Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
The facility failed to include each resident's required ADL assistance in individualized care plans. The RN responsible for restorative care stated only transfer assistance was care planned, while bathing, dressing, bed mobility, eating, and mobility were not addressed. The Administrator confirmed the care plans did not reflect ADL needs other than transfers, and the RN stated no resident was independent with all ADLs and all residents required supervision or hands-on assist.
The facility failed to keep garbage/refuse container lids closed. During observation, one of two dumpsters was found with its lid open, even though the Garbage Disposal Policy states the dumpster should be kept closed at all times. A CNA confirmed the lids are to be closed at all times.
The facility failed to maintain dignity for two residents during care. A CNA stood while feeding a resident breakfast, despite the DON confirming staff should sit with residents during feeding. In another instance, a resident with a stage 4 sacral pressure ulcer, DM2, and VRE had wound care performed while naked from the waist down, with the privacy curtain not pulled and the resident’s buttocks exposed to the doorway and hallway until the resident was covered with a sheet.
The facility failed to document nonpharmacologic interventions before giving psychotropic meds to three residents and failed to complete GDRs for two residents. One resident with dementia received Seroquel and PRN Hydroxyzine without a documented behavior plan or personalized interventions, another resident received PRN Ativan almost daily for anxiety despite no anxiety being documented in behavior logs, and a third resident received PRN olanzapine without documented agitation or prior nonpharmacologic attempts. Staff also confirmed that behavior management plans and individualized interventions were not in place.
A facility failed to maintain complete dialysis documentation for multiple residents receiving hemodialysis. Physician orders did not identify the access site or access type for one resident and lacked individualized dialysis prescription details for another, while dialysis communication forms were not completed by facility nursing staff before transport or returned with dialysis unit documentation after treatment. Staff interviews showed confusion about completing the forms, and the DON confirmed the top portion should be filled out by nurses, but the required communication records were still missing.
Staff failed to use full EBP PPE during a high-contact sit-to-stand lift transfer for a resident with a stage 4 pressure ulcer, indwelling urinary catheter, and VRE-related orders, and the CNA involved stated a gown and gloves should have been worn. The facility also did not post EBP alert signage for another resident with a colostomy and bilateral LE venous ulcers, despite orders and care plan requirements for EBP during wound care and other high-contact activities.
Abuse and refusal of care during hands-on bathing: Staff continued bathing and perineal care on a resident with dementia after he repeatedly refused, yelled for them to stop, and pulled away. Multiple staff held his arms and hands down while he remained naked in bed and showed distress, and the DON and administrator reviewed the video but did not initially consider the actions abuse.
A resident with an indwelling Foley catheter and a history of recurrent UTIs and urosepsis had repeated abnormal urinary findings documented by nursing staff, including blood-tinged urine, dark urine, thick sediment, mucus, catheter obstruction, and decreased output, but the provider was not notified and no assessment, diagnostic workup, or intervention was documented. Family also reported ongoing concerns about the urine and catheter. The resident later developed fever, respiratory distress, altered mental status, and sepsis secondary to UTI, with an obstructed catheter noted in the ED and subsequent death.
A resident with vascular dementia, memory deficits, and other behavioral diagnoses was started on new psychotropic medications, but the facility did not document notifying the resident’s POA/sister or obtaining her signature on the consent forms. Nursing notes did not show POA notification for either medication change, and the DON stated the facility’s policy is to notify the POA and have them sign required consents for cognitively impaired residents.
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 Care Plan ADL Assistance Needs
Penalty
Summary
The facility failed to develop individualized care plans that documented the level of assistance each resident required for Activities of Daily Living (ADLs). The facility's policy required an individualized comprehensive care plan with measurable objectives and timetables reflecting each resident's medical, nursing, mental, and/or psychological needs and preferences, but the care plans reviewed only addressed transfer assistance. Based on observation, record review, and interview, bathing, dressing, bed mobility, eating, and mobility were not addressed on residents' care plans. The Restorative Nurse stated she was responsible for ADL care plans and only care planned transfer assistance, while the Administrator confirmed none of the resident care plans addressed ADL assistance needs except transfers. The Restorative Nurse also stated there was not a resident in the facility who was independent with all ADLs and that all residents required supervision or hands-on assistance with ADLs.
