under a prep table had missing tiles with accumulated debris. The gas stove top had excessive food and grease buildup, and the third-floor steam table contained leftover orzo from the previous night. The Director of Dietary and the Kitchen Supervisor confirmed these issues, and the facility Administrator acknowledged them during a walkthrough.
A resident with a history of falls and requiring extensive assistance was injured due to inadequate supervision. An LNA, unfamiliar with the resident's care needs, attempted a transfer without the necessary equipment and staff, resulting in a fall and a tibial plateau fracture.
The facility failed to assess two residents for self-administration of medications and did not initiate care plans. A resident was found with medications in their room without a self-administration assessment or care plan. Another resident had pills left at their bedside without proper assessment or physician's order. The facility lacked a policy for self-administration of medications.
A resident with quadriplegia expressed a preference to be up by 8:00 AM, which was not consistently honored by the facility. Despite the resident's cognitive intactness and communication of their preference, the care plan did not reflect this, leading to frustration. The Unit Manager confirmed the oversight in updating the care plan.
A resident with quadriplegia and muscle spasms missed multiple doses of Finasteride and Dantrolene due to pharmacy unavailability. The MAR confirmed missed doses, and nursing notes cited medication unavailability. The Unit Manager reported ongoing issues with medication delivery, affecting multiple residents, while the Administrator and DON were unaware of the problem.
A resident was found to have medications improperly stored on a windowsill, including a Mannitol Supplement and an Albuterol Inhaler. The resident did not have a lock box for securing these medications and had not informed nursing staff about the Mannitol Supplement. The facility lacked a policy for securing self-administered medications, leading to a deficiency.
A facility failed to maintain signed and dated x-ray reports in a resident's clinical record, placing them at risk for unmet care needs. The deficiency was due to unclear processes and responsibilities for entering x-ray reports into the facility's records, as highlighted by interviews with staff and a community health center APRN.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to inform a resident's responsible party in advance about the risks and benefits of a newly prescribed psychoactive medication, as well as treatment alternatives or other options. The responsible party expressed concerns regarding the resident's increased number of falls and the initiation of a new medication for sleep, but was unable to identify the medication. Record review showed that the resident was started on Trazodone 25mg as needed for insomnia, and received the medication on several occasions before any documented informed consent was obtained from the responsible party. Facility policy requires written consent and documentation of discussions regarding the risks and benefits of psychotropic medications prior to administration. However, there was no evidence that informed consent was obtained or that the responsible party was notified before the medication was administered. Documentation showed that only after the medication had been given multiple times was a message left for the responsible party, and verbal consent was documented more than three weeks after the initial order. Interviews with facility staff confirmed the lack of timely documentation and consent.
Failure to Notify Resident Representative of Injury
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition when a resident sustained a bruise to the right foot and toes after the footboard fell off the bed and landed on the resident's foot. Observations showed the resident self-propelling in a wheelchair barefoot with visible bruising. The Unit Manager was unaware of the injury and could not confirm how long it had been present or how it occurred. During an interview, the resident's representative expressed concerns about recent falls and new medication but was unaware of the injury until informed by surveyors. The Unit Manager confirmed that the representative had not been notified of the injury.
Failure to Care Plan for Bowel Incontinence in Resident with Paraplegia
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing bowel incontinence for a resident with paraplegia, cognitive communication deficit, and anoxic brain injury. The resident was documented as always incontinent of bowel function in both the Minimum Data Set (MDS) and daily bowel movement records. Despite this, the resident's care plan did not include interventions or goals related to bowel incontinence. The resident reported being unaware of incontinence episodes and stated that incontinence checks were not performed between morning and evening care, resulting in long periods without assessment or care. Interviews with facility staff, including the Unit Manager RN and the Director of Nursing (DON), confirmed that the resident was not care planned for bowel incontinence, despite chronic incontinence being documented. The DON acknowledged that residents with chronic incontinence should have a care plan addressing this need. The lack of a care plan for bowel incontinence was identified through record review and staff interviews, highlighting a failure to meet regulatory requirements for comprehensive care planning.
