Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rushville Nursing & Rehab Ctr during CMS and state inspections, most recent first.
A resident with a history of CVA, hemiplegia, and moderate cognitive impairment experienced multiple falls due to the facility's reliance on education and signage as fall prevention interventions. Despite repeated incidents, staff did not implement interventions suited to the resident's cognitive deficits, and both the LPN and DON acknowledged the inadequacy of these measures.
The facility failed to follow infection control protocols, including hand hygiene and masking during a flu outbreak. A CNA did not wash hands after glove removal while caring for two residents with urinary catheters. Additionally, a hairdresser was observed without a mask during the outbreak, indicating a communication lapse. These actions compromised infection control efforts, potentially affecting all residents.
The facility failed to serve food at safe temperatures, with trays left unattended and food cooling before residents were present. A CNA confirmed this practice, and the Dietary Manager acknowledged frequent temperature complaints.
The facility failed to implement an effective antibiotic stewardship program, resulting in the inappropriate use of prophylactic antibiotics for several residents without documented symptoms or appropriate diagnoses. The Infection Prevention and Control Program's protocols were not followed, and the consultant pharmacist's reviews did not include antibiotic usage. The facility's leadership acknowledged the program's deficiencies.
A staff member was observed using a personal cell phone while assisting a resident with eating, contrary to the facility's policy prohibiting phone use during care. The resident, who is rarely understood, did not respond to questions. The DON and Administrator confirmed that staff should not use phones during care.
A resident with dementia and behavioral disturbances was over-sedated due to inappropriate use of psychotropic medication. Initially prescribed Risperdal orally, the medication was changed to a monthly injection after the resident refused the pill form. This led to significant sedation and a decline in physical functioning, as the resident slept for extended periods post-injection. The facility failed to monitor and adjust the medication use appropriately, resulting in the use of a chemical restraint.
A facility failed to conduct a PASRR Level II assessment after a resident experienced a significant change in mental health status. The resident, initially admitted without a serious mental illness diagnosis, was later hospitalized and returned with a new bipolar disorder diagnosis. Despite this change, the required PASRR was not completed, as confirmed by the Social Service Director and Administrator.
Two residents with indwelling urinary catheters were found with catheter bags and tubing in unsanitary conditions, contrary to the facility's policy. One resident's catheter bag was hanging from a wheelchair with tubing dragging on the floor, while another's catheter bag and tubing were resting on the floor. Both residents had care plans emphasizing infection control, which were not followed.
The facility failed to provide proper respiratory care for two residents by not adhering to the oxygen administration policy. One resident frequently removed their oxygen, and staff did not consistently reapply it or provide education. Another resident had overdue oxygen tubing changes, and both lacked required ear pads. The administration was unaware of the policy requirements.
A facility failed to ensure coordinated communication and availability of hospice documents for a resident with a terminal diagnosis. The hospice plan of care, election forms, and clinical notes were missing from the resident's record. Staff interviews revealed inadequate communication and documentation practices, with no specific hospice binder for the resident and hospice documents not scanned into the record. The hospice nurse also did not leave the plan of care or visit notes at the facility.
A resident with multiple health issues, including legal blindness and muscle weakness, fell and fractured her femur due to the facility's failure to use a gait belt during ambulation, as required by their policy. Staff confirmed the resident needed assistance with a gait belt and walker, but it was not used at the time of the fall, leading to hospitalization and surgery.
A resident's call light was not accessible while in bed, contrary to facility policy. The call light was clipped to a bedside commode, requiring the resident to get out of bed to reach it. A CNA confirmed the issue and cleaned the call light before handing it to the resident. An RN later affirmed that call lights should always be within reach.
A facility failed to complete a PASARR for a resident who was later diagnosed with Schizoaffective Disorder. Initially admitted with Guillain-Barre syndrome, the resident's medical record lacked a PASARR after the new diagnosis. The Social Service Director confirmed the oversight.
A resident with a diagnosis of Foot Drop did not receive a lower extremity ROM program, despite facility policies requiring such care. The resident was unable to flex her ankle joints and reported not receiving exercises from staff. The care plan only addressed upper extremity ROM, and the DON confirmed the absence of a lower extremity program.
