Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Estates At Rush City Llc during CMS and state inspections, most recent first.
The facility failed to ensure that nursing staff were trained and competent in blood glucose checks and infection control, affecting two residents. An LPN was observed improperly handling a glucometer and admitted to not receiving orientation. The facility also did not confirm agency staff received necessary training before working with residents, as evidenced by incomplete orientation checklists.
A facility failed to properly clean and disinfect a shared glucometer between residents, leading to an infection control deficiency. An LPN was observed using the glucometer without following proper cleaning protocols, despite the facility's expectation that each resident should have their own device. The Director of Nursing confirmed a lack of training for the LPN, and the incident involved three residents with type 2 diabetes mellitus.
The facility failed to obtain blood sugars as ordered for three residents with type 2 diabetes, leading to blood glucose checks being conducted after meals instead of before. An LPN was observed using a shared glucometer without proper cleaning, and the DON confirmed a lack of specific training on glucometer use.
A resident at risk for pressure ulcers did not receive adequate care as per their care plan, which included repositioning and toileting every two to three hours. Nursing staff failed to offer these services during an observation period, and interviews revealed a lack of communication and adherence to the care plan. The DON expected staff to offer care and document refusals, which was not done.
The facility exceeded the acceptable medication error rate with two errors involving insulin administration to two residents with diabetes. An LPN primed an insulin pen incorrectly, and another LPN failed to prime the pen before administration. The DON confirmed the expectation to prime with 2 units, but no policy was provided.
A resident with cognitive impairments and a history of falls experienced multiple falls, including one resulting in a fracture, due to the facility's failure to conduct a comprehensive fall analysis and implement appropriate interventions. The care plan lacked specific measures to address the resident's fall risk factors, and staff did not consistently follow the care plan or communicate fall incidents effectively.
A resident with a pressure ulcer on admission was not comprehensively assessed or monitored by the facility, leading to a large unstageable ulcer being discovered at the hospital. Despite care plans and orders for monitoring, documentation was inadequate, and staff were unaware of the ulcer's severity. The facility's policy for pressure ulcer management was not followed, resulting in a significant deficiency.
A resident with multiple health conditions, including cerebral infarction and diabetes, was not adequately assessed or monitored for hydration needs in an LTC facility. Despite being at risk for dehydration, the facility failed to conduct a comprehensive nutritional assessment or involve a dietitian in the resident's care. The resident's fluid intake was poorly documented, leading to hospitalization for dehydration and altered mental status.
The facility failed to comprehensively assess and address fall risks for two residents, leading to deficiencies in their care. One resident, severely cognitively impaired, fell from bed and sustained a cervical fracture due to inadequate assessment and intervention related to an air mattress. Another resident, admitted with a history of falls, experienced multiple self-transfer attempts and falls without timely interventions or thorough analysis. The facility's inaction and lack of comprehensive assessment resulted in repeated incidents and inadequate care.
Deficiency in Staff Training and Infection Control
Penalty
Summary
The facility failed to ensure that direct-care nursing staff were appropriately trained and competent in performing blood glucose checks and adhering to infection control policies. This deficiency was observed in two residents who had their glucose levels checked. An LPN was seen carrying a glucometer with a used glucose strip and wearing gloves inappropriately in the hallway. The LPN did not clean the glucometer before entering a resident's room and only cleaned it after being prompted. The LPN admitted to not receiving any orientation or training on the facility's policies, procedures, or equipment prior to working with the residents. Additionally, the facility did not confirm that agency staff received facility and resident-specific orientation and training before working with residents. The Temporary Agency Staff Orientation Checklist (TASOC) for the LPN was blank, indicating no orientation was completed before their first shift. Another RN's TASOC was completed months after their initial shift. The Director of Nursing confirmed that the required education and orientation were not completed on the first day of work, as expected, but rather days later. A facility policy for the orientation of agency staff was requested but not provided.
Improper Cleaning of Shared Glucometer
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of a shared glucometer between residents, leading to a deficiency in infection prevention and control. Three residents with type 2 diabetes mellitus were involved in the incident, where a Licensed Practical Nurse (LPN) was observed carrying a glucometer with a used glucose strip without cleaning it between uses. The LPN did not follow proper procedures for cleaning and disinfecting the glucometer, as she used only one wipe and did not adhere to the manufacturer's instructions for contact time. This oversight occurred despite the facility's expectation that each resident should have their own glucometer, and the shared device was intended for emergencies only. The Director of Nursing (DON) confirmed that there was no training provided to the LPN on the proper use of the glucometer. The LPN admitted to not cleaning the glucometer before placing it back in the container and was unaware of the correct wet/kill time required for disinfection. The facility's documentation and the glucometer's user manual both emphasized the importance of cleaning and disinfecting the device after each use to prevent the risk of infection from bloodborne pathogens. However, these protocols were not followed, resulting in a breach of infection control practices.
