Rushville Nursing & Rehab Ctr

Inspectors wroteBased on observation, record review, and interview the facility failed to care plan the level of assistance each resident requires for Activities of Daily Living (ADL). This effects all 68 residents residing at the facility. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 6/28/26 documents the facility census as 68 residents. The facility's Care Plan Policy dated October 2022 documents An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident. The policy further documents the Comprehensive Care Plan has been designed to reflect the resident's needs and preferences. On 6/29/26 at 9:50 AM V12 (Registered Nurse) reported resident care needs are on the resident's individualized care plan. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure garbage/refuse container lids are closed. This has the potential to effect all 68 residents. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 6/28/26 documents the facility census as 68 residents. The facility's undated Garbage Disposal Policy documents Keep dumpster closed at all times. On 6/29/26 at 7:00 AM the dumpster lid was not closed on one of the two dumpsters. V4 (CNA/Certified Nursing Assistant) verified dumpster lids are to be closed at all times and stated, Sometimes we need three of them.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain dignity for two (R5, R7) of two residents reviewed for dignity in a total sample of 68.

Inspectors wroteBased on observation, interview and record review, the facility failed to attempt any nonpharmacologic intervention prior to using psychotropic medications for three residents (R17, R26, R27) and failed to GDR (Gradual Dose Reduction) for two residents (R17, R27) of 5 residents reviewed for unnecessary medications in total sample of sixty-eight. Findings Include: The facility's Psychotropic Medication policy dated 2/2025 documents Use of Anxiolytic/Sedative drugs for purposes other than sleep induction should only occur when 1. Evidence exists that other possible reasons for the resident's distress have been considered and ruled out. The facility's Psychotropic Medication policy documents Antipsychotic medications in persons with dementia should not be used if one or more of the following is/are the only indication: 1. Wandering 2. Poor self care 3. Restlessness 4. Impaired memory 5. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide documentation of communication with the dialysis facility for three residents (R1, R2, R42), failed to have appropriate physician orders for two residents (R1, R42), and failed to implement a care plan for one resident (R1) of three residents reviewed for dialysis in a sample of 68.

Inspectors wroteBased on interview, observation and record review the facility failed to ensure staff utilized appropriate PPE/Personal Protective Equipment during mechanical lift transfer of one resident (R5) on Enhanced Barrier Precautions and failed to post Enhanced Barrier Precautions alert signage for one (R47) of 24 residents reviewed for Infection Control in the total sample of 68. The facility's Enhanced Barrier Precautions policy, dated 03/21/24 documents the following: It is the practice of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms (MDRO). Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for .residents with wounds or indwelling medical devices. Initiation of Enhanced Barrier Precautions - b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff respected R1's right to refuse care, failed to prevent staff from using physical force during care, and failed to protect R1 from abuse when staff held R1's arms and hands down and provided care against R1's expressed refusal while R1 repeatedly yelled No, Get off me, and Let go of me. These failures resulted in R1 being manually restrained during care, caused R1 fear, distress, and psychosocial harm, and created Immediate Jeopardy to resident health and safety. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 10/28/25 when staff forced care on R1 despite R1's refusal and signs of distress. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 5/28/26 at 9:25 am. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely assessment, monitoring, physician notification, diagnostic evaluation, and intervention for significant changes in condition related to urinary catheter complications and signs and symptoms of urinary tract infection (UTI) for one (R1) of three residents reviewed for urinary catheters in the sample of three. The facility failed to recognize, investigate, escalate, and respond to repeated abnormal urinary findings and changes in condition despite R1's known history of recurrent UTIs, urosepsis, and rapid clinical decline requiring prior hospitalizations. [...]

Inspectors wroteBased on interview and record review the Facility failed to notify medication changes to a Resident Representative for one of seven Residents (R1) reviewed for new medications in a sample of seven.

Inspectors wroteBased on record review and interview the Facility failed to initiate appropriate fall interventions for one of four Residents (R6) reviewed for falls in a sample of six.

Inspectors wroteBased on observation, interview and record review the facility failed to perform hand hygiene after glove removal for two (R41 and R119) of 18 reviewed for infection control and failed to adhere to masking during an influenza outbreak. The failure of non-masking has the potential to affect all 71 residents currently residing in the facility. Findings Include: The Facility's undated Preventing and Controlling ARI (Acute Respiratory Illness) in Skilled Nursing Facilities and Other Facilities Providing Nursing Care documents Ensure everyone, including residents, visitors, and HCP (Health Care Providers) are aware of recommended Infection Prevention and Control (IPC) practices in the facility, including when specific IPC actions are being implemented in response to new infections in the facility or increases in respiratory virus levels in the community. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food stays warm for six residents (R11, R12, R26, R47, R50, and R119) of six residents reviewed in a total sample of 33. Findings Include: The Facility's undated Hot Food Service Temperatures policy documents foods will be served to the residents at a temperature that is palatable to prevent injury such as burned mouth or lips. Food will be offered to be reheated if it is not within resident's preferred food temperatures or another tray will be offered. On 4/8/25 at 8:30 AM R11, R12, R26, R47, R50, and R119's breakfast trays were sitting out on the dining room tables with either a lid or other plates on top of the dishes. R11, R12, R26, R47, R50, and R119 were not in the dining room at this time. [...]

