The Estates at Rush City LLC

In the surveyor’s words

From the most serious findings on record at The Estates at Rush City LLC, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 6, 2024

  Based on interview and document review the facility failed to complete comprehensive fall analysis to determine accurate causal factors and implement appropriate care plan interventions to prevent or mitigate the risk of recurrent falls for 1 of 3 residents (R1) reviewed for falls. The facility's failures resulted in actual harm when R1 fell and sustained an acute nondisplaced fracture involving sacral (tailbone). Findings include: R1's Face Sheet, undated, identified R2 had diagnoses that included Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery (stroke) and fracture of T7-T8 vertebra (thoracic area of back). R1's Admission data collection tool dated 8/23/24, identified R1 arrived at facility on 8/23/24 at 12:00 noon. […]

• No harm, potential for more than minimal, widespreadF812Jan 29, 2026

  Based on observation, interview, and document review the facility failed to ensure dishes were properly dried and stored to prevent the growth of bacteria. In addition, the facility failed to ensure safe storage of resident personal food item occurred at the facility. These deficient practices had the potential to impact all residents who dined at the facility and or stored food in the designated resident fridge. Findings include:During an observation on 1/28/26 at 9:40 a.m., the dietary aide (DA-A) was washing dishes in the kitchen. DA-A removed plates from the washing rack, stacked the plates, and then put them in the plate cart. The plates had visible droplets of water on them. DA-A removed wet plate holders and lids from wash racks, stacked them, and then placed them on storage carts. […]

• No harm, potential for more than minimal, patternF641Jan 29, 2026

  Based on interview and document review, the facility failed to ensure accuracy of the minimum data set (MDS) for 3 of 4 residents (R1, R26, R34) reviewed for accuracy of assessments.Findings include:R1's quarterly minimum data set (MDS) dated [DATE], identified severe cognitive impairment and diagnoses of metabolic encephalopathy and palliative care. The functional assessment, section GG, was not completed.R1's care plan dated 1/27/26, identified R1 was non-ambulatory and needed assistance with all activities of daily living (ADL)s. R26's admission minimum data set (MDS) dated [DATE], identified intact cognition with diagnoses of disc displacement of the lumbar region, chronic pain, and congestive heart failure (CHF). […]

• No harm, potential for more than minimal, patternF880Jan 29, 2026

  Based on observation, interview and record review, the facility failed to ensure proper personal protective equipment (PPE), hand cleaning and gloving practices were in place during the care of a resident on enhanced barrier precautions (EBP) for 1 of 1 resident (R1) reviewed for catheter care. In addition, the facility failed to provide hand hygiene or sanitation prior to meals. This had the ability to affect all residents who ate in the dining room.Findings include: R1: During a medication administration observation on 1/29/26 at 11:25 a.m., licensed practical nurse (LPN-B) was getting R20's medications ready for administration. LPN-B stepped to the wall hand sanitizer, sanitized their hands, and without gloves broke one of R20's pills in half. […]

• No harm, potential for more than minimal, patternF726Dec 5, 2024

  Based on observation, interview and document review, the facility failed to ensure direct-care nursing staff were appropriately trained and competent on blood glucose checks and infection control policies of the facility for 2 of 2 resident (R2, R7) who had their glucose checked. The facility also failed to confirm agency staff (staff brought in on a temporary basis to assist in resident cares) received facility and resident specific orientation and training prior to working with the residents. Findings include: The facility Temporary Agency Staff Orientation Checklist (TASOC) undated, indicated agency staff would be oriented to facility policies and practices that included emergency preparedness, abuse policy, use of mechanical lifts, medication systems and infection control. […]