Ruleville Community Care Center

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident received treatment and services to manage pain as evidenced by the facility failing to administer fentanyl patches as ordered for one (1) of five (5) medication reviews (Resident #106). This failure resulted in missed doses of prescribed pain medication and escalating pain levels causing actual harm through unnecessary suffering. Resident #106Findings Include: Review of the facility policy titled Pain Evaluation/Management reviewed 8/25 revealed under, Policy: All residents will be evaluated for pain at the time of administration, readmission, quarterly and as needed. An interview on 8/25/2025 at 10:55 AM with Resident #106 revealed he hurt in 26 different areas of his body and had chronic pain every day. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement a care plan for resident's dependent on staff for nail care (Resident #6, #16, #102), showers (Resident #88, #94) and pain management (Resident #106) for six (6) of 31 sampled residents. Resident #6, #16, #88, #94, #102, #106 Findings Include: Review of the facility policy titled Comprehensive Person-Centered Care Plans unrevised, revealed, Policy: Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Resident #6 Record review of the Care plans for Resident #6 revealed under, Goals: I will maintain my current level of ADL (activities of daily living) status. Also revealed under, Interventions: [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide basic hygiene care by not ensuring that a dependent resident received showers (Resident #88 and Resident #94) and routine nail care (Resident #6, Resident #16, and Resident #102) for five (5) of eight (8) residents reviewed for activities of daily living (ADLs). Findings Include Review of the facility policy titled Fingernails/Toenails Care unrevised, revealed, Policy: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Record review of undated facility policy, Bath/Shower-Dependent revealed, A bath (shower/tub) for cleanliness and comfort is scheduled at least weekly for each resident. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents' rights to reasonable accommodation of needs by not providing access to oral hydration for two (2) of ninety-six residents reviewed (Resident #38 and Resident #47). Findings IncludeTop of Form Record review of the facility policy titled, Resident [NAME] of Rights undated, revealed, Each resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the Facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life . 10. Reside and receive services in the facility with reasonable accommodation of resident needs. Resident #38 Observation and interview on 8/25/2025 at 10:25 AM, revealed Resident #38 sitting in her room. [...]

Inspectors wroteBased on staff and resident interview, record review and facility policy review, the facility failed to resolve a grievance for one (1) of eight (8) residents present at the resident council meeting. (Anonymous Resident). Findings IncludeReview of the facility policy titled Grievance/Missing Property with a revision date of 8/17 revealed under Purpose .to provide an opportunity for residents, resident representatives and/or family to present concerns or grievance to the proper authorities at the facility and to receive responses to the issue(s) raised. Under Procedure .A.3 .Supervisory personnel shall be responsible for notifying the resident of resolution and so indicate on grievance form .An interview on 8/25/25 at 10:15 AM, Anonymous Resident complained that Certified Nursing Assistant (CNA) #6 jerked his legs when she turned him and it hurt his back. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility failed to maintain a safe, clean, and comfortable environment as evidenced by a bathroom floor covering that had been removed, leaving bare concrete with a black stained area around the toilet for one (1) of 38 residents on sample. Resident #43 Findings Include: Review of a typed statement on facility letterhead revealed the facility did not have a policy regarding maintenance repairs and was signed by the Administrator. On 8/25/25 at 9:05 AM, an observation revealed Resident #43's bathroom floor covering was removed. The floor was bare concrete with a black substance around the toilet base. During an observation and interview with the Housekeeper #1 on 8/26/25 at 11:06 AM, he stated he mopped the area, but the concrete floor could not be cleaned properly and that it had been that way for some time. [...]

Inspectors wroteBased on resident and staff interviews, record reviews and facility policy review the facility failed to protect a resident's right to be free from verbal abuse for one (1) of five (5) residents reviewed for Abuse and Neglect. Resident #3 Findings IncludeTop of Form Top of Form Top of Form Review of the facility policy titled: Abuse Prevention undated, revealed, The facility is committed to protecting the residents from abuse by anyone, including, but not necessarily limited to: facility staff. Definitions: b) Verbal Abuse: The use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents . Review of the facility policy titled: Resident [NAME] of Rights, with a revision date of 1/23, revealed A. Facility residents shall have the right to: 36 . be free of abuse, neglect, exploitation, misappropriation of resident property . [...]