Failure to Verify Blood Glucose Readings for Visually Impaired Diabetic Resident
Penalty
Summary
The facility failed to ensure quality of care for a resident with type 1 diabetes mellitus and diabetic retinopathy by not following physician orders and care plan instructions regarding blood glucose monitoring. The resident's orders specified that blood sugar should be checked before meals and at bedtime using the facility's glucometer, with nursing staff required to observe and verify the reading. The care plan also noted the resident's impaired vision and required nursing staff to read the glucometer after the resident checked their own blood glucose. During observation, a nurse asked the resident for their blood sugar reading and accepted the resident's verbal report without directly observing the glucometer or the reading. Interviews with staff confirmed that the resident used their personal glucometer and that staff often relied on the resident's verbal report rather than verifying the reading themselves, despite the resident's visual impairment and the facility's instructions that staff must observe and verify the result using the facility's equipment.
Failure to Provide Adequate Supervision for Resident with Recurrent Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent potential injury for a resident with a history of falls and multiple medical conditions, including Parkinson's with dementia, polyosteoarthritis, epilepsy, anemia, and mild cognitive impairment. The resident was dependent on staff for activities of daily living, exhibited impulsivity, and was noted to wander and sit on the floor. Despite these risk factors, the care plan did not include interventions addressing the resident's wandering behavior or the need for increased supervision. Over a five-month period, the resident experienced 20 falls in their room, 19 of which were unwitnessed, as well as additional unwitnessed falls in the dining room and hallway. Observation revealed the resident self-propelling in a wheelchair without shoes and with a visible bruise on the right foot and toes. Incident reports and interviews confirmed ongoing concerns about the frequency of falls and the lack of effective supervision or interventions to address wandering. The unit manager acknowledged the resident's wandering and history of unwitnessed falls, but the care plan remained insufficient in addressing these specific supervision needs.
Failure to Assess and Address Trauma Triggers for Resident with PTSD
Penalty
Summary
The facility failed to conduct a trauma-informed care assessment for a resident diagnosed with post-traumatic stress disorder (PTSD). During observations, the resident was found alone in their bathroom, screaming and yelling obscenities, and expressed distress when approached. Staff indicated that this behavior was not unusual for the resident. Record review showed that the resident's care plan addressed mood problems related to anxiety, PTSD, and a history of passive suicidal ideation, but did not include any assessment of trauma, identification of possible triggers, or interventions to manage PTSD or prevent re-traumatization. The social worker confirmed that no trauma assessment or trigger evaluation had been completed for the resident, and that the care plan did not address these issues, stating that residents already in-house at the time trauma-informed care became a focus were not assessed.
Sanitation and Drying Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure proper sanitation and drying procedures in the kitchen, leading to several deficiencies. During an observation, a baking sheet and a small steam table pan were found to be wet and improperly stacked without being air-dried. The Director of Dietary confirmed these items were not dried before storage and acknowledged the issue. Additionally, the floor under a food prep table had missing tiles, exposing subflooring with accumulated liquid and food particles, and the table leg had a buildup of dirt and grease. The gas stove top was also noted to have excessive food and grease buildup, despite staff signing off on daily cleaning. Further inspection revealed that the third-floor steam table contained pieces of orzo in the water, which should have been drained and cleaned after the previous night's dinner service. The Director of Dietary and the Kitchen Supervisor confirmed the presence of orzo and acknowledged the failure to clean the steam table. The facility Administrator confirmed these observations during a walkthrough and noted that repairs were being made in the kitchen.
Inadequate Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent an accident that resulted in harm to a resident. The resident, who had a history of falls, dementia, hemiplegia, and other conditions, required extensive assistance and a sit-to-stand lift by two staff members for toileting and transfers. However, on the day of the incident, an LNA who was unfamiliar with the resident's care requirements attempted to assist the resident without the necessary equipment and additional staff, leading to a fall in the bathroom. The incident resulted in the resident suffering a tibial plateau fracture, as confirmed by x-rays. The LNA involved did not understand the resident's need for a sit-to-stand lift and assumed the resident required only one-person assistance for transfers. This misunderstanding and deviation from the care plan led to the resident being inappropriately moved, causing significant injury.
Failure to Assess and Care Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to assess two residents for their ability to self-administer medications and did not initiate care plans related to self-administration. Resident #92 was found with two medications in their room: a Mannitol supplement and an Albuterol inhaler. The resident reported using the inhaler independently and receiving the supplement from family members. However, there was no evidence of a self-administration assessment or a care plan for these medications. The Assistant Director of Nursing confirmed the lack of assessment and care planning, and the facility did not have a policy for self-administration of medications. Resident #82 was observed with a black pill and two rust-colored pills left at their bedside. The resident stated that the nurse left the black pill because they were not taking their medication quickly enough and left the rust-colored pills, identified as Ibuprofen, for potential future use. There was no documented assessment or care plan for self-administration, nor was there a physician's order for such practice. The Unit Manager confirmed that the resident had not been assessed for self-administration, and medications should not have been left at the bedside without proper assessment and documentation.
