Ruleville Community Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600May 31, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF657May 31, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689May 31, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF742May 31, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF600Jan 21, 2023

  Based on observation, record review, interviews, and facility policy/procedure review the facility failed to protect three (3) of 11 residents from abuse as evidenced by the failure to protect Resident #2 and Resident #8 of physical abuse from Resident #1 after Resident #1 physically attacked Resident #8 on 9/8/22 and Resident #2 on 12/22/22. On 12/26/22, Resident #1 was sent to Geri-psych for treatment and returned on 12/29/22 due to refusal to take his medications and treatment. He requested to go home to his Resident Representative's (RR) home and was discharged . The facility transported him to his RR's home without notifying the RR of the discharge. The RR was out of state and Resident #1 was left at the locked home in a chair on the front porch. […]