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to ensure that all alleged abuse violations were reported to the State Survey Agency as required. This deficient practice had the potential to place residents at risk for abuse and/or neglect. For three (3) of the five (5) alleged abuse violations reviewed. Resident #3, Anonymous Resident, and Resident #68. Findings Include Review of the facility policy titled: “Abuse Prevention” dated 10/22, revealed, “The facility is committed to protecting the residents from abuse by anyone, including, but not necessarily limited to: facility staff… under Reporting: [...]

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to provide restorative nursing services for residents with contractures for two (2) of 31 sampled residents. Resident #16 and Resident #94. Findings Include: Review of the facility policy, Range of Motion revealed that A range of motion program will be developed for a resident as indicated Purposes of ROM (Range of Motion) 1. Maintain or improve joint and soft tissue mobility. 2 Minimize contractures RESIDENT #16 An observation and interview on 08/25/25 at 2:45 PM with Resident #16, revealed her sitting in her wheelchair in the dining room. She had a contracture to her left wrist/hand and there was no orthotic device in use. An observation on 08/26/25 at 8:38 AM revealed Resident #16 lying in bed in her room. She had contracture to her left wrist/hand, and she had no orthotic device in place. [...]

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to maintain accurate medical records for one (1) of five (5) medication reviews. Resident #106Findings include: Review of the facility policy titled Medication Administration -General Guidelines revised 8/16 revealed under, Policy: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Also revealed under, Procedure: . 9 . This individual records the administration on the resident's MAR/eMAR (medication administration record) and TAR/eTAR (treatment administration record) after the medication is given. [...]

Inspectors wroteBased on staff and resident interviews, record review and facility policy review the facility failed to investigate allegations of abuse for two (2) of five (5) residents reviewed for abuse. Residents #68 and Anonymous Resident Findings IncludeReview of the facility policy titled, with a revision date of 10/22 revealed under Investigate: .the facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. An interview on 8/25/25 at 10:15AM with an Anonymous Resident revealed that Certified Nurse Assistant (CNA) #6 and CNA #7 came in to turn him and they jerked his legs and hurt his back. He admitted that he reported it to staff that he thought it was CNA #6 and admits that she hasn't worked with him since. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review the facility failed to prevent a resident from being physically restrained with a sheet tied to the wheelchair. The facility also failed to obtain physician orders, consent and failed to assess a resident for the need of restraints (mattress with elevated sides and wedges) for one (1) of six (6) residents reviewed. Resident #1.

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to report an allegation of mistreatment when a resident was physically restrained with a sheet tied to the wheelchair for one (1) of six (6) residents reviewed. Resident #1. Findings Included: Review of the facility policy titled, Abuse Prevention, revealed the definition of mistreatment means inappropriate treatment of a resident. All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than two hours after the allegation is made. Record review of the facility occurrence, completed by the Director of Nursing (DON) revealed that an investigation was conducted on 6/10/24, when the DON was informed of a resident possibly having a sheet tied on her wheelchair the previous day. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review the facility failed to protect one (1) of 108 residents right to be free from neglect as evidenced by [DATE] Resident #3 being unwilling to sleep in his room with his roommate due to Resident #1 getting in the bed with Resident #3. This resulted in the death of another resident (Resident #2) when Resident #1 laid on top of Resident #2 who was placed in the room with Resident #1. The facility's neglect to identify roommate incompatibility and provide appropriate person-centered behavioral interventions from [DATE]-[DATE] placed Resident #2 at risk, caused his death and placed other residents in a situation which was likely to cause serious injury, harm, impairment, or death. [...]

Inspectors wroteBased on staff interview, care plan review, record review, and facility policy review, the facility failed to revise a comprehensive care plan related to behaviors for (1) one of 13 residents reviewed for care plans. Resident #1 The facility's failure to revise Resident #1's care plans with appropriate interventions related to his known behavior of getting into bed with other residents resulted in staff not having access to preventative measures to deter this behavior. On [DATE], Resident #1 was found in bed on top of Resident #2 with only his hands visible beneath Resident #1. Resident #2 was unresponsive and did not respond to life sustaining measures and was pronounced dead. This placed the residents residing in the facility at risk, and in a situation that was likely to cause serious injury, harm, impairment, or death. [...]