Failure to Honor Resident's ADL Preference
Penalty
Summary
The facility failed to honor a resident's preference for activities of daily living (ADL) care, specifically regarding the time they preferred to get out of bed. The resident, who has quadriplegia and requires extensive assistance for dressing and transfers, expressed a preference to be up by 8:00 AM or before breakfast. Despite this preference being previously documented in their care plan, it was removed in November 2023. The resident reported that aides often did not start their morning care until 9:00 AM or later, which occurred 1-3 times a week, and sometimes even later. This inconsistency in honoring the resident's preference led to frustration and dissatisfaction, as the resident felt this was becoming a norm. The resident, who was assessed to have a BIMS score of 15, indicating cognitive intactness, communicated their concerns to the social service department via email in February 2024. However, the care plan did not reflect the resident's preference to get out of bed before 8:00 AM. The Unit Manager acknowledged awareness of the resident's preference and confirmed that it should have been included in the care plan and Kardex but was not. This oversight in updating and maintaining the care plan to reflect the resident's preferences contributed to the deficiency identified in the report.
Pharmaceutical Service Deficiency
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #11, who has diagnoses including quadriplegia and muscle spasms. Despite having a cognitive assessment score indicating intact mental status, Resident #11 reported missing 1-2 doses of Finasteride and Dantrolene each month due to unavailability from the pharmacy. The Medication Administration Records (MAR) from June 1, 2024, through September 18, 2024, confirmed that Resident #11 missed seven doses of Dantrolene and six doses of Finasteride. Nursing notes indicated that the medications were not available on the specified dates. The Unit Manager acknowledged ongoing issues with obtaining medications that cannot be combined in a bubble pack, affecting Resident #11 and others on the unit. Despite contacting the pharmacy monthly, the problem persisted. The Administrator and Director of Nursing were unaware of these issues, indicating a lack of communication or oversight regarding the pharmacy's failure to deliver all ordered medications on time.
Improper Medication Storage for Resident
Penalty
Summary
The facility failed to ensure proper storage of medications for a resident, leading to a deficiency. During an observation and interview, it was found that a resident had two medications, Mannitol Supplement and an Albuterol Inhaler, stored on the windowsill of their room. The resident explained that the Mannitol Supplement was brought in by family members to prevent urinary tract infections, and the Albuterol Inhaler was used to prevent wheezing. The resident did not have a locked box to secure these self-administered medications and had not discussed the use of the Mannitol Supplement with the nursing staff. The facility's administrator confirmed that the resident should have had a lock box in their room for securing medications and acknowledged that there was no existing policy regarding the securing of self-administered medications. This lack of proper medication storage and policy led to the identified deficiency.
Failure to Maintain Signed X-Ray Reports in Resident's Record
Penalty
Summary
The facility failed to maintain signed and dated x-ray reports in the clinical record of one resident, identified as Resident #24. This deficiency was identified during a review of the resident's medical records, which revealed that x-ray reports for a chest x-ray and a left hand x-ray were missing. The x-rays were ordered on specific dates, but there was no documentation in the resident's record indicating that the reports were received or reviewed by a physician. This oversight placed the resident at risk for unmet care needs. Interviews with facility staff and a community health center APRN highlighted a lack of clarity and communication regarding the process for entering x-ray reports into the facility's medical records. The Unit Manager was unaware of how x-ray reports were entered, and the APRN, who reviews the reports through a portal, was unsure of how they were subsequently documented in the facility's records. The Administrator and Director of Nursing acknowledged that while some staff have access to the portal, it is the provider's responsibility to upload the reports and notes into the facility's system. This lack of coordination and responsibility led to the deficiency in maintaining accurate and complete medical records for the resident.
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Illustrative
What surveyors actually found near you
We read the 13 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rutland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountain View Center Genesis Healthcare | 0.3 mi | ★★★★★ | 7 | 0 |
| Rutland Healthcare & Rehabilitation Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Gill Odd Fellows Home Of Vermont | 19.2 mi | ★★★★★ | 6 | 0 |
| Granville Center For Rehabilitation And Nursing | 20.5 mi | ★★★★★ | 0 | 0 |
| Slate Valley Center For Rehabilitation And Nursing | 22.6 mi | ★★★★★ | 0 | 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.