A resident with vascular dementia and on anticoagulants sustained a bruise during a transfer due to staff not using a gait belt as per facility policy. Instead, staff held the resident's arm, leading to the injury. The resident's medical records indicate dependency on staff for transfers and a history of conditions that contribute to easy bruising.
A facility failed to document justification for a resident's use of two antidepressants, Bupropion and Paroxetine, as required by its Psychotropic Medications Policy. A nurse managing psychotropic medications was unsure of the reason for the duplicative therapy and confirmed the absence of documentation in the resident's medical record, despite the resident not posing harm to herself or others.
Failure to Implement Appropriate Fall Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement appropriate fall prevention interventions for a resident with a history of multiple falls and cognitive impairment. The resident, who had diagnoses including cerebrovascular accident (CVA), osteoarthritis, depression, diabetes, hemiplegia, and short-term memory deficits, experienced several falls over a period of months. Despite documented falls in both common areas and the resident's bathroom, the interventions implemented by the facility primarily consisted of education and signage, such as reminders to lock wheelchair brakes and to wear non-skid socks or shoes. These interventions were not tailored to the resident's cognitive limitations, as the resident had moderate cognitive loss and required substantial to maximal assistance with transfers. Staff interviews confirmed that the interventions were not appropriate for the resident's cognitive status. The restorative nurse and the director of nursing both acknowledged that education and signage were insufficient for a resident with cognitive impairment. The facility's own policies required ongoing assessment and the implementation of pertinent interventions to prevent subsequent falls, but the actions taken did not address the resident's specific needs, resulting in repeated falls and a failure to ensure a safe environment free from accident hazards.
Infection Control Lapses in Hand Hygiene and Masking During Flu Outbreak
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, specifically in hand hygiene and masking during an influenza outbreak. Observations revealed that staff did not perform hand hygiene after glove removal, as required by the facility's policies. This was noted in the care of two residents with indwelling urinary catheters, where a Certified Nursing Assistant (CNA) did not wash hands after removing soiled gloves and before donning new ones. This lapse in protocol occurred despite the facility's clear guidelines on hand hygiene, which emphasize washing hands after glove removal to prevent infection. Additionally, the facility did not enforce masking protocols during a flu outbreak, which could potentially affect all 71 residents. A sign at the facility entrance indicated that masking was recommended, yet a hairdresser was observed walking through the facility without a mask. The Infection Preventionist confirmed that not wearing a mask during a flu outbreak could put residents at risk. The hairdresser was unaware of the masking requirement, indicating a communication breakdown regarding infection control measures. The facility's policies on infection control, including hand hygiene and the use of personal protective equipment, were not followed, leading to potential risks of infection spread. The CNA involved in the care of residents with urinary catheters did not adhere to the hand hygiene protocol, and the lack of consistent masking during an influenza outbreak further compromised the facility's infection control efforts. These deficiencies highlight the need for strict adherence to established infection prevention protocols to protect residents from potential health risks.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and safe temperature for six residents. On the morning of April 8, 2025, breakfast trays for these residents were observed sitting on dining room tables with lids or other plates on top, despite the residents not being present. A Certified Nurse Aid/Transportation staff member, V4, confirmed that trays were routinely delivered to residents' regular spots regardless of their presence, and noted that the food was often not hot when served. This practice was confirmed by the Dietary Manager, V6, who acknowledged that food should only be served if residents are present. During the same morning, V6 was observed taking a tray to a resident's room, where the resident was found sitting in a recliner with her eyes closed. The food temperatures at that time were recorded as 89 degrees Fahrenheit for scrambled eggs and 88 degrees Fahrenheit for sausage, which are below the recommended serving temperatures. The Dietary Manager admitted that there were frequent complaints about food temperatures, attributing the issue to the loss of temperature once food leaves the steam table.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to properly implement and monitor an antibiotic stewardship program, as evidenced by the lack of identification, monitoring, and review of prophylactic antibiotic use for four residents. The Infection Prevention and Control Program, dated 2019, outlined the need for an antibiotic stewardship program, including protocols and a system to monitor antibiotic use. However, the facility did not adhere to these protocols, as the Infection Control Log showed that residents received prophylactic antibiotics without signs or symptoms of infection. The consultant pharmacist's Medication Regimen Review reports did not include antibiotic usage, and the Infection Report Summary lacked data on prophylactic antibiotic use. Specific cases included residents receiving antibiotics for urinary tract infection prophylaxis without documented symptoms or appropriate diagnoses. For instance, one resident had a physician's order for an antibiotic with no end date, and another had an order for an antibiotic without a documented reason. The facility's Quality Assurance Committee meetings did not address antibiotic usage, and the Infection Preventionist acknowledged that certain diagnoses, such as urge incontinence, did not require antibiotics. The facility's administrator and director of nursing admitted that the antibiotic stewardship program was incomplete and needed improvement.