Open Dumpster Lid
Penalty
Summary
The facility failed to ensure garbage and refuse container lids were closed. Based on observation, interview, and record review, one of the two dumpsters had its lid open at 7:00 AM, despite the facility's Garbage Disposal Policy stating to keep the dumpster closed at all times. A CNA verified that dumpster lids are to be closed at all times and stated, "Sometimes we need three of them." The facility census was 68 residents.
Failure to Maintain Resident Dignity During Feeding and Wound Care
Penalty
Summary
The facility failed to maintain dignity for two residents during care and feeding. For one resident, a CNA was observed standing next to the resident while feeding breakfast and stated she was going table to table to help residents and usually sat when she had help in the dining area. The DON later confirmed that staff should be sitting with residents when assisting them with feeding. The facility’s policies stated that residents should be treated with respect and dignity and that staff should sit with the person and assist with the meal as needed. For another resident, who had a stage 4 sacral pressure ulcer, type 2 diabetes mellitus, and a VRE urinary tract infection, wound care was observed to the coccyx. During the treatment, two CNAs held the resident on her right side facing the window, and the resident was without clothing from the waist down with her naked buttocks exposed to the doorway. The privacy curtain was not pulled around the resident. The RN opened the room door to access the treatment cart while the resident’s buttocks remained exposed to the hallway for about one minute before the cart was moved to the doorway and the resident was covered with a sheet. The CNAs and RN later confirmed that the privacy curtain should have been pulled and that the resident should have been covered before the door was opened.
Psychotropic Medications Used Without Documented Nonpharmacologic Interventions or Required GDRs
Penalty
Summary
The facility failed to attempt nonpharmacologic interventions before administering psychotropic medications for three residents and failed to complete gradual dose reductions for two residents. The facility’s psychotropic medication policy stated that anxiolytic/sedative drugs should only be used after other possible reasons for distress have been considered and ruled out, and that antipsychotics in persons with dementia should not be used for behaviors such as wandering, poor self-care, restlessness, mild anxiety, insomnia, or uncooperativeness unless the behaviors present a danger to the resident or others. The policy also required documentation supporting unsuccessful dose reduction attempts and justification for continued use. One resident with dementia, behavioral disturbance, diabetes, and repeated falls was receiving Seroquel nightly and later Hydroxyzine for dementia/anxiety. Surveyors observed the resident calm and confused, propelling self into walls and other residents, while the record showed behavior logs documenting refusal of care but no other monitored behaviors. A pharmacist recommendation accepted a gradual dose reduction from 25 mg to 12.5 mg, but the physician later returned the resident to the previous dose and the resident continued to receive both Seroquel and PRN Hydroxyzine. Staff stated the Hydroxyzine was intended to manage anxiety and get the resident off the antipsychotic, but that plan was not documented in the medical record. The social services director stated the resident’s behaviors were not harmful and that no personalized behavior interventions had been developed. Another resident with anxiety, osteomyelitis, and type 2 diabetes received PRN Ativan almost daily, sometimes twice daily, even though behavior logs documented zero instances of anxiety for the month and the record contained no documentation of nonpharmacologic interventions before administration. The resident stated the medication began during hospitalization and that no other ways to manage anxiety had been offered. A third resident with schizoaffective disorder, dementia, major depressive disorder, generalized anxiety disorder, and COPD had PRN olanzapine for agitation, but behavior logs documented only one agitation instance and the medication was given on a day with no documented agitated behavior. The record contained no documentation of nonpharmacologic interventions before the olanzapine dose, and staff confirmed there were no personalized interventions on the care plan for this resident either.
