Waters of Rushville: Discontinued Pain Med Given - IN
The medication error occurred July 16 at Waters of Rushville Skilled Nursing Facility, where Qualified Medication Aide 5 administered oxycodone 5 milligrams to Resident E at 8:30 p.m. The pain medication had been discontinued that same morning at 11:45 a.m.
The aide had worked at the facility for about a month.
Director of Nursing told inspectors during an August interview that the staff member "did not check the resident's medication administration record as that staff member would have found out the pain medicine had been DC'd." She said she regularly tells staff to "read and double check those MAR's."
Records show the oxycodone order began July 9 with directions to take one capsule every four hours as needed for pain for seven days. The facility received 30 tablets July 10, and Resident E had received his first dose that evening at 7:00 p.m.
By July 16, the patient had received seven total doses of the medication. The final authorized dose was July 15 at 8:00 p.m.
But the medication remained physically present in the medication cart after the order was discontinued. The Director of Nursing explained that "the med had not been pulled from the med cart yet, because the nurses aren't allowed to dispose of meds without the DON or ADON being present."
The aide gave the unauthorized dose without making any entry in progress notes or signing the medication administration record.
Two days later, on July 18, a staff nurse and the Assistant Director of Nursing disposed of the remaining 23 doses of oxycodone.
The facility's investigation found no complications from the medication error during a 72-hour follow-up on the resident.
The Director of Nursing told inspectors this was the only medication error that had occurred since the facility's most recent annual survey at the end of June. The error was identified the day after it happened.
The discontinued order had been updated in the computer system and appeared correctly on the medication administration record, showing the July 16 discontinuation date.
The medication error occurred on the same day the facility began staff education related to medication administration citations from their recent annual survey.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to residents. The inspection was conducted in response to complaints about the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters of Rushville Skilled Nursing Facility, The from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WATERS OF RUSHVILLE SKILLED NURSING FACILITY, THE in RUSHVILLE, IN was cited for violations during a health inspection on August 22, 2025.
The pain medication had been discontinued that same morning at 11:45 a.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.