The Estates at Rush City LLC

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and document review, the facility failed to ensure informed consent, as well as the risk, benefits, and alternatives to psychotropic medications were provided to 1 of 5 residents (R26) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to provide the resident or their representative a written bed hold notice for 1 of 3 residents (R36) reviewed for hospitalization.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure timely turning, repositioning and oral care for the comfort for a resident on end-of-life services for 1 of 2 (R1) residents and in addition, the facility failed to provide ordered interventions for a resident with constipation for 1 of 2 residents (R26) reviewed for quality of care. R1's quarterly minimum data set (MDS) dated [DATE], identified severe cognitive impairment and diagnoses of metabolic encephalopathy, palliative care, unstageable pressure ulcer (PU) left buttock, stage four PU to the right elbow, vascular dementia, restlessness, agitation, and delusional disorder. The MDS also reflected that R1 received hospice and end-of-life care. The functional assessment at section GG was not completed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 2 residents (R9) had accessibility to their call light to call for help.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a shared glucometer was properly cleaned and disinfected between residents for 3 of 3 residents (R2, R7, R11) reviewed for blood glucose monitoring.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure blood sugars were obtained as ordered for 3 of 3 residents (R2, R7, R11) reviewed for blood glucose monitoring.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure repositioning and checking and changing were offered for 1 of 3 residents (R12) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 5.56 % with 2 errors out of 36 opportunities for error involving 2 of 7 residents (R9, R5) who were observed during the medication passes.

Inspectors wroteBased 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).

Inspectors wroteBased on observation, interview and document review the facility failed to comprehensively assess pressure ulcers and monitor for skin breakdown to prevent and/or mitigate the risk of deterioration resulting in potential harm when 1 of 1 residents (R1)'s wound was not comprehensively monitored or cleaned.

Inspectors wroteBased on interview and record review, the facility failed to comprehensively assess, monitor for signs and symptoms of dehydration and implement timely interventions for 1 of 1 residents (R1) reviewed for hydration status.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess when a new fall risk was identified and failed to safely implement and maintain resident equipment for 1 of 3 residents (R1) who utilized an air mattress that was not maintained at the recommended pressure. Additionally, the facility failed to assess and immediately implement new interventions for 1 of 3 residents (R2) who had falls related to self-transfers.

Inspectors wroteBased on interview and document review, the facility failed to ensure mail was delivered to residents on Saturdays. This had the potential to affect all residents who receive mail to the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food was stored in accordance with professional standards for food service safety by failing to maintain safe food storage temperatures. This practice had the potential to affect all residents consuming food at the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 1 resident (R8) reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a comprehensive assessment was completed to identify causative factors and ensure appropriate interventions were implemented to promote healing for 1 of 1 residents (R21) who's heel wound was observed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed in a timely manner for 1 of 1 residents (R11) reviewed for respiratory care.