Dialysis Orders and Communication Documentation Missing
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for residents receiving hemodialysis. The report states that the facility did not have documentation of communication with the dialysis facility for three residents, did not have appropriate physician orders for two residents, and did not implement a care plan for one resident. The facility policy, Hemodialysis Guidelines, required communication between the outpatient dialysis provider and the facility, including written communication forms with review of daily weights and changes in condition or mood, as well as documentation of access checks and other dialysis-related care. For one resident, the physician orders for hemodialysis did not identify the dialysis access site location or the type of access used for treatment. The resident’s access site was not identified in the physician orders, care plan, or nursing progress notes, and there were no orders or parameters for laboratory monitoring related to dialysis treatments. During observation, the resident stated the access was a fistula and had a dressing on the left upper arm. The care plan coordinator confirmed there was no documentation of the resident’s dialysis access site in the current medical record, care plan, or physician orders. For another resident, the physician orders for hemodialysis did not specify individualized dialysis prescriptions such as treatment length, dialyzer type, electrolyte composition of the dialysate, blood flow rate, dialysate flow rate, anticoagulation, or target weight. The resident’s dialysis communication forms lacked documentation by facility staff prior to dialysis treatments. Staff interviews showed uncertainty about whether nurses were to complete the top portion of the dialysis communication form and whether vital signs and weight were to be obtained before transport. The DON confirmed nurses were to complete the top portion of the form, but the forms were not being completed consistently, and staff reported the dialysis communication form did not return with residents from the dialysis center. The facility was also unable to provide completed dialysis communication forms for three residents documenting vital signs, weight, and condition information by facility nursing staff before transport to the dialysis unit, or documentation by dialysis unit staff identifying the residents’ condition and vital signs after treatment. One resident’s most recent dialysis communication form in the electronic health record was dated months earlier, despite the resident receiving hemodialysis twice weekly. The report also notes that the transporter/medical records staff stated the lack of completed dialysis communication forms had been an ongoing issue.
Enhanced Barrier Precautions Not Followed for Transfer and Room Signage
Penalty
Summary
The facility failed to ensure staff used appropriate PPE during a high-contact transfer for a resident with Enhanced Barrier Precautions in place. R5 had diagnoses including a stage 4 sacral pressure ulcer, type 2 diabetes mellitus, and a urinary tract infection site not specified-VRE. R5’s physician orders documented Enhanced Barrier Precautions and strict isolation due to a positive wound culture, and the care plan noted an indwelling urinary catheter, a stage 4 coccyx pressure ulcer, and the need for gown and gloves during high-contact resident activities and transfers via sit-to-stand lift. On 6/29/26, two CNAs were observed preparing to transfer R5 with a sit-to-stand mechanical lift, and one CNA was placing the sling around R5’s upper torso while wearing only gloves. The CNA later confirmed she should have been wearing a gown and gloves for that activity. The facility also failed to post Enhanced Barrier Precautions alert signage for R47. R47 had diagnoses including lymphedema, colostomy, and bilateral lower extremity venous ulcers. R47’s physician orders included Enhanced Barrier Precautions related to the ostomy, and treatment orders documented colostomy care and extensive wound treatments and dressing changes for open wounds on both lower extremities. The care plan identified that R47 required Enhanced Barrier Precautions due to the colostomy and open wound. During observations, no EBP signage was posted on or near R47’s room door on multiple occasions, including when the resident was seated in the room with dressing wraps in place and drainage visible through both wraps, and the wound nurse later removed soiled dressing wraps exposing multiple open wounds. The infection preventionist verified that the EBP alert signage was still not present and should have been posted on or near the door to alert staff and visitors to the need for specific PPE during high-contact activities.
Abuse and refusal of care during hands-on bathing
Penalty
Summary
The facility failed to protect a resident from abuse and failed to respect the resident’s right to refuse care when staff continued hands-on bathing and perineal care after the resident repeatedly said no, get off me, and let go of me. The resident had diagnoses including vascular dementia, anxiety, depression, and chronic pain. The resident’s care plan identified refusal of care, yelling/screaming, and combative behavior with care, and directed staff to ensure the resident was safe, remove themselves from the situation, and re-attempt care later when the resident became combative to the point staff safety was threatened. A video recording showed multiple staff members entering the resident’s room to clean him despite his immediate verbal refusal. One CNA attempted to wash the resident’s face while another held the resident’s left hand and wrist, and a third staff member later washed the resident’s perineal area while the resident remained naked in bed and continued yelling for staff to get off him and let go of him. Staff held the resident’s arms and hands down during the care, and the resident pulled against the hold with enough force that one staff member’s upper body moved. The resident remained lying flat during the care and showed physical and emotional distress, including noticeable changes in breathing, use of accessory muscles, and abdominal breathing. The resident’s family member reported that staff did not listen to the resident’s refusal and held his arms and hands while he was yelling and pulling away. The family member also stated the resident was in distress and wanted staff to stop. The administrator and DON reviewed the video and acknowledged that staff held the resident’s hands and arms during care to keep staff from being hit, but they did not think it was abuse. The DON stated staff should have left the room and re-approached later, and a CNA stated staff held the resident’s arms and hands during cares because he resisted and refused most of the time and that staff felt they had to provide care regardless of refusals.