Failure to Obtain Blood Sugars as Ordered
Penalty
Summary
The facility failed to ensure blood sugars were obtained as ordered for three residents with type 2 diabetes mellitus. The active orders for these residents required blood glucose monitoring before meals and at bedtime, with insulin administration based on a sliding scale. However, observations revealed that blood sugars were not consistently checked before meals. For instance, one resident's blood sugar was checked after they had already eaten, and another resident's blood sugar was checked after their meal was finished. This indicates a failure to adhere to the prescribed timing for blood glucose monitoring. Additionally, there were issues with the handling and cleaning of the glucometer used for blood sugar checks. An LPN was observed carrying a glucometer with a used strip and did not clean the device before using it on another resident. The Director of Nursing (DON) acknowledged that there was no specific training provided to the LPN on glucometer use and expected that such training would have been part of their nursing education. The DON also stated that each resident should have their own glucometer, and the one used by the LPN was intended only for emergencies.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper care for a resident with pressure ulcers, as observed during a survey. The resident, who was cognitively intact and required substantial assistance with activities of daily living, was at risk for pressure ulcers due to conditions such as fibromyalgia, muscle weakness, and incontinence. The care plan for the resident included turning and repositioning every two to three hours and assisting with toileting at similar intervals. However, during a continuous observation period, the nursing staff did not offer repositioning, toileting, or checking and changing to the resident. Interviews with nursing assistants revealed a lack of adherence to the care plan. One nursing assistant admitted to not offering any care unless the resident activated the call light, assuming that the night staff had already attended to the resident. Another nursing assistant confirmed that no plan for the resident's care had been communicated, despite the resident's history of refusing care. The Director of Nursing stated that staff should offer care regardless of past refusals and document any refusals, which was not done in this case.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 5.56% due to two errors out of 36 opportunities. One error involved a resident who was cognitively intact and had diabetes mellitus. The resident was supposed to receive 10 units of Lantus insulin at bedtime. However, the LPN primed the insulin pen with 2 units before attaching the needle, which is not the correct procedure. The LPN confirmed this was her usual practice during an interview. Another error involved a resident who was moderately cognitively intact and also had diabetes mellitus. The resident was ordered to receive 20 units of insulin glargine in the morning. The LPN dialed the insulin units with the pen cap on and without a needle, then placed the pen in a box. After the resident initially refused the injection, the RN cleaned the pen, attached a needle, and administered the insulin after the resident consented. The LPN later acknowledged the need to prime the needle with one unit of insulin, which was not done initially. The director of nursing stated that the expectation was to prime the needle with 2 units of insulin, but no policy on priming insulin pens was provided.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to conduct a comprehensive fall analysis and implement appropriate care plan interventions for a resident, leading to actual harm. The resident, who had a history of falls and cognitive impairments, was admitted with specific care instructions, including wearing a back brace and monitoring for falls. Despite these instructions, the resident experienced multiple falls, including an unwitnessed fall that resulted in an acute nondisplaced fracture of the sacral area. The facility's care plan did not include specific interventions to address the resident's fall risk factors, such as confusion, impaired memory, and unsteady gait. Interviews and document reviews revealed that the facility's staff were aware of the resident's fall history and risk factors but failed to implement effective interventions. The resident's care plan lacked specific measures to prevent falls, and the interdisciplinary team did not complete a thorough analysis to identify and address the resident's contributing risk factors. The facility's fall prevention policy required staff to evaluate and document risk factors and implement interventions to reduce falls, but these steps were not adequately followed. The facility's failure to provide adequate supervision and implement effective fall prevention measures resulted in the resident experiencing multiple falls, including one that led to a serious injury. The facility's staff did not consistently follow the care plan, and there was a lack of communication and documentation regarding the resident's fall incidents. The facility's policy required immediate notification of falls to the director of nursing, physician, and family, but this was not consistently done, contributing to the deficiency.
