Inspection·December 4, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. Gait belts should be used by all staff when ambulating or transferring a resident with an unsteady gait. R2's Electronic Medical Record/EMR document R2's diagnosis to include: Displaced supracondylar fracture with intracondylar extension of lower end of left femur, Muscle wasting and atrophy, Muscle Weakness, Chronic obstructive pulmonary disease, Heart Disease, Hypertension, Peripheral vascular disease, Displaced fracture of proximal phalanx of left lesser toe, Displaced fracture of proximal phalanx of right little finger, Legal blindness, and osteoporosis. R2's Quarterly, Minimum Data Set, dated [DATE] [seven days before R2's fall], document: Section GG The resident is dependent-helper does all of the effort. Resident does none of the effort to complete the activity [For transfers] chair/bed to chair transfer, toilet, transfer, and tub/shower transfer. [And the resident is a] partial/moderate assist to walk 10 feet and to walk 50 feet with two turns. Positioning sit to lying, lying to sitting on the side of the bed, and sit to stand, resident requires substantial/maximal assistance-helper does more than half the effort. R2's progress notes document: 10/29/24 3:35 p.m., Called to resident room. Resident noted to be sitting on floor left leg turned inward from hip to knee, Resident complaining of pain. Right ankle turned inward. Complaining of pain, no pulse noted. Aide to back of resident sitting behind her. States resident went to pivot and tried to sit too soon and fell to floor. Called for assistance. VS [Vital Signs] obtained. Called 911. POA [Power of Attorney] called. Resident to be transported to [hospital] for eval[uation]; 10/29/24 3:50 p.m., Ambulance left with resident to transport to [hospital]; 10/29/24 7:07 p.m., [hospital] called, and states resident is being flown out to [another hospital] for multiple fractures; 10/30/24 11:25 a.m., This nurse called [hospital] and had her x-ray reports faxed to the facility. X-ray reports resulted in resident having a left acute, comminuted fracture of the distal femur with intra-articular extension in the knee, and a right interval splining of the comminuted fractures of the distal tibia and fibula diaphysis; 11/4/24 4:16 p.m., [R2], an [AGE] year old female, was readmitted from hospital after her recent hospitalization for orthopedic surgery. During the resident's hospitalization, [R2] has experienced a decline in her ability to function. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145488 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 12/04/2024 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)