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to provide adequate supervision to reduce the risk of an accident/hazards when a resident with behaviors got into other resident's beds and did not have any increased supervision/monitoring put in place resulting, in the physical assault and death of a resident for (1) one of (4) four residents reviewed for accidents. (Resident #2) The facility's failure to provide adequate supervision and monitoring, placed Resident #2 and other residents residing in the facility at risk, and in a situation which caused Resident #2's death and was likely to cause serious injury, serious harm, serious impairment, or death for others. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to recognize behaviors and provide appropriate person-centered behavioral interventions for one (1) of three (3) residents with documented behaviors resulting in the physical assault and death of a resident. (Resident #1) The facility's failure to identify behaviors and failure to provide appropriate person-centered behavioral interventions and supervision, from [DATE] through [DATE] resulted in the death of Resident #2 and placed other residents at risk, and in a situation which was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE], which began on [DATE], when the facility failed to identify behaviors, and ensure appropriate services for residents with behavioral needs. [...]

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to ensure controlled medications were stored in a secure locked container for two (2) of six (6) narcotic storage containers. Findings Include: Review of the facility policy, Medication Storage revealed, Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy. Observation on 11/28/23 11:03 AM, of the [NAME] Wing Nurses Station medication room revealed a medication refrigerator with a red lock box for controlled drugs. The medication box was not locked but was secured to the refrigerator shelf. [...]

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to maintain clean ice machines, as evidenced by observations during the annual survey of two (2) of two (2) unclean ice machines, for 96 of 105 residents in the nursing facility who use ice. Findings Include: Review of the facility policy titled, Ice Handling and Cleaning, for the Guideline and Procedure Manual . 2020, revealed Guideline: Ice will be stored and served to residents in a sanitary manner. Procedure: . 6. Ice machine will be emptied at least quarterly and thoroughly cleaned with an approved sanitizer to remove any settlement or mineral build-up . An observation on 11/28/23 at 10:35 AM, of the ice machine in the kitchen, revealed a black buildup that was located on the upper right side of the opening of the ice container under the door to the ice storage bin. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a dining experience that promotes dignity as evidenced by staff standing while providing feeding assistance to one (1) of three (3) residents who required feeding assistance in the dining room. Resident #38. Findings Include: An observation of the lunch meal service in the west dining room for Resident #38 on 11/28/23 at 12:48 PM, revealed that the resident was sitting in his wheelchair at the table and Certified Nursing Assistant (CNA) #2 was standing beside the resident feeding him lunch. Upon interview with CNA #2 on 11/28/23 at 12:50 PM, she stated that she should not be standing while feeding Resident #38. She stated that she should be sitting at eye level while feeding so the resident does not feel intimidated with staff standing over him. [...]

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to submit a change in status referral for a Level II Pre-admission Screen and Resident Review (PASRR) resident review related to a new Mental Disorder (MD) diagnosis for one (1) of six (6) residents reviewed. Resident # 75.

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to complete a Pre-admission Screening and Resident Review (PASRR) for a resident with an identified Mental Disorder for one (1) of five (5) residents reviewed. Resident # 101.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to implement a care plan for changing behavior and side effect monitoring for a resident taking anticoagulants and psychotropic medications (Resident # 56) and failed to fully develop and implement a care plan for a Gastrostomy Tube (Resident #88) for (2) two of 23 residents reviewed for care plans.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility failed to prevent the potential for an accident by not utilizing appropriate staff when transferring a resident for one (1) of five (5) residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with a gastrostomy tube received care to prevent complications as evidenced by failure to check tube placement prior to medication administration for Resident #88; for one of five care observations. Findings Include: Review of the facility policy titled, Tube Feeding, with a revision date of July 2018, revealed the policy/procedure failed to address the checking of residual with a gastrostomy tube (G tube) when administering medications. Record review of the November 2023 Physician Orders for Resident #88 revealed an order dated 1/18/23, CHECK PLACEMENT OF G TUBE VIA RESIDUAL. CHECK HOLD IF RESIDUAL IS > 100 CC . Record review of the Electronic Medication Administration Record (eMAR) for Resident #88 revealed CHECK PLACEMENT OF G Tube VIA RESIDUAL, dated 1/18/23. [...]

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to ensure a resident was monitored for medication side effects for the use of an anticoagulant medication for one (1) of three (3) residents reviewed.

Inspectors wroteBased on staff interview, record and policy review the facility failed to ensure a resident received behavioral interventions or side effect monitoring with the use of psychotropic medications for one (1) of three (3) residents reviewed.

Inspectors wroteBased on record review, staff and resident interview and facility policy review the facility failed to ensure a resident was free from abuse when a Certified Nursing Assistant (CNA) threw water on a resident for one (1) of six (6) residents reviewed for abuse. Resident # 1.

Inspectors wroteBased on observation, staff interview and resident interview the facility failed to provide a safe and clean homelike environment as evidenced by dirty floors and loose metal corner molding in resident rooms for two (2) of 64 rooms observed.