Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Northrise Wellness & Rehabilitation during CMS and state inspections, most recent first.
A facility failed to document baseline care plans within 48 hours of admission for two residents. One resident admitted with acute pyelonephritis, hypothyroidism, and DM2 had no baseline care plan documented, and another resident admitted with UTI, vascular dementia, and difficulty walking had a baseline care plan completed after the required timeframe. The DON confirmed the omissions and stated the expectation was to complete the baseline care plan within 48 hours of admission.
Care plan not updated to reflect independent bathing ability. A resident with difficulty walking had OT documentation showing independence with bathing/showering and tub/shower transfers, and the OT confirmed no assistance was needed. However, the care plan still stated the resident required physical assistance from one staff member for bathing/showering, and the DON confirmed the plan did not reflect the resident’s current level of function.
A resident admitted with acute pyelonephritis and UTI did not receive the prescribed continuation of Augmentin from the hospital because the order was not entered on the MAR. The resident later had dark yellow, cloudy, foul-smelling urine and a urinalysis was ordered, but the chart showed Levaquin was not ordered until later and there was no documentation that the MD was contacted to change the antibiotic. The DON confirmed the hospital convalescent order was missed and that staff should have followed the discharge orders unless changed by the MD.
A resident admitted with acute pyelonephritis, hypothyroidism, and type 2 DM had a small open shearing area on the coccyx documented on admission, but no MD order or treatment record was obtained for the wound. The WCN stated the resident only received barrier cream that was not ordered, and the DON confirmed the admission nurse failed to obtain orders for the coccyx shear.
The facility failed to provide documented EBP training for 4 of 4 sampled staff members, including 3 LPNs and 1 CNA. Record review found no training records for these staff, and the Regional Clinical Nurse stated that the training curriculum was not available and could not confirm they had received EBP training.
Incomplete Comprehensive Care Plans: Multiple residents had care plans that did not reflect documented needs and treatments. Records showed omissions involving high-risk meds such as anticoagulants, opioids, insulin, wound care for pressure ulcers, EBP, discharge planning, activity preferences, weekly weights, edema with refusal to elevate legs, oxygen use, and dialysis details. The DON confirmed several of these omissions.
Missing discharge, transfer, and bed-hold documentation: The facility failed to provide required transfer/discharge notices for three residents, including appeal rights and Ombudsman contact information, and failed to document a bed-hold notice for one resident’s hospital transfer. For two residents, the medical record also lacked discharge summaries with recapitulation of stay, resident status, medication reconciliation, and follow-up information. The DON confirmed the missing notices and documentation, and stated that copies of discharge or transfer notices were not sent to the Ombudsman.
A facility failed to complete baseline care plans within 48 hours of admission for 5 of 5 residents reviewed. Record review showed each resident was admitted, but the medical record lacked the required baseline care plan, and the DON confirmed the omission for each resident during interview.
The facility failed to hold timely IDT meetings for three residents after completion of their admission MDS assessments, and no documentation showed the meetings were held. In addition, a resident's care plan was not updated after a PEG tube was placed and an order for EBP was written, even though the DON confirmed the resident should have been on EBP for high-contact care.
Delayed Documentation of Code Status: The facility failed to immediately document full code status for three residents after admission. Although each resident’s CCO showed full code status, the medical record did not reflect that status until two to four days later. The DON confirmed the code status was in the CCOs but not documented in the medical record upon admission, and stated it should be verified and documented at admission.
Activities program failed to reflect resident preferences for two residents. One resident reported no interesting activities and no church services, while the MDS showed important preferences for reading materials, music, animals, news, group activities, favorite activities, fresh air, and religious services that were not included in the care plan. A Spanish-speaking resident said he had not been made aware of activities; the AD stated activities were offered twice daily, but were not based on assessments, and there were no evening or weekend activities or Spanish-speaking activity staff.
Activities Director Lacked Required Qualifications: The facility failed to ensure a qualified AD directed the activities program for two residents. Record review showed the AD did not have the required license, experience, or state-approved training, and interviews confirmed the AD was recently hired, lacked activities experience, and was being supervised by the Administrator with only remote oversight from the Corporate AD.
