Ralls Nursing Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure a safe environment free from physical and verbal abuse for Resident #1 when LVN A, CNA B and CNA C forced Resident #1 to leave the dining room and go to bed when they dragged Resident #1 with a blanket to her room. LVN A, CNA B and CNA C made verbal comments about Resident #1 on front of and to Resident #1 mind your own business, calling to find another place for her to live, why haven't they made her move yet. The noncompliance was identified as PNC. The IJ began on 12/19/25 and ended on 01/07/2026. The facility had corrected the noncompliance before the survey began on 01/12/2026. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement written policies and procedures that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of known source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Administrator for 1 of 8 residents (Resident #1) reviewed for abuse. The facility failed to follow their policy for abuse and neglect when LVN A, CNA B and CNA C failed to report an incident with Resident #1 for 2 days and the ADON and BOM failed to immediately report Resident #1's allegation of abuse to the ADM prior to investigation. The noncompliance was identified as PNC. The IJ began on 12/19/25 and ended on 01/07/2026. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to the abuse coordinator, the facility Administrator for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to follow their policy for reporting abuse and neglect when LVN A, CNA B and CNA C did not report an incident with Resident #1 for 2 days. LVN A, CNA B and CNA C continued to work with Resident #1 because they failed to report the abuse to the ADM. The noncompliance was identified as PNC. The IJ began on 12/19/25 and ended on 01/07/2026. The facility had corrected the noncompliance before the survey began on 01/12/2026. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure of 5 of 8 residents (Residents #2, #3, #4, #5, and #6) were free from misappropriation of personal property. The facility did not prevent RN D from taking residents #2, #3, #4, #5 and #6's personal property. This failure could place residents at risk for decreased quality of life and distrust for the staff.

Inspectors wroteBased on Observations, interviews and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 1 resident (Resident #1), reviewed for pharmacy services. The facility failed to ensure Resident #1 was free of significant medication errors when MA B administered Tegretol 200mg (prescribed for seizures, bipolar disorder, and nerve pain), Lipitor 40mg (prescribed to lower cholesterol), Baclofen10mg (muscle relaxer), Metoprolol 25mg (prescribed to lower blood pressure), Neurontin 300mg (prescribed for seizures and nerve pain), Quetiapine Fumarate 200mg (medication prescribed for bipolar disorder and schizophrenia) to Resident #1 on 10/13/25, when these medications were prescribed to another resident. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 14 of 35 confidential residents who were reviewed for resident council. The facility failed to provide a private space for resident council meetings. Based on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 14 of 35 confidential residents who were reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents at risk of not being able to voice concerns due to a lack of privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 14 of 35 confidential residents reviewed for resident rights. The facility failed to ensure 14 confidential residents were provided, the Grievance Procedure, information in regard to who the facilities' grievance officer was, their contact information, and how to file an anonymous grievance. Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 14 of 35 confidential residents reviewed for resident rights. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 3 of 30 days (8/30/2025, 9/4/2025, and 9/13/2025) reviewed for RN coverage.- The facility failed to ensure that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 8/30/2025, 9/4/2025, and 9/13/2025. This failure could place residents at risk of not having adequate qualified personnel in case of a health crisis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to ensure frozen pork was not stored above ready-to-eat foods in the freezer. The facility failed to ensure the window seal directly above the kitchen sink was free of dirt build-up and grime. The facility failed to ensure a container of ice used to prepare drinks for lunch, did not have a scoop stored inside of it. The facility failed to ensure all condiments had expiration or use-by dates. The facility failed to ensure a cleaning schedule was followed and monitored. These failures could place residents who received meals and/or snacks from the kitchen at risk of food contamination and food borne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 16 (Resident # 37) residents reviewed for abuse and neglect.- The facility did not report to the State Agency when Resident #37, was found unresponsive and not breathing in her room on 8/3/2025. On 8/9/2025 the DON was made aware that EMS reported food in Resident #37 airway, as a possible cause for Resident #37's medical emergency. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure a safe environment free from physical and verbal abuse for Resident #1 when LVN D grabbed and pulled Resident #1 from behind the nurse's station, and Resident #1 was observed with redness on 07/13/25, and with bruises to both hands and wrists on 07/14/25. During this incident LVN D said to the resident three times that her daddy was dead. The noncompliance was identified as PNC. The IJ began on 07/13/25 and ended on 07/14/25. The facility had corrected the noncompliance before the survey began on 07/15/25. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm.

