Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waters Of Rising Sun, The during CMS and state inspections, most recent first.
A resident with diabetes, ESRD, anemia, HF, HTN, anxiety, and depression had repeated blood glucose readings above the physician’s notification threshold, but the record did not show that the MD was notified. The resident was cognitively intact, and the order required notification when blood glucose was greater than 400; RN documentation of physician notification was absent for multiple elevated readings.
MDS assessments were inaccurate for two residents. One resident’s quarterly MDS listed insulin, antianxiety, and antidepressant meds but did not include current diagnoses of diabetes, anxiety, or depression, even though the MDS Coordinator confirmed those diagnoses were present. Another resident’s discharge MDS listed discharge back to the hospital, but the record showed the family signed AMA paperwork and took the resident home; the MDS Coordinator stated the discharge location should have been documented as home.
A resident with severe cognitive impairment, HTN, and DM had physician orders for PRN Lasix when daily weight gain exceeded 3 pounds. The EMAR/ETAR showed weight gains over that threshold on multiple occasions, but there was no documentation that the PRN Lasix was given when the weight gains occurred. RN stated daily weights were to be documented in the EMAR/ETAR and meds given per the physician’s order.
Missing Dialysis Communication Forms: The facility failed to complete and retain dialysis communication forms for a resident with ESRD who received dialysis three times weekly. Staff reported they obtained pre-dialysis weights and vital signs, sent the form with the resident, and were to review it after return, but multiple forms were missing from the clinical record and the MDS Coordinator could not locate them.
Unlabeled and Undated Food in Pantry Snack Refrigerator: The Pantry Snack Refrigerator contained a resident-labeled container of soup and a resident-nicknamed fast-food bag with a burger, but neither item was dated. The ADON stated the items were brought in by residents' families and should have been labeled with the resident's name and the date brought into the facility. The DON-provided policy required outside food to be labeled and dated with the resident's name, room number, and date received.
Insufficient resident room square footage was identified in 2 rooms after review of room size certification and facility observations. Two SNF/NF rooms were set up for 3 beds each but provided only 67.5 and 69.6 square feet per resident, respectively. During observation, residents had adequate space to move about the rooms and store belongings, and the Administrator verified the measurements and stated she wanted to continue the room waiver.
An LPN administered a nebulizer treatment to a resident with dementia and COPD, obtained vital signs, started the treatment, and then left the room while it continued. The resident’s record did not include an order or assessment for self-administration, and staff stated nebulizer treatments should include lung sounds and vital signs before and after the treatment and should not be left unattended.
An LPN prepared the wrong pain medication for a resident with seizure disorder, glaucoma, and cerebral palsy, selecting Tramadol instead of the ordered Oxycodone. The error was later found during medication cart counts, and the DON confirmed the resident had no order for Tramadol.
Unsafe Van Lift Transfer: A resident with anemia, HF, HTN, renal insufficiency, anxiety, and depression was injured during a van transfer when the lift suddenly lowered to the ground as staff were moving her wheelchair out of the van. The resident’s wheelchair tipped back, she fell to the ground, and she developed bruising to her upper back and soreness; staff later noted the lift strap was not in place during the transfer.
A resident with multiple health conditions experienced several falls due to the facility's failure to implement a care-planned intervention of placing non-skid strips on the floor. Despite the resident's care plan and facility policy requiring such measures, observations confirmed the absence of these strips, contributing to repeated falls.
A resident with limited mobility developed unstageable pressure ulcers on her elbow and thigh due to the facility's failure to identify and manage the wounds in a timely manner. The wounds, attributed to friction from a wheelchair, were not assessed until they had progressed significantly, despite the facility's policy on pressure injury prevention.
A resident with a history of UTIs experienced a delay in treatment due to late initiation of antibiotics, despite positive lab results for Escherichia coli and ESBL. The urine sample was collected and results were reported, but antibiotics were not started until eight days later, contrary to facility policy requiring prompt medication initiation.