Inappropriate Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by an incident involving a staff member's inappropriate use of a personal cell phone during resident care. The facility's policy on personal cell phone use mandates that phones must be turned off and stored away during work hours, and not carried on the employee's person while actively working. However, a Transportation/Certified Nurse Aid was observed using her phone to text while assisting a resident with eating, holding a utensil in one hand and her phone in the other. This occurred despite the facility's clear policy prohibiting phone use in resident areas. The resident involved, who was rarely or never understood according to their Minimum Data Set, did not respond to questions during the surveyor's visit. The Director of Nursing and the Administrator confirmed that staff should not be on their phones while providing care.
Inappropriate Use of Psychotropic Medication as Chemical Restraint
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications, resulting in the over-sedation and decline in physical functioning of a resident, identified as R12. R12 was admitted with diagnoses including conversion disorder with seizures, generalized anxiety, and unspecified dementia with behavioral disturbances. Initially, R12 was prescribed Risperdal 2 mg orally for unspecified dementia with behavioral disturbances. However, after an increase in aggressive behaviors and a subsequent psychiatric hospitalization, the medication was changed to Risperidone 125 mg administered subcutaneously once a month. Observations and interviews revealed that R12 exhibited behaviors such as agitation, cursing staff, restlessness, and hallucinations. Despite these behaviors, R12's Minimum Data Set (MDS) assessments documented no physical or verbal behavioral symptoms directed towards others, and no rejection of care. The facility's social services and nursing staff confirmed that R12's behaviors included false allegations and yelling during care, but there was no evidence of self-harm or aggression towards other residents. The change in medication form was due to R12's refusal to take the oral medication. The administration of the antipsychotic injection led to R12 experiencing significant sedation, as noted in nurse's notes and staff interviews. R12 was observed to sleep for extended periods post-injection, which contributed to a decline in her physical condition and ability to perform activities of daily living. The facility's failure to appropriately monitor and adjust the use of psychotropic medication for R12, in accordance with their own procedures, resulted in the use of a chemical restraint that was not required to treat medical symptoms or behavior manifestations of mental illness.
Failure to Conduct PASRR After Significant Change
Penalty
Summary
The facility failed to obtain a Preadmission Screening and Resident Review (PASRR) after a significant change in condition for a resident. The facility's admission policy requires that PASRR screens be valid and reviewed on admission, annually, and upon any significant change. The resident in question was admitted with diagnoses including conversion disorder with seizures, dementia, and anxiety, but no serious mental illness was documented at the time of admission. However, after being sent to the hospital due to increased behaviors and subsequently transferred to an inpatient psychiatric hospital, the resident returned with a new diagnosis of bipolar disorder and a prescription for Risperidone. Despite this significant change in the resident's mental health status, the facility did not conduct a repeat PASRR Level II assessment as required. The Social Service Director confirmed that the bipolar diagnosis was new following the hospitalization, and the Administrator acknowledged that a Level II PASRR should have been completed but was not. This oversight represents a failure to comply with the facility's policy and regulatory requirements for monitoring and assessing residents' mental health needs.