Inspectors wroteBased on interview and record review the facility failed to identify, monitor, and review prophylactic antibiotic use for four of four residents (R17, R21, R38, R49) for antibiotic stewardship in the sample of 33.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident was treated with respect for one resident (R46) of 18 residents reviewed for respect and dignity in a total sample of 33. Finding Include: The Facility's undated Personal Cell Phone Use documents purpose: to assure that the resident privacy issues are maintained and to eliminate any distraction from responsibilities and duties. Personal cell phones must be turned off when reporting for work and stored in the employee's purse, car, or locker. They are not allowed to be carried on the employee's person while actively working. Employees may check/use their cell phones during break times only Please note employees may not bring the cell phone into any resident areas at any time regardless to break status. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure chemical restraints were not utilized for one resident (R12) of five residents reviewed for psychotropic medication in a total sample of 33. This failure resulted in over sedation and physical functioning for R12. Findings Include: The Facility's Abuse Prevention Policy and Procedure, dated 2/2020, documents Chemical Restraint is any drug that is used for discipline or convenience and is not required to treat medical symptoms or behavior manifestations of mental illness. [...]

Inspectors wroteBased on record review and interview the facility failed to obtain a Preadmission Screening and Resident Review (PASRR) after a significant change in condition for one resident (R12) of one reviewed for PASRRs in a total sample of 33. Findings Include: The Facility Admission policy dated November 2016 documents PASSR screens must be valid and reviewed on admission, annually and upon any significant change. All residents with a newly evident or possible serious mental disorder, intellectual disability, or a related condition should be referred for a level II resident review upon a significant change in status admission. R12's admission Physician Order Sheet dated March 2024 documents R12 was admitted with diagnoses that include but were not limited to conversion disorder with seizures, dementia and anxiety. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure indwelling urinary catheters were placed securely off the floor in a sanitary manner for two (R41 and R119) of six residents reviewed for indwelling urinary catheters in the sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing is changed weekly and ear pads are used for residents wearing oxygen for two (R25 and R119) of two residents reviewed for respiratory care in the sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to attempt gradual dose reduction for one resident (R12) and failed to have clinical indication for the use of an antipsychotic medication for one resident (R119) of five residents reviewed for psychotropic medications in the sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Hospice's coordinated communication and required documents were available and accessible to the facility staff. This deficiency affects one of one resident (R11) reviewed for Hospice care management in a sample of 33 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to utilize a gait belt during ambulation, for one resident (R2) of three residents, in a total sample of three residents reviewed for supervision. This failure resulted in R2 being hospitalized , with a femur fracture which required surgical intervention. Findings Include: Facility Policy, entitled Gait Belts, dated 4/13, document, Gait belts are used to help prevent injury of staff or residents during transfers and ambulation; 1. Gait belts should be used by all staff when ambulating or transferring a resident with an unsteady gait. R2's Electronic Medical Record/EMR document R2's diagnosis to include: [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure a call light was accessible within a resident's reach for 1 of 24 residents (R9) reviewed for accommodation of needs in the sample of 35.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed after a facility resident was later identified with a mental disorder for one of three residents (R31) reviewed for PASARR in the sample of 35.

Inspectors wroteBased on Observation, Interview and Record review, the facility failed to provide lower extremity Range of Motion programing to a resident with limited joint mobility and a diagnosis of Foot Drop for one of one resident (R61) reviewed for limited range of motion in the sample of 35.

Inspectors wroteBased on interview and record review the facility failed to safely transfer 1 resident (R27) of 6 residents reviewed for transfers in a sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to document justification for the use of duplicative antidepressant therapy for one of five residents (R1) reviewed for psychotropic medications in the sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to observe ingestion of medication for one resident (R3) during observation of a routine medication pass. Findings Include: The Facility's Medication Administration Policy dated 01/2018 documents Medications shall be prepared and administered only to residents for whom they were ordered, by the same licensed nurse. Setting up doses for more than one (1) scheduled administration is not permitted. No medication may be returned to its original container once removed from the container. The Facility's Medication Administration Policy also documents Residents to indicate a desire to self administer medications will be assessed, using an assessment tool, by the interdisciplinary care plan team and information given to the physician for approval. [...]