The facility failed to follow physician's orders for medication administration parameters for two residents. One resident received midodrine despite blood pressure readings exceeding prescribed limits, while another received Metoprolol despite a heart rate below the specified threshold. The facility's medication administration policy was not adhered to, resulting in these deficiencies.
The facility failed to ensure proper use of hairnets in the kitchen, as observed with two dietary aides who had portions of their hair exposed while in food preparation and serving areas. Despite the facility's policy requiring full hair coverage, the aides were seen with uncovered hair during food-related activities.
The facility did not meet the required minimum square footage per resident in two rooms. One room measured 217 sq ft for three beds, providing 79.3 sq ft per resident, and another room measured 224 sq ft for three beds, providing 74.6 sq ft per resident. Despite this, residents had adequate space to move and store belongings. The Administrator confirmed the room sizes and expressed a desire to continue the room waiver.
Failure to Notify Physician of Elevated Blood Glucose
Penalty
Summary
The facility failed to notify the physician of changes in a resident’s condition related to elevated blood glucose levels for 1 of 15 residents reviewed for notification of change. Resident 12’s record showed the resident was cognitively intact and had diagnoses including end stage renal disease, anemia, heart failure, hypertension, diabetes, anxiety, and depression. An open-ended physician’s order dated 09/26/2025 directed Humalog per sliding scale and required physician notification if blood glucose was greater than 400. The clinical record did not show that the physician was notified when the resident’s blood glucose exceeded 400 on four occasions: 459 at 8:00 P.M. on 01/29/2026, 473 at 8:00 P.M. on 01/31/2026, 481 at 11:00 A.M. on 02/18/2026, and 474 at 11:00 A.M. on 02/25/2026. During interview, RN 3 stated that if physician notification was needed related to medications, she would call the physician or use the facility communication system and then document the notification in a progress note. The facility policy stated that the resident, attending physician, and Responsible Party/POA are to be notified promptly of changes in condition, status, or treatment.
MDS Assessments Did Not Match Resident Diagnoses or Discharge Location
Penalty
Summary
The facility failed to ensure accurate MDS assessments for Resident 17 by not documenting current diagnoses in the Active Diagnoses section of the Quarterly MDS dated 12/31/2025. Although the Medications section showed the resident received Basaglar and Humalog for diabetes, Alprazolam for anxiety, and Duloxetine for depression during the assessment review period, the assessment did not list diabetes, anxiety, or depression as active diagnoses. The MDS Coordinator later stated the resident’s diagnoses included diabetes, depression, and anxiety, and that the MDS should reflect the resident’s current diagnoses. The facility also failed to accurately document the discharge location for Resident 55. The resident was admitted from the hospital and later had a discharge assessment dated 01/13/2026 indicating an unplanned discharge with return anticipated and discharge back to the hospital. However, the progress note for that day stated the resident’s family member decided to take the resident home and care for her there due to cognitive issues, signed AMA paperwork, and left with the resident’s hospital discharge paperwork. The MDS Coordinator stated that when a resident left AMA, the discharge MDS should indicate the resident went home, and that this resident’s discharge MDS should have reflected that discharge location.
Failure to Follow PRN Lasix Order for Weight Gain
Penalty
Summary
The facility failed to follow a physician’s order related to weight management for Resident 32, whose record showed severe cognitive impairment and diagnoses including hypertension and diabetes. An open-ended order dated 02/21/2025 directed that Lasix be given as needed for weight gain greater than 3 pounds in a day, with the physician to be notified if the weight gain was greater than 3 pounds in 1 day or 5 pounds in 1 week, but the order did not include a dosage amount. A separate open-ended order dated 02/20/2025 directed Lasix 20 mg as needed for a weight gain of more than 3 pounds in 1 day. The January and February 2026 EMAR/ETAR showed weight gains greater than 3 pounds in 1 day on 01/07/2026 to 01/08/2026 and on 02/20/2026 to 02/21/2026, but the EMAR/ETAR lacked documentation that the resident received the PRN Lasix on 01/28/2026 or 02/21/2026 when the weight gain occurred. During interview, RN 3 stated resident daily weights would be documented in the EMAR/ETAR and medication given per the physician’s order. The facility policy stated it was the policy of the facility to follow the orders of the physician.
