Inspection·June 13, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: R31's OBRA-I (Omnibus Budget Reconciliation Act) Initial Screen form (dated 06/01/21) documents screening indicated nursing facility services are appropriate, and R31's face sheet documents R31's primary diagnosis at time of admission [DATE]) to the facility was Guillain-Barre syndrome. R31's Current Diagnosis documents R31 was later diagnosed with Schizoaffective Disorder on 02/24/22. R31's medical record does not include a Preadmission Screening and Resident Review after R31 was diagnosed with Schizoaffective Disorder on 02/24/22. On 06/13/24 at 09:53 AM, V5 (Social Service Director) stated R31 never had a PASARR completed when she was diagnosed with Schizoaffective Disorder on 02/24/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based 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. Findings include: The facility's Rehabilitative Nursing Care policy, dated 4/2007, documents Rehabilitative nursing care is provided for each resident admitted . General rehabilitative nursing care is that which does not require the use of a qualified professional therapist to render such care. Nursing personnel are trained in rehabilitative nursing which is developed and coordinated through the resident's care plan. The facility's Range of Motion policy, dated 1/31/2018, documents The facility will ensure that a resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable. The facility will ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. On 6/11/24 at 10:05 AM, R61 was sitting in her room in a recliner chair with her feet elevated. R61's bilateral feet were stationary in the extended toe pointed position. When asked R61 could not bend her ankle joints back towards her legs for flexion. At this time R61 stated she isn't in therapy and she does not get exercises with Nursing Assistants or Nurses. R61 stated No they do not come in and do any exercises with me. R61's care plan, dated 6/11/2024 documents (R61) requires active range of motion to BUE (Bilateral Upper Extremities) related to Hypertension, Restless legs syndrome, Pain in left hip, Pain in right hip and Other fatigue and requires a restorative nursing AROM (Active Range of Motion) program. (R61) will maintain useful motion to BUE, as evidence by (R61) will perform two sets of reps of AROM to BUE with staff supervision and verbal cues two times a day through next review. This care plan does not document the limitations to R61's bilateral lower extremities or list a Range of Motion plan for her lower extremities. R61's electronic face sheet, printed on 6/12/24, documents R61 has a diagnosis of Foot drop, left foot, Diagnosis 1/9/24, chronic. On 6/13/24 at 11:55 AM, V2 (Director of Nursing) confirmed (R61) is not receiving physical therapy, has a medical diagnosis of Foot Drop and does not have a Range of Motion program in place for her lower extremities. V2 stated I'm not sure who puts that programming in place or why (R61) doesn't have a lower extremity restorative programming. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: The Gait Belt policy dated 4/13 documents Gait belts are used to help prevent injury of staff or resident during transfers and ambulation. 1. Gait belts should be used by all staff when ambulating or transferring a resident with an unsteady gait. 9. To transfer the resident, assist to standing by holding the belt at the waist and pivot the resident to the chair. On 6/10/24 at 1:46 PM, V10/R27's Power of Attorney stated that there are times when R27 has bruises on her arms and the facility said it happened when transferring R27. On 6/12/24 at 12:38 PM, V2/Director of Nursing (DON) stated that the staff are to use a gait belt and not hold on to a resident's arm when doing a transfer. R27's current computerized medical record, documents R27 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Vascular Dementia, Unspecified Severity, with Other Behavioral Disturbance, Chronic Obstructive Pulmonary Disease, Chronic Diastolic (Congestive) Heart Failure, and Long Term (Current) Use of Anticoagulants, Eliquis. R27's MDS (Minimum Data Set) dated 4/10/24 documents a BIMS (Brief Interview for Mental Status) Score of 10/15, indicating moderate mental impairment and dependent on staff for transfers. R27's Care Plan dated 6/4/24, documents, (R27) has a bruise to her right hand/lower arm received during transfer. R27's Skin Issue Details Report dated 6/4/24 at 11:00 AM, documents that R27 has a new bruise to her right hand 12 cm/centimeters by 5 cm. R27's Skin Occurrence Report dated 6/4/24 at 11:00 AM, documents that R27 has a bruise to her right hand. The CNAs were in-serviced on transfers. Other contributing factors: Anticoagulants- bruises easily. Resident Statement: The girls held onto my arm when they helped me up. R27's Investigation Report dated 6/4/24 documents that V2/DON was alerted at 11:00 AM on 6/4/24 that R27 has a bruise to her right hand. When R27 was asked what happened R27 stated The girls held onto my arm when they helped me up. An In-service was provided to CNA's (Certified Nursing Assistants) on proper transfer techniques. R27's Nursing Note dated 6/4/2024 at 1:41 PM, documents Orders received to monitor bruise to right hand received during transfer daily until healed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based 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. Findings include: The facility's Psychotropic Medications Policy (undated) documents the following: This facility shall ensure that residents do not receive psychotropic drugs unless such therapy is necessary to treat a specific condition is diagnosed by the attending physician or psychiatric consultant. Attempts will be made to reduce or discontinue use of such medications whenever possible without compromising resident's health and safety, ability to function appropriately, or the safety of others. R1's current Physician's Orders document the following medication orders: Bupropion (antidepressant) 200 milligrams by mouth daily; and Paroxetine (antidepressant) 40 milligrams by mouth twice daily. On 06/13/24 at 01:30 PM, V3 (Registered Nurse) stated she is the individual that manages psychotropic medications for the residents in the facility. V3 stated that R1 is not a harm to herself or others and she rarely displays any adverse behaviors. V3 stated she is not sure why R1 is taking two antidepressants, and verified that this information was not documented in R1's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 5 of 5