Inspectors wroteBased on observation, interview and record review the facility failed to implement written policies and procedures that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of known source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Administrator for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure a safe environment free from physical and verbal abuse for Resident #1 when LVN D grabbed and pulled Resident #1 from behind the nurse's station, and Resident #1 was observed with redness on 07/13/25, and with bruises to both hands and wrists on 07/14/25. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to the abuse coordinator, the facility Administrator for 2 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure a safe environment free from physical and verbal abuse for Resident #1 on 7/13/25 at 6:07 PM when LVN D grabbed and pulled Resident #1 from behind the nurse's station, and Resident #1 was observed with redness on 07/13/25, and with bruises to both hands and wrists on 07/14/25. During this incident LVN D said to the resident three times that her daddy was dead. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 of 3 residents (Residents #32) reviewed for infection control. The facility failed to ensure CNA A utilized proper hand hygiene during incontinence care for Resident #32. This failure could place residents at risk for infection and cross contamination.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, on facility grounds in 1 of 2 parking lots (front entrance parking lot) in that: The facility failed to ensure the trash was emptied into the dumpster for five hours. This failure could attract unwanted pests and cause the facility to have an unsightly appearance.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents had the right to be free from sexual abuse for 3 (Resident #3, Resident #4 and Resident #6) of 9 residents reviewed for abuse. 1. The facility failed to put protective measures in place on 05/11/24 to protect Resident #4 from sexual abuse after knowing Resident #2 had displayed inappropriate sexual behavior with Resident #3. 2. The facility failed to put protective measures in place on 06/02/24 to protect Resident #3 in place from sexual abuse after knowing Resident #5 had a history of inappropriate sexual behavior. 3. The facility failed to put protective measures in place on 06/02/24 to protect Resident #6 in place from sexual abuse after knowing Resident #5 had a history of inappropriate sexual behavior. On 06/07/24 at 5:00 PM an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse and neglect for 4 (Resident #1, Resident #3, Resident #4, and Resident #6) of 9 residents reviewed for abuse and neglect. The facility failed to implement their abuse and neglect policy when: 1. The facility failed to investigate the fall incident that occurred with Resident #1 while in the care of CNA E on 05/30/24. CNA E failed to notify the nurse of the fall. Resident #1 sustained a hip fracture. 2. The facility failed to report to the state agency and investigate a sexual incident that occurred on 05/10/24 between Resident #2 and Resident #3. 3. The facility failed to report to the state agency and investigate a sexual incident that occurred on 05/11/24 between Resident #2 and Resident #4. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury to the administer of the facility and to other officials including the State Survey Agency in accordance with State law through established procedures for 5 of 9 residents (Residents #2, #3, #4, #5 and #6) reviewed for abuse and neglect. 1. The facility failed to report a sexual incident which occurred on 05/10/24 between Resident #2 and Resident #3. 2. The facility failed to report a sexual incident which occurred on 05/11/24 between Resident #2 and Resident #4. 3. [...]