Missing Dialysis Communication Forms
Penalty
Summary
The facility failed to complete assessments before and after a resident's dialysis treatments for 1 of 1 resident reviewed for dialysis. Resident 12 was cognitively intact, had a diagnosis of end stage renal disease, and received dialysis three days a week while residing at the facility. Staff stated that before the resident left for dialysis, they obtained weights and vital signs, documented them on a communication form, and sent the form with the resident to dialysis. After the resident returned, staff were to check vital signs again, review the communication form, and place it in the DON's box. The resident's clinical record did not contain Dialysis Communication Forms for multiple dialysis dates in January and February 2026. The MDS Coordinator stated she had been overseeing the forms since the beginning of February 2026 and could not locate the missing forms, although they should have been completed and placed in the resident's clinical record. The facility's undated policy, Community Hemodialysis, stated that a dialysis communication sheet would return with the resident after the dialysis session to communicate information regarding the dialysis session.
Unlabeled and Undated Food in Pantry Snack Refrigerator
Penalty
Summary
The facility failed to maintain a resident snack refrigerator in accordance with professional standards because 1 of 1 reviewed snack refrigerator contained unlabeled and undated food items. During observation with the Assistant Director of Nursing, the Pantry Snack Refrigerator contained a clear half-gallon container of soup with a resident's name written on the lid but no date, and a brown fast-food bag with a box containing a burger inside, with a resident's nickname written on the bag but no date. During interview, the ADON stated the items had been brought into the facility by residents' families and that the food should be labeled with the resident's name and the date it was brought to the facility. The facility policy provided by the DON stated that foods or beverages brought in from outside sources are to be labeled and dated with the resident's name, room number, and the date the item was brought into the facility for consumption or storage.
Insufficient Resident Room Square Footage
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in 2 of 28 resident rooms. Review of the facility’s room size certification documentation showed that one SNF/NF room measured 202.5 square feet and had capacity for 3 beds, which equaled 67.5 square feet per resident, and another SNF/NF room measured 209 square feet with capacity for 3 beds, which equaled 69.6 square feet per resident. During observations of both rooms, each resident had adequate space to move about the room and store belongings, and the room measurements were confirmed. The Administrator verified the room sizes and stated she would only use the beds as a last option and wanted to continue the room waiver.
Improper Self-Administration and Nebulizer Treatment Supervision
Penalty
Summary
The facility failed to ensure that a resident who self-administered medications was appropriately assessed before being left alone to administer a complete breathing treatment. During an observation on 02/26/2026 at 9:24 A.M., an LPN obtained the resident’s blood pressure, heart rate, and oxygen saturation, placed the nebulizer medication in the reservoir, held the mask to the resident’s face, secured the straps, turned the nebulizer on, and then left the room while the treatment was in progress. The resident involved was moderately cognitively impaired per an annual MDS assessment dated 12/08/2025 and had diagnoses including dementia and COPD. The resident’s physician order dated 02/23/2026 directed Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg four times daily for wheezes for three days. The record lacked a physician’s order for self-administration and lacked a medication self-administration assessment. The DON stated there were no residents in the facility who self-administered medications, and an LPN stated that nebulizer treatments should include lung sounds and vital signs before and after treatment and that the resident should not be left alone during the treatment.
Medication Administration Error Involving Wrong Pain Medication
Penalty
Summary
The facility failed to follow physician orders related to medication administration for one resident reviewed for pharmacy services. The resident had diagnoses including seizure disorder, glaucoma, and cerebral palsy, and a Quarterly MDS assessment indicated the resident was rarely/never understood. The resident was receiving scheduled opioid pain medication, Oxycodone 5-325 mg. A nursing progress note documented that an LPN prepared the resident's 2:00 P.M. pain medication but accidentally prepared Tramadol 50 mg instead of the prescribed Oxycodone 5-325 mg. The medication error was discovered later when staff were counting medications in the cart at the end of the shift. The EMAR showed the resident received the scheduled Oxycodone at 2:00 P.M., and the DON stated the nurse had prepared Tramadol instead of Oxycodone, did not give both medications, and that the resident did not have an order for Tramadol.