Failure to Maintain Sanitary Conditions for Indwelling Urinary Catheters
Penalty
Summary
The facility failed to ensure that indwelling urinary catheters were maintained in a sanitary manner for two residents, R41 and R119, who were reviewed for catheter care. The facility's Urinary Catheter Care policy, dated September 2005, specifies that catheter tubing and drainage bags should be kept off the floor to prevent urinary tract infections. However, observations revealed that R41's catheter bag was hanging from his wheelchair without a protective dignity bag, with the tubing dragging on the floor. Similarly, R119 was found in bed with the catheter drainage bag and tubing resting on the floor, also without a protective dignity bag. Both residents had physician orders for the use of a 16 FR/10cc balloon indwelling urinary catheter due to urinary retention. Their care plans included goals to manage catheter care appropriately to prevent infections and reduce the spread of infectious agents. The care plans also emphasized the importance of not allowing the catheter tubing or drainage system to touch the floor and following the facility's infection control policies. Despite these documented interventions, the facility did not adhere to its own procedures, as confirmed by the Administrator and Director of Nursing.
Failure to Adhere to Oxygen Administration Policy
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, R25 and R119, by not adhering to the established oxygen administration policy. For R119, who was readmitted with diagnoses including pneumonia and chronic lung disease, the facility did not consistently use ear pads or ensure the nasal cannula was in place, despite physician orders and care plans indicating the need for continuous oxygen. Observations revealed that R119 frequently removed the oxygen, and staff did not consistently reapply it or provide education on its necessity. Additionally, the care plan did not address R119's behavior of removing the oxygen, and staff confirmed non-compliance with the oxygen administration. For R25, the facility did not change the oxygen tubing and humidifier weekly as required, with labels indicating they were overdue for change. The staff confirmed the oversight, and there was also a lack of ear pads on the tubing. The facility's administration and DON were unaware of the policy requirement for ear pads for residents on continuous oxygen. These deficiencies highlight a failure to follow the facility's oxygen administration policy, potentially compromising the residents' respiratory care.
Lack of Coordinated Hospice Care and Documentation
Penalty
Summary
The facility failed to ensure coordinated communication and availability of required hospice documents for a resident receiving hospice care. The hospice services policy indicated that hospice staff should conduct assessments, develop a hospice plan of care, and maintain it in the medical record for interdisciplinary staff access. However, the facility did not have a hospice plan of care, election forms, physician certification of terminal illness, or clinical notes for the resident in question. The resident, who was admitted with a terminal diagnosis of dementia and age-related osteoarthritis with a pathological fracture of the femur, had elected hospice benefits, but their current care plan lacked specific hospice responsibilities or interventions. Interviews with facility staff revealed a lack of communication and documentation regarding hospice services. A Licensed Practical Nurse (LPN) stated that nurses assess residents at shift change to determine hospice status, but there was no specific hospice binder for the resident. The social services staff confirmed that hospice documents were not scanned into the resident's record. Additionally, the hospice nurse admitted to not leaving the resident's plan of care or visit notes at the facility, further contributing to the deficiency in hospice care management.
Failure to Use Gait Belt Results in Resident Injury
Penalty
Summary
The facility failed to utilize a gait belt during ambulation for a resident, resulting in the resident being hospitalized with a femur fracture that required surgical intervention. The facility's policy, dated April 2013, mandates the use of gait belts by all staff when ambulating or transferring residents with an unsteady gait. The resident in question had multiple diagnoses, including a displaced supracondylar fracture, muscle weakness, and legal blindness, and required substantial assistance for transfers and ambulation. Despite these needs, the resident was not wearing a gait belt at the time of the fall, which occurred when the resident attempted to pivot and sit too soon, leading to a fall and subsequent hospitalization. Interviews with facility staff confirmed that the resident required assistance with a gait belt and walker for ambulation. The Director of Nursing, Director of Rehabilitation, and Assistant Director of Nursing all acknowledged that a gait belt was not used during the incident. The resident also confirmed not wearing a gait belt at the time of the fall. The facility's failure to adhere to its own policy on gait belt usage directly contributed to the resident's fall and injury.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was accessible within a resident's reach, specifically for one resident (R9) out of a sample of 35. The facility's policy, revised in August 2008, mandates that call lights must be accessible to residents from their bed or other sleeping accommodation. On June 10, 2024, at 10:25 AM, R9 was observed lying in bed with the call light clipped to a bedside commode approximately three feet away, out of her reach. R9 expressed that she consistently had to get out of bed to access the call light, which should not be necessary. A Certified Nursing Assistant (V7) confirmed the call light was not within reach and proceeded to clean it before handing it to R9. On June 13, 2024, a Registered Nurse (V3) affirmed that call lights should always be within a resident's reach when they are in bed.
