Rushville Nursing & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Rushville Nursing & Rehab CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 1, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF690Jun 1, 2026

  Based 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. […]

• Actual harm, isolatedF689Dec 4, 2024

  Based 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. […]

• Actual harm, isolatedF686May 25, 2023

  Based on observation, record review and interview, the facility failed to implement pressure relieving interventions and perform daily Diabetic foot skin assessments for one of two residents (R47) reviewed for impaired skin integrity, in a sample of 27. These failures resulted in R47 developing unstageable pressure ulcers to the right and left heel after being admitted to the facility, which lead to osteomyelitis of the left heel and a delay in his discharge back to home. Findings include: The facility policy, titled Pressure Ulcer and Wound Prevention/Management Program (updated 12/05/2006) documents, Purpose: To identify residents who are at risk for pressure ulcers and skin breakdown. To prevent pressure ulcers and skin breakdown. […]

• Actual harm, isolatedF689Dec 8, 2022

  Based on record review and interview, the facility failed to ensure a resident identified as a fall risk was wearing proper footwear and was provided adequate supervision, and failed to conduct a fall investigation according to facility policy, for one of three residents (R1) reviewed for falls in a sample of three. These failures resulted in R1 falling in her room on 11/04/22 and sustaining a Left Femoral Neck Fracture (Hip). Findings include: The facility policy, titled Falls - Clinical Protocol (revised August 2008) documents, 1. As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. The policy indicates, 3. […]