Waters of Rushville Skilled Nursing Facility, the

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's personal and medical information were protected from possible observation by other persons in the area during 5 medication administration observations with 5 staff and 11 residents. (Resident F and LPN 4)

Inspectors wroteBased on interview and record review, the facility failed to ensure staff members correctly administered medications as ordered for 1 of 4 residents reviewed for accuracy of medication receipt. (Resident E and QMA 5)

Inspectors wroteBased on interview and record review, the facility failed to ensure a medication that had been discontinued was not administered by facility staff to 1 of 4 residents reviewed for accuracy of medication receipt. (Resident E, QMA 5)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication was stored safely in the absence of staff for 1 of 1 medication during 5 medication administration observations with 5 staff and 11 residents. (Resident F and LPN 4)

Inspectors wroteBased on interview and record review, the facility failed to have a Registered Nurse (RN) on duty at the facility for 5 of 30 days reviewed for RN coverage. This had the potential to affect 43 of 43 residents that reside in the facility.

Inspectors wrote2. During an interview with Resident B on 6/24/25 at 12:32 p.m., they indicated the resident had to wait up to 30 minutes for the call light to be answered. The resident indicated they had a cell phone and timed how long they had to wait. Resident B indicated because they had to wait 30 minutes, it caused them to be incontinent of bowel and bladder. The resident indicated it was embarrassing to have the Certified Nurse Aides (CNAs) clean them up when this happened. The resident indicated they could not get out of bed by themselves due to frequent falls. Resident B indicated the weekends were when it happened the most. The resident did report this to the staff at the time it happened. [...]

Inspectors wrote2. The clinical record for Resident 12 was reviewed on 6/26/25 at 11:25 a.m. The diagnoses included, but were not limited to, type 1 diabetes mellitus. She was admitted to the facility on [DATE]. The physician's orders indicated to administer ten units of insulin lispro (fast-acting insulin) injection solution 100 UNIT/ML (units per milliliter) with meals, effective 6/15/25; 15 units twice daily, effective 3/7/25; and sliding scale for blood sugar readings as follows, effective 6/15/25: 151 - 200 = two units; 201 - 250 = four units; 251 - 300 = six units; 301 - 350 = ten units; 351 - 400 = 12 units, subcutaneously three times a day, and to call the physician if blood sugar reading was below 60 or above 400. The 5/14/25 physician's order indicated to set up an appointment with Resident 12's endocrinologist. This order was revised on 6/2/25 to include the specific endocrinologist. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow-up on optometry (eye and vision professional) recommendations and orders for 1 of 1 resident reviewed for optometry services. (Resident 25)

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely coordinate counseling services for 1 of 5 residents reviewed for unnecessary medications. (Resident 12)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician instructions for medication administration were followed for 1 of 4 residents observed during 1 of 3 medication administrations with 1 of 3 staff. (Resident D and Qualified Medication Aide 2)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety precautions were adhered to by failure to keep a medication cart locked and unsupervised during 1 of 3 medication administration observations with 1 of 3 staff and failed to ensure labeling of three insulin syringes, located in the west hall medication cart, included the dates each were opened or the date to dispose of the insulin during an observation of the medication carts for of 2 of 4 medication carts observed. (Resident 18, Qualified Medication Aide 2, and Registered Nurse 3)