Unsafe Van Lift Transfer
Penalty
Summary
The facility failed to operate the facility van lift safely and appropriately for 1 of 3 residents reviewed for accidents. Resident D, who was cognitively intact and had diagnoses including anemia, heart failure, hypertension, renal insufficiency, anxiety, and depression, reported that while exiting the facility van with staff assistance, the van lift felt like it gave out and went straight to the ground. She stated her wheelchair tipped back and she fell to the ground, causing bruising to her upper back and soreness, and she was sent to the hospital without fractures or bleeding. At the time of observation, Resident D had a baseball-sized bruise to her upper left back. Facility staff described the event inconsistently, but multiple interviews indicated that the resident was being transferred from the van when the lift suddenly lowered to the ground. RN 4 stated the resident was lying on the ground outside the van, her wheelchair was on the lift, the lift was all the way on the ground, and the lift strap was not in place. RN 4 also reported the transporter said she did not have time to put the strap in place before the lift went down. The clinical record documented that the resident was found on the ground outside the van, complained of back and head pain, and was transported to the emergency room for evaluation. The facility’s transport and maintenance staff and the van lift company representative all discussed the incident afterward, with the facility indicating the lift was operational when checked and that the event may have involved user error or the lift not being positioned flush with the van. The current facility policy required the resident to be secure and safe during use of the transport vehicle lift and to secure the seat belt, but the lift strap was not in place during the transfer.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to ensure a care-planned fall intervention was in place for a resident who was reviewed for Quality of Care. The resident, who was cognitively intact and had diagnoses including anemia, cirrhosis, diabetes, hypotension, and hypertensive heart disease, experienced multiple falls. Despite a care plan intervention initiated on 12/06/24 to place non-skid strips on the floor beside the resident's bed, these strips were not present during observations on 01/02/25 and 01/09/25. The resident had experienced falls on 12/06/24, 12/13/24, and 01/05/25, with interventions such as placing fluorescent tape on the call light and ensuring the bed was in the lowest position being implemented, but the non-skid strips were not addressed. During interviews, a CNA indicated the resident had not had any recent falls that she was aware of, and noted the resident's reluctance to use a cane or non-skid socks. The Assistant Director of Nursing confirmed the absence of non-skid strips, acknowledging that they were supposed to be in place as per the care plan. The facility's policy on incidents, accidents, and falls required a site investigation and new care plan interventions for each fall, but the lack of non-skid strips suggests a failure to fully implement the planned interventions to prevent further falls.
Failure to Timely Identify and Manage Pressure Ulcers
Penalty
Summary
The facility failed to identify pressure ulcers in a timely manner for a resident, leading to the development of unstageable pressure ulcers. The resident, who had limited mobility in her right arm, reported having a wound on her right elbow and another on her right thigh, which were not covered and had defined edges. The resident indicated that the thigh wound was caused by rubbing against the wheelchair armrest. The facility's Assistant Director of Nursing (ADON) confirmed that the elbow wound was first observed on December 24, 2024, and was unstageable with necrotic tissue. The thigh wound was discovered later and was attributed to friction from the wheelchair. Interviews with staff revealed that the Certified Nurse Aides (CNAs) were responsible for reporting any skin integrity issues, but the wounds were not identified until they had progressed significantly. The ADON noted that the wounds should have been noticed before becoming unstageable, and the resident's care plan included interventions like a pressure redistribution mattress and a wheelchair cushion. However, the resident's Braden Scale score categorized her as low risk for pressure sores, which may have contributed to the oversight. The facility's policy on pressure injury prevention emphasized the importance of timely identification and intervention for at-risk residents. Despite this, the resident's wounds were not assessed and documented promptly, leading to their progression. The facility's failure to adhere to its guidelines and the lack of timely wound assessments contributed to the deficiency in care for the resident.