Failure to Monitor and Assess Pressure Ulcers
Penalty
Summary
The facility failed to comprehensively assess and monitor a resident's pressure ulcers, leading to potential harm. Upon admission, the resident was identified with redness in multiple areas and a pressure ulcer on the left buttock. However, the facility did not conduct comprehensive assessments of these areas, including descriptions, staging, measurements, or pain assessments. The care plan and physician orders required daily monitoring and weekly skin inspections, but the documentation was limited to check marks without detailed information. Throughout the resident's stay, progress notes repeatedly indicated no open wounds, despite the initial identification of a pressure ulcer. Interviews with staff revealed a lack of awareness and documentation regarding the resident's wound, with some staff recalling only redness and not the presence of an ulcer. The resident's condition was not adequately communicated to the hospital upon transfer, where a large unstageable pressure ulcer was identified, contradicting the facility's reports of healing. The facility's policy required comprehensive assessments and routine monitoring of pressure ulcers, which were not followed in this case. Interviews with the nursing staff and management confirmed the absence of a comprehensive assessment and treatment orders for the resident's pressure ulcer. The lack of documentation and communication regarding the resident's wound care highlights a significant deficiency in the facility's pressure ulcer management practices.
Failure to Monitor and Maintain Resident Hydration
Penalty
Summary
The facility failed to comprehensively assess and monitor a resident's hydration status, leading to a deficiency in providing adequate food and fluids to maintain the resident's health. The resident, who had multiple diagnoses including cerebral infarction, diabetes, and benign prostatic hyperplasia, was admitted with a mechanically altered diet and required assistance with feeding. Despite these needs, the facility did not conduct a comprehensive nutritional assessment to determine the resident's daily caloric and fluid needs. The fluid intake and output logs from the resident's records showed inadequate monitoring and evaluation of daily intake to ensure proper hydration. Interviews with facility staff revealed that the resident had poor oral intake and was at risk for dehydration, especially given the resident's COVID-19 status and pressure ulcers. The registered dietitian noted that the resident could have benefited from supplemental hydration, but the facility did not notify her of any concerns or involve her in the resident's care. The resident's progress notes indicated fluctuating levels of alertness and orientation, with instances of disorientation and febrile conditions, yet there was no evidence of continuous assessment or monitoring for dehydration symptoms. The facility's policy on hydration outlined procedures for assessing and monitoring residents' fluid needs, but these were not followed in the resident's case. Interviews with nursing staff and the nurse practitioner highlighted a lack of communication and documentation regarding the resident's fluid intake and risk of dehydration. The resident was eventually hospitalized due to altered mental status and dehydration, as confirmed by emergency medical services and hospital records. The facility's failure to implement timely interventions and involve the dietitian in the resident's care contributed to the deficiency in maintaining the resident's hydration status.
Failure to Address Fall Risks for Two Residents
Penalty
Summary
The facility failed to comprehensively assess and address fall risks for two residents, leading to deficiencies in their care. One resident, identified as R1, was severely cognitively impaired and required extensive assistance for mobility. Despite being at risk for falls due to various factors, including medication use and cognitive impairments, the facility did not conduct a thorough fall analysis or address potential risks associated with the use of an air mattress. R1 experienced a fall from bed, resulting in a cervical fracture, but the facility's documentation lacked a detailed investigation or timely intervention to prevent recurrence. Another resident, R2, was admitted with a history of falls and multiple fractures. Despite being identified as a high fall risk, the facility did not implement timely interventions to address his self-transfer attempts and frequent falls. The documentation showed multiple instances of R2 attempting self-transfers and being found on the floor, yet the facility's response was inadequate, with delayed updates to his care plan and insufficient analysis of the falls. The facility's failure to assess and implement effective interventions for R2's fall risk contributed to repeated incidents. Overall, the facility's inaction and lack of comprehensive assessment for both residents' fall risks resulted in deficiencies in their care. The documentation and interviews revealed a lack of timely and effective interventions, inadequate investigation of fall incidents, and insufficient communication among staff regarding the residents' needs and risks. These deficiencies highlight the facility's failure to ensure a safe environment and adequate supervision to prevent accidents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rush City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ecumen North Branch | 12.4 mi | — | 0 | 0 |
| Burnett Medical Center | 14.7 mi | — | 14 | 0 |
| Gracepointe Crossing Gables | 15.5 mi | — | 0 | 0 |
| St Clare Living Community Of Mora | 21.4 mi | — | 8 | 1 |
| Parmly On The Lake Llc | 22.8 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.