Inspectors wrote2. On 6-23-25 at 7:46 p.m., during a medication administration observation, QMA 2 was observed to prepare five (5) oral medications for Resident 99. Those medications and their physician instructions included the following: - atorvastatin 40 milligrams (mg) at bedtime for elevated blood fats. - tab-a-vite one tablet once daily for unspecified vitamin deficiency. - hydroxyurea 500 mg twice daily on Monday, Wednesday and Friday and once daily on Tuesday, Thursday, Saturday and Sunday for gout: wear gloves when handling or crushing; do not crush. - furosemide 40 mg twice daily for congestive heart failure. - metoprolol succinate extended-release 50 mg twice daily for high blood pressure. QMA 2 was observed to touch each medication with his bare hands during the preparation of the medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who was admitted to the facility with a pressure ulcer received thorough assessment upon admission, initiated a treatment timely for an identified pressure ulcer, and initiated treatment changes per the wound provider promptly for 1 of 3 residents reviewed for pressure ulcers. (Resident C) This deficient practice was corrected on 2/14/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 3 residents reviewed for falls had a minimum of 72 hours post-fall assessments, including neurological (neuro) checks as appropriate. (Residents B, F and G)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who admitted to the facility had their orders transcribed correctly into the electronic health record (EHR) that resulted in medication errors for 1 of 3 residents reviewed for medication administration. (Resident D) This deficient practice was corrected on 2/12/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure eight hours of consecutive RN coverage for 9 of 91 days reviewed. This deficient practice had the potential to affect 34 residents.

Inspectors wroteBased on interview and record review, the facility failed to accurately code Section J regarding falls for 2 of 17 residents reviewed for Minimum Data Set accuracy. (Resident 14 and Resident 16)

Inspectors wroteBased on observations, interview, and record review, the facility failed to accurately monitor residents for bruising per physician order for 2 of 3 residents reviewed for bruising.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a pressure relieving intervention as ordered by the podiatrist for a resident with an unstageable pressure ulcer (full thickness tissue loss ulcer covered by eschar) on the right heel for 1 of 2 residents reviewed for pressure ulcers (Resident 4).

Inspectors wroteBased in interview, observation, and record review, the facility failed to ensure a left-hand protector or brace was available for 1 of 1 resident reviewed for contractures. (Resident 2)

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the fall mat was in place for a resident while in bed for 1 of 3 residents reviewed for falls. (Resident 7)

Inspectors wroteBased on interview and record review, the facility failed to timely enter a resident with a significant weight loss into the Skin and Weight Assessment Team (SWAT) program for 1 of 3 residents reviewed for significant weight loss.

Inspectors wroteBased on interview and record review, the facility failed to timely inform Resident 14's provider of a significant weight change for 1 of 3 residents reviewed for nutritional needs.

Inspectors wroteBased in interview and record review, the facility failed to ensure that a pharmacy recommendation was completed in a timely manner for 1 of 5 residents reviewed for pharmacy services. (Resident 2)

Inspectors wroteBased on interview and record review, the facility failed to ensure a prescription narcotic was not administered to a resident without an appropriate prescription for the narcotic for 1 of 6 residents reviewed for correct receipt of medications. (Resident C)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure their medication administration error rate remained under five (5) percent during 3 observations with 4 staff and 11 residents. (Residents E,and G)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control measures of handwashing and hand-hygiene were utilized during a medication pass administration observation conducted during 3 observations with 4 staff and 11 residents. (Residents E, F and G, )

Inspectors wroteBased on observation, interview and record review, the facility failed to develop care plans related to the use of a wanderguard (safety device used as an audible alarm to notify staff of an exit or elopement attempt from a secured area) for 2 of 3 residents reviewed for the use of wanderguards. (Resident B and E)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate supervision, related to the use of a wanderguard (safety device used as an audible alarm to notify staff of an exit or elopement attempt from a secured area), for 2 of 3 residents reviewed for the use of wanderguards. (Resident B and E)

Inspectors wroteBased on record review and interview the facility failed to complete a significant change of condition assessment within 14 days of change of condition for a resident electing hospice service for 1 of 2 residents reviewed for significant change of condition. (Resident 37)

Inspectors wroteBased on record review and interview the facility failed to accurately indicate weight gain/loss for Resident 28, dehydration for Resident 29 and failed to indicated hospice services and prognosis of 6 months or less for Resident 37 for 3 of 6 residents for accuracy of Minimum Data Set (MDS) Assessments.