Delayed Treatment of UTI in Resident
Penalty
Summary
The facility failed to treat a resident for a urinary tract infection (UTI) in a timely manner. Resident B, who was severely cognitively impaired and had a history of UTIs, was not started on antibiotics until eight days after a urine sample tested positive for Escherichia coli and Extended-spectrum beta-lactamase (ESBL). The urine sample was collected on December 8th, received by the lab on December 9th, and the results were reported on December 13th. However, the resident was not started on an antibiotic until December 16th, despite the facility's policy that residents should be started on medication within six hours of receiving lab results. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that there were issues with the lab taking a long time to process the results, and there was a delay in contacting the doctor for orders. The ADON indicated that the resident should have been started on an antibiotic sooner, and the DON expressed that it was not best practice to wait so long to treat the resident. The facility's policy requires notifying the attending physician of any diagnostic test results outside normal parameters and obtaining orders promptly, which was not adhered to in this case.
Failure to Follow Medication Administration Parameters
Penalty
Summary
The facility failed to adhere to physician's orders regarding medication administration parameters for two residents. Resident 12, who was cognitively intact and diagnosed with conditions including anemia, cirrhosis, diabetes, hypotension, and hypertensive heart disease, was prescribed midodrine to be held if systolic blood pressure exceeded 130 or diastolic blood pressure exceeded 90. However, the medication was administered on multiple occasions when the resident's blood pressure readings were above these parameters, as documented in the Electronic Medication Administration Record (EMAR) for November and December 2024, and January 2025. An LPN confirmed that medication orders sometimes included parameters and that she would hold medication if vital signs were out of range, but this was not consistently followed in Resident 12's case. Similarly, Resident 29, who was moderately cognitively impaired and diagnosed with dementia, depression, and hypertension, was prescribed Metoprolol to be held if the heart rate was less than 60. Despite this, the medication was administered on several occasions when the resident's heart rate was below 60, as recorded in the EMAR for October, November, and December 2024. The facility's medication administration policy, which requires reviewing orders and following special instructions, was not adhered to, leading to the administration of medication against the specified parameters for both residents.
Improper Use of Hairnets in Kitchen
Penalty
Summary
The facility failed to adhere to appropriate guidelines regarding the use of hairnets in the kitchen, as observed during a survey. Specifically, two dietary aides were noted to have improperly worn hairnets, with portions of their hair exposed while in food preparation and serving areas. Dietary Aide 4 was observed on multiple occasions with three inches of her bangs uncovered by her hairnet, both while preparing food and while pushing a food cart. Similarly, Dietary Aide 5 was seen with two inches of hair around her face not covered by her hairnet. During an interview, Dietary Aide 4 acknowledged that hairnets should cover the entire head and all hair. The facility's Hair Restraints policy, dated 2017, mandates that staff wear hair restraints in all food preparation, dishwashing, and serving areas.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in two of its rooms, leading to a deficiency. Specifically, room [ROOM NUMBER] in the Skilled Nursing Facility/Nursing Facility (SNF/NF) was measured at 217 square feet, accommodating three beds, which equates to 79.3 square feet per resident, falling short of the 80 square feet requirement. Similarly, room [ROOM NUMBER] was 224 square feet with a capacity for three beds, providing only 74.6 square feet per resident. Despite the deficiency, observations noted that each resident had adequate space to move and store belongings. The room sizes were confirmed by the Administrator, who indicated that these beds would only be used as a last option and expressed a desire to continue the room waiver.
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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 Rising Sun
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Boonespring Transitional Care Center, Llc | 7.8 mi | ★★★★★ | 0 | 0 |
| Gallatin Nursing And Rehab | 11.4 mi | ★★★★★ | 3 | 0 |
| Waters Of Dillsboro-ross Manor, The | 11.7 mi | ★★★★★ | 11 | 0 |
| Ridgewood Health Campus | 11.8 mi | ★★★★★ | 0 | 0 |
| Envive Of Lawrenceburg | 12 mi | ★★★★★ | 13 | 0 |
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