Failure to Complete PASARR for Resident with New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed for a resident who was later identified with a mental disorder. Initially, the resident was admitted with a primary diagnosis of Guillain-Barre syndrome, as documented on the OBRA-I Initial Screen form and the face sheet at the time of admission. However, the resident was later diagnosed with Schizoaffective Disorder. Despite this new diagnosis, the resident's medical record did not include a PASARR after the diagnosis of Schizoaffective Disorder. The Social Service Director confirmed that a PASARR was never completed following the diagnosis.
Failure to Provide Lower Extremity ROM Program for Resident with Foot Drop
Penalty
Summary
The facility failed to provide a lower extremity Range of Motion (ROM) program for a resident diagnosed with Foot Drop, resulting in a deficiency. The resident, who was observed sitting in a recliner with her feet elevated, was unable to flex her ankle joints and reported not receiving any exercises from nursing staff. Despite having a care plan that required active ROM for her upper extremities, there was no documented plan for her lower extremities, which is crucial given her diagnosis of Foot Drop. The Director of Nursing confirmed that the resident was not receiving physical therapy and did not have a ROM program in place for her lower extremities. The facility's policies on rehabilitative nursing care and ROM emphasize the importance of providing appropriate treatment to prevent further decrease in ROM, yet these were not followed for the resident's lower extremities. This oversight highlights a gap in the facility's implementation of its own policies, leading to the deficiency noted in the report.
Improper Transfer Technique Leads to Resident Injury
Penalty
Summary
The facility failed to safely transfer a resident, identified as R27, which resulted in a bruise on the resident's right hand and lower arm. The facility's Gait Belt policy mandates the use of gait belts during transfers to prevent injuries, specifying that staff should assist residents to stand by holding the belt at the waist. However, it was reported that staff held onto R27's arm during a transfer, contrary to the policy. This improper technique was identified as the cause of the bruising, as confirmed by R27's statement that staff held her arm when helping her up. R27 is a female resident with a history of vascular dementia, chronic obstructive pulmonary disease, chronic diastolic heart failure, and long-term use of anticoagulants, which can cause easy bruising. The resident's medical records indicate moderate mental impairment and dependency on staff for transfers. The incident was documented in R27's care plan and skin issue reports, noting the bruise's size and location. The Director of Nursing acknowledged the requirement for gait belt use and confirmed that staff should not hold a resident's arm during transfers.
Lack of Justification for Duplicative Antidepressant Therapy
Penalty
Summary
The facility failed to document justification for the use of duplicative antidepressant therapy for a resident reviewed for psychotropic medications. According to the facility's Psychotropic Medications Policy, residents should not receive psychotropic drugs unless necessary to treat a specific diagnosed condition, and efforts should be made to reduce or discontinue such medications when possible. The resident in question had current physician's orders for two antidepressants: Bupropion 200 milligrams daily and Paroxetine 40 milligrams twice daily. During an interview, a registered nurse responsible for managing psychotropic medications stated that the resident was not a harm to herself or others and rarely displayed adverse behaviors. The nurse was unsure why the resident was taking two antidepressants and confirmed that this information was not documented in the resident's medical record.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rushville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beardstown Health & Rehab Ctr | 10.8 mi | ★★★★★ | 0 | 0 |
| Mount Sterling Health And Rehab Center | 14.2 mi | ★★★★★ | 4 | 1 |
| Cass County Senior Living & Rehabilitation Llc | 22.1 mi | ★★★★★ | 16 | 0 |
| Elms, The | 23.2 mi | ★★★★★ | 1 | 0 |
| Wesley Village | 23.3 mi | ★★★★★ | 4 | 0 |
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