Incomplete documentation affected a resident with a PEG tube, another resident transferred for chest pain, and a third resident discharged from the facility. Staff did not record PEG placement departure/return details, feeding administration, residuals, or time off the pump; they also failed to document the circumstances of a hospital transfer and key discharge details such as status, who the resident left with, education, and any meds or equipment sent.
The facility failed to maintain EBP for residents with wounds and indwelling devices. A resident with a PEG tube, a resident with an open foot wound and IV antibiotics, a resident with a Foley catheter and toe wound, and a resident with a PICC line all had issues with EBP signs, PPE placement, or gown use during high-contact care. Staff and the IP confirmed that gowns and gloves were expected for close contact tasks such as transfers, showering, wound care, and device care, but residents reported staff often used gloves and masks without gowns.
Resident Grievance Process Not Explained: A resident stated staff did not tell her how to file a grievance for missing items. The Administrator said the grievance process was reviewed in resident council or by the SSD, but the facility did not have an SSD. The AD said she thought she was supposed to file grievances for residents and had not reviewed the grievance process during resident council or with residents individually.
PRN Alprazolam Orders Continued Without Required Provider Rationale: Two residents had PRN alprazolam orders for anxiety/agitation that were written without an end date and without a provider-documented clinical rationale for use beyond 14 days. The DON and RCN confirmed the orders were indefinite and that the medical record lacked the required rationale.
The facility failed to complete effective discharge planning for two residents. For one resident, the record lacked a discharge plan, documented discussions about discharge, and a post-discharge plan of care after the resident insisted on going home and the provider approved discharge. For another resident, staff did not hold the planned IDT meeting, did not document discharge planning in the care plan or medical record, and the family member reported not being told what was needed for a safe discharge home.
A resident reviewed for pressure ulcers did not have a comprehensive admission MDS completed within the required 14-day timeframe after admission. Record review showed the MDS was dated before completion but was not finished within 14 days of admission, and the DON and Regional Clinical Nurse confirmed the delay during interview. Staff were expected to complete admission MDS assessments within 14 days of admission.
A resident was discharged from the facility, but the medical record did not contain a Discharge MDS assessment. The DON and Regional Clinical Nurse confirmed the missing assessment and stated that staff were expected to complete a Discharge MDS after discharge.
A resident’s MDS was inaccurate because insulin use was documented in the insulin section but not in the high-risk drug classes section, even though the resident had an order for daily Lantus for diabetes mellitus. The MDS Coordinator confirmed the omission during interview.
Failure to Monitor Ordered Weights: Two residents at risk for malnutrition had physician-ordered weekly weights for four weeks and then monthly weights, but staff documented only two weights for each resident and did not complete the ordered weekly monitoring. The DON confirmed the weights were not performed as ordered.
A resident with a recent hospital stay for severe AKI and dialysis had visible bilateral leg swelling that was observed by surveyors, while the resident said he did not know what staff were doing for the edema. Nursing notes did not document assessments for several days, an LPN was unaware of the edema until interviewed, and the provider later documented 3+ pitting edema in both legs and ordered furosemide.
Failure to monitor a resident with a PEG tube included missed weekly weights, lack of documentation of enteral feeding administration and water flushes, no recorded total feed volume infused, and missed residual checks. Staff also did not document how long the resident was off the feeding pump each day, and the DON, Dietitian, and Regional Clinical Nurse confirmed the resident had significant weight loss and that ordered monitoring was not completed.
A resident used oxygen when lying down in bed, and an oxygen concentrator was observed next to the bed. The resident’s CCO included PRN oxygen by nasal cannula, and the MDS documented intermittent oxygen use, but the medical record did not contain an oxygen order. The DON and RCN confirmed the resident used oxygen at night and that the oxygen order had not been documented in the chart.
The facility failed to effectively manage pain for two residents by not consistently assessing and documenting pain levels before and after PRN analgesics were given. One resident with a lumbar compression fracture had repeated doses of acetaminophen, ibuprofen, and Percocet documented without numerical pain scores, and the NAR showed no documented pain assessments over an extended period. A second resident with rib fractures had hydrocodone-acetaminophen and acetaminophen given for pain, but staff often omitted pain scores and left long gaps between reassessments. The DON confirmed staff did not assess and document the residents’ pain levels.