Inspectors wroteBased on interview and record reviews the facility failed to have evidence that all violations, in response to abuse, neglect, exploitation or mistreatment, were thoroughly investigated for 6 of 9 residents (Residents #1, #2, #3, #4, #5 and #6) reviewed for abuse and neglect. 1. The facility failed to investigate a fall incident that occurred on 05/30/24 with Resident #1 while in the care of CNA E. 2. The facility failed to investigate a sexual incident that occurred on 05/10/24 between Resident #2 and Resident #3. 3. The facility failed to investigate a sexual incident that occurred on 05/11/24 between Resident #2 and Resident #4. 4. The facility failed to investigate a sexual incident that occurred on 06/02/24 between Resident #5 and Resident #3. 5. The facility failed to investigate a sexual incident that occurred on 06/02/24 between Resident #5 and Resident #6. [...]

Inspectors wroteBased on interviews and record review the facility failed to immediately inform the resident representative when there was an incident that involved the resident's physical, mental, or psychosocial status for 1 resident (Resident #3) of 9 residents reviewed for notifications. The facility failed to notify Resident's #3's representative (Family Member C) that Resident #3 had been involved in an incident of inappropriate sexual behavior that occurred on 05/10/24. This failure could affect residents by causing the resident's family to be unaware of changes in residents' condition.

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 (Residents #1) residents reviewed for adequate supervision and prevention of accidents. The facility staff (Administrator and DON) failed to adequately address Resident #2's ongoing behavior of entering Resident #1's room. The facility (Administrator and DON) failed to address resident #2's ongoing physical and verbal behavior with appropriate interventions. These failures to put supervision measures in place could result in harm to Resident #2 and the remaining residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure to address, resolve and have a prompt resolution of all grievances in accordance with facility policy for 1 of 8 (Resident #1), 1 Family Member (Family Member J) and staff (CNA E). The facility failed to document, resolve, and follow up on grievances related to Resident #2's behavior on behalf of Resident #1. The facility failed to document, resolve, and follow up on grievances related to Resident #2's behavior on behalf of Family Member J. The facility failed to document, resolve, and follow up on grievances related to Resident #2's behavior on behalf of CNA E. This failure had the potential to cause residents, staff and family feelings of helplessness, diminished quality of life and at risk for grievances not being addressed or resolved promptly.

Inspectors wroteBased on, interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 8 residents (Residents #1) reviewed for abuse and neglect. The facility Staff (Administrator) failed to report the incident that occurred on 03/30/2024 and 04/04/2024 between Resident #1 and Resident #2 to the governing state agency. CNA H &I failed to report allegations of abuse to the abuse coordinator within 2 hours of incident. These failures could place the residents in the facility at risk of lacking timely reporting of incidents, risk of abuse, neglect, exploitation, or misappropriation of their property by staff members and contribute to further resident abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 8 residents (Resident #2) reviewed for care plan revisions. The facility failed to ensure Resident #2's care plan (focus, goals and interventions) was updated to reflect his increasingly ongoing incident of physical and verbal aggressive behaviors. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 4 staff (Dietary [NAME] A and the DM) and 1 of 1 kitchen, in that: 1) The DM failed to store, serve or process foods in a manner to prevent contamination 2) Dietary [NAME] A and the DM failed to properly wear hair restraints while in the food preparation area. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure the residents had the right to participate in his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 5 of 15 residents ( Resident #2, Resident #9, Resident #13, Resident #21 and Resident #22) reviewed for resident rights . The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available from Resident #2 prior to administering Perphenazine (is used to treat intermittent explosive disorder (impulse control disorder)). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive services with reasonable accommodation of resident's needs and preferences for 1 of 15 (Resident #24) residents reviewed for call light placement. The facility failed to ensure the call light system in Resident #24's room was in a position which was accessible. This failure could place residents at risk of being unable to obtain assistance in the event of an emergency.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial well-being for 1 of 15 residents (Resident #13) reviewed for care plans as follows: Resident #1's care plan did not accurately reflect his code status: DNR These failures could place residents at risk of not receiving the care required to meet their Individualized needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 of 15 (Resident #24) residents reviewed for activities. The facility failed to provide activities for Resident #24. These failures could place residents at risk of decline in their physical, mental, and psychosocial well-being.