Ruleme Center

In the surveyor’s words

From the most serious findings on record at Ruleme Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Dec 6, 2023

  Based on record review, interview, and policy and procedure review the facility failed to ensure the residents rights were honored by failing to provide an opportunity to formulate advance directives. Resident #1's advance directive for Do Not Resuscitate (DNR) was not honored by the facility when they failed to obtain clarification of code status during the admission process, per facility policy. This failure resulted in the resident experiencing serious psychosocial harm by not honoring the resident's wishes for a natural, dignified death. Successful Cardiopulmonary Resuscitation (CPR) may result in major physical trauma including broken ribs, lung bruising, damage to the airway and internal organs, and internal bleeding. […]

• No harm, potential for more than minimal, widespreadF885Mar 21, 2022

  Based on interview and record review the facility failed to inform residents, their representatives and families by 5 PM, the next calendar day each time a confirmed infection of Covid-19 was identified. Findings: Review of the Facility Covid -19-line listing provided by the facility indicated that three residents were confirmed positive for Covid-19 infection on 2/12/2022. Review of the Cliniconex communication record dated 2/14/2022 at 11:06 AM read: Good morning, all, this message is to inform you that there are three staff members and three residents as of 2/14/2022 who are positive with COVID. Please note that even though the facility is on outbreak, it will not affect visitations. If you would like to visit you loved one, please know you are doing so at your own risk. […]

• No harm, potential for more than minimal, patternF812Apr 20, 2023

  Based on observation, interview, and policy and procedure review, the facility failed to ensure food is safely stored, covered, labeled, or discarded in the kitchen and 1 of 2 nourishment rooms. Findings include: During an observation of the kitchen conducted on [DATE] at 09:16 AM with the Certified Dietary Manager (CDM) of the walk-in cooler there was what appeared to be bulk ham, pork tenderloin, sliced cheese, and pre-packaged pancakes that were not in their original containers, did not have identifying labels and were not dated. On the counter and rack for clean pots and pans there were dirty cloths and scrub pads. An interview was conducted with the CDM on [DATE] at 9:23 AM. […]

• No harm, potential for more than minimal, patternF761Nov 18, 2021

  Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles and included the expiration date when applicable in 3 of 4 medication carts and 1 medication room. Findings: On 11/15/2021 at 9:10 AM, an observation of Medication Cart #1 with Staff B, Registered Nurse (RN), showed one opened [MEDICATION(S)] Insulin pen with no opened or expiration dates, and two opened bottles of artificial tears with no opened or expiration dates. […]

• No harm, potential for more than minimal, isolatedF552Jan 23, 2026

  Based on record review and interview, the facility failed to ensure residents' treatment choice for 1 of 4 residents reviewed, Resident #28.Findings include:Review of Resident #28's physician order dated 6/18/2024 read, [name of palliative care provider]: Resident/resident representative request no further weights to be obtained.Review of Resident #28's weight records revealed the resident's weights were obtained on 7/2/2024 (141.7 pounds), 8/2/2024 (139.5 pounds), 12/4/2024 (128.0 pounds), 10/2/2025 (132.3 pounds), 11/4/2025 (140.5 pounds), 12/4/2025 (139.4 pounds), and 1/7/2026 (133.2 pounds).During an interview on 1/22/2026 at 8:29 AM, Staff A, Licensed Practical Nurse, confirmed Resident #28's representative had requested no more weight to be obtained. […]