Failure to Respond to Catheter-Related UTI Signs and Symptoms
Penalty
Summary
The facility failed to ensure timely assessment, monitoring, physician notification, diagnostic evaluation, and intervention for a resident with an indwelling urinary catheter who had a known history of recurrent UTIs, urosepsis, urinary retention, COPD, depression, and anxiety. The resident’s care plan called for catheter drainage assessment, catheter changes as ordered, catheter care every shift and as needed, avoidance of drainage obstruction, and reporting of UTI symptoms such as foul odor, concentrated urine, blood in urine, fever, and other changes. Facility policies required staff to observe urine for abnormal color and blood, monitor for signs and symptoms of UTI and urinary retention, and promptly notify the physician of changes in condition. Between the documented dates reviewed, nursing staff repeatedly recorded abnormal urinary findings including blood-tinged urine, dark urine, thick sediment, mucus, orange urine, catheter obstruction findings, and decreased urinary output. These findings were documented in 43 nursing progress notes without documentation of physician or practitioner notification, nursing assessment, diagnostic testing, intervention, or escalation of care. Multiple licensed nurses confirmed in interview that they documented the abnormal urinary findings but did not notify the provider or initiate interventions. The nurse practitioner’s notes during the same period did not address the abnormal urinary findings despite the resident’s ongoing urinary symptoms and history of recurrent urinary infections. The resident’s family member reported repeatedly alerting staff to concerns about decreased output, blood, mucus, sediment, and lack of catheter irrigation, and stated concern that the resident was septic because of the urinary symptoms and prior urosepsis. When the resident later deteriorated, staff documented fever, shaking, mumbling, panic, elevated respiratory rate, and respiratory distress, and EMS was called. The resident was transported to the emergency department in respiratory distress and altered mental status, where the Foley catheter was noted to have brown sediment and the resident was diagnosed with sepsis secondary to UTI, acute respiratory failure, and atrial fibrillation/supraventricular tachycardia refractory to treatment. Hospital documentation described an obstructed Foley catheter with thick mucus and dried dark substances, and the resident died after the family chose comfort measures only.
Failure to Notify POA of New Psychotropic Medications
Penalty
Summary
The facility failed to notify a resident representative of medication changes for one resident reviewed for new medications. The facility policy dated 10/1/24 states that changes in resident condition or treatment are to be immediately shared with the resident or resident representative and reported to the attending physician, with notification documented in the medical record. The resident had diagnoses including vascular dementia with other behavioral disturbance, major depressive disorder, anxiety disorder, and degenerative disease of the nervous system, and the care plan documented memory deficits and risk for adverse consequences related to antidepressant medication. The resident’s physician order sheet documented orders for Mirtazapine/Remeron starting 10/20/25 and Ramelteon/Rozerem starting 12/8/25. Nursing progress notes did not document notification of the resident’s power of attorney/sister for either medication change, and the informed consent forms for both psychotropic medications did not contain the power of attorney’s signature. The face sheet identified the sister as the resident’s emergency contact and power of attorney. The sister stated she was not notified of any medication changes and that the resident, who was cognitively impaired, signed the consents instead of her. The DON stated it was the facility’s policy to notify the power of attorney and have them sign required medication consents for cognitively impaired residents.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 65 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 1 | 0 |
| Mount Sterling Health And Rehab Center | 14.2 mi | ★★★★★ | 4 | 1 |
| Cass County Senior Living & Rehabilitation Llc | 22.1 mi | ★★★★★ | 13 | 0 |
| Elms, The | 23.2 mi | ★★★★★ | 15 | 0 |
| Wesley Village | 23.3 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.