A resident with ESRD was receiving dialysis, but the facility had no order for the dialysis treatment and did not consistently complete dialysis communication documentation. The record lacked documentation of how communication with the dialysis provider would occur, who was responsible, and where responses would be recorded, and the DON confirmed there was no post-dialysis communication completed or other documentation of coordination with the dialysis center.
A resident’s oxycodone was not documented after two doses were given, and the controlled substance log showed 50 capsules should have been present while only 48 were found in the medication card. An LPN said she administered the doses before the resident’s appointment but did not document them, and the DON stated the controlled substance log should be current when narcotics are dispensed.
Failure to monitor antibiotic use occurred when staff did not ensure an amoxicillin order for a resident with a tooth infection had an end date. The resident received the antibiotic longer than the typical 7-10 day course, and the DON and RCN confirmed the order should have included a stop date and should have been identified during review of new antibiotic orders.
A resident’s POA informed the ADON at admission that the resident wished to be DNR and stated he had a DNR form in his car, but he did not return with the form. The ADON did not document the POA’s DNR request in the medical record and did not contact the provider to obtain a DNR order, leaving no DNR order on file. When the resident was later found unresponsive, staff called EMS, applied AED pads, and EMS initiated CPR and transported the resident to the hospital. An intake report noted that CPR was initiated against the POA’s DNR wishes, demonstrating a failure to honor the requested code status due to missing documentation and physician orders.
A resident was admitted with an unstageable pressure ulcer documented on the Admission MDS, along with a need for pressure ulcer/injury care, but the baseline care plan created within 48 hours did not include the pressure ulcer or the need for wound care. During interview, the DON confirmed the omission and stated the expectation that nurses care plan wounds and necessary wound care within the first 48 hours of admission.
Surveyors found that two residents with documented unstageable pressure ulcers and identified needs for pressure ulcer care on their admission MDS and Care Area Assessments did not have corresponding pressure ulcer or wound care interventions included in their comprehensive care plans. One resident’s care plan lacked any pressure ulcer component despite multiple unstageable and deep tissue injuries noted on admission, and another resident’s care plan omitted pressure ulcer care until it was added at a later date. The DON acknowledged that the comprehensive care plans for these residents did not address their pressure ulcers or wound care needs, contrary to facility expectations.
Surveyors found that wound care orders for two residents’ buttock wounds were not accurately documented on the Treatment Administration Record (TAR). One resident’s ordered daily wound care was missing documentation on multiple specific days, and another resident’s ordered wound care lacked documentation over an extended period. The Wound Care Nurse reported that she completed the ordered treatments on numerous dates but did not record them on the TAR, sometimes relying on the unit nurse to document instead. This resulted in incomplete and inaccurate medical records related to wound care.
A staff member was employed as an LPN using false credentials and provided care to residents without a valid license. During her employment, she demonstrated significant skill deficiencies, including improper Foley catheter handling, medication errors, incomplete documentation, and required frequent supervision and assistance from other staff. These issues were reported by multiple staff members and confirmed through disciplinary records and interviews.
A resident was subjected to improper medication administration and incomplete care by a staff member who was later found to be working under false credentials. Staff observed and reported concerns about this individual's actions, including leaving medications at the bedside and attempting incorrect IV procedures, but the facility did not report these allegations of neglect to the State Agency as required.
The facility failed to implement a water management program to minimize the risk of Legionella and other pathogens, potentially affecting all 27 residents. Key staff, including the Director of Maintenance and the DON, were unaware of their roles in preventing pathogen growth, contributing to the deficiency.
The facility failed to designate a qualified Infection Preventionist (IP) for its Infection Prevention and Control Program (IPCP). The DON is currently performing IP duties due to the IP's leave related to nursing license issues. This deficiency could affect all 27 residents in the facility.
The facility failed to develop comprehensive care plans for three residents, omitting critical information such as severe vision impairment, activity preferences, and required assistance for ADLs. This lack of documentation could lead to staff being unaware of the residents' needs.
The facility failed to ensure proper IDT participation in care plan meetings and did not update a resident's care plan to reflect a new pressure ulcer. Meetings often lacked key team members, and a resident's care plan was not revised to include a newly developed stage I pressure ulcer, potentially affecting care quality.
The facility failed to secure treatment carts on the East Unit, leaving them unlocked and unsupervised. An IV treatment cart containing sterile needles and catheters was found open, confirmed by an RN to be against protocol. Another cart with medications and scissors was also left unlocked, as confirmed by an LPN.
A fish oil supplement, 1000 mg, was found expired in the medication cart on the East Unit, intended for residents with rheumatoid arthritis. RN #16 confirmed the expiration, and the DON stated that expired medications should not be present and should be checked each shift.
The facility failed to ensure that call light pull cords in resident rooms were accessible, with cords being too short to reach unless residents were in bed. One resident's wife noted her husband was not cognizant enough to use the cord, while another resident had a trash bag tied to the cord to extend its reach. The Maintenance Director confirmed the cords were shortened to prevent tangling, leaving no alternative for residents unable to pull the cord.
The facility failed to provide written notifications to residents and their representatives regarding transfers and discharges, affecting five residents. One resident's POA only received a verbal notice and had to independently seek appeal information. The facility did not issue written transfer notices for hospitalizations due to various medical conditions. Staff confirmed that notifications were made via phone, and the Ombudsman was not informed of discharges or transfers.
The facility failed to provide written bed hold notices to residents or their representatives when transferred to the hospital. This deficiency affected four residents who were hospitalized for various medical conditions, including altered mental status and gastrointestinal bleeding. The Director of Nursing confirmed that staff did not complete the required notices, potentially leaving residents unaware of the bed hold policy.
The facility failed to ensure accurate MDS assessments for four residents, leading to discrepancies in documenting conditions such as pressure ulcers, falls, and MASD. Interviews confirmed these inaccuracies, which could result in inadequate care planning.
The facility failed to document accurate baseline care plans within 48 hours for three residents, leading to potential risks of inadequate care. One resident's wounds and necessary interventions were omitted, another's MASD diagnosis was not documented, and a third resident's dysphagia, PEG tube, and diet orders were not included. The MDS Coordinator confirmed these omissions.
A facility failed to obtain and implement wound care orders for a resident with a Stage II pressure ulcer on the coccyx. Despite the ulcer being present upon admission, there were no wound care orders in place until several days later. Nursing staff did not consult with the facility provider to obtain necessary orders, and the Director of Nursing acknowledged the oversight, which could lead to inconsistent interventions and worsening of the ulcer.
A facility failed to ensure a resident with a condom catheter had a physician's order and a documented clinical condition justifying its use. The resident, who was continent, had a catheter without an order or clinical documentation. The DON confirmed the absence of necessary documentation, contrary to facility expectations.
A facility failed to change a resident's nasal cannula within the required 7-day period, as observed during a survey. The resident's cannula lacked a date indicating when it was last changed, despite a physician's order for continuous oxygen. The DON stated that cannulas are changed weekly, but a CNA could not confirm if the resident's cannula had been changed, potentially affecting the resident's oxygen supply.
A resident was inappropriately administered Remeron, an antidepressant, for muscle weakness, which is not a valid medical diagnosis for its use. The resident's diagnoses included cognitive communication deficit and severe dementia without behavioral disturbances, none of which justified the medication. The DON confirmed the inappropriate prescription, highlighting a failure to ensure medications were medically necessary.
The facility failed to provide appropriate treatment and care for two residents, leading to deficiencies in wound care and skin condition management. One resident did not receive documented wound care for several days after admission, and another resident developed MASD without provider notification or treatment documentation. Staff interviews confirmed lapses in assessing and documenting care, highlighting a failure in the facility's processes for managing residents' conditions.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to create a baseline care plan within 48 hours of admission for 2 of 3 residents reviewed for baseline care plans, R #24 and R #25. The facility policy dated June 2020 stated that a person-centered baseline care plan must be developed for each resident within 48 hours of admission and updated for changes in condition or needs before the comprehensive care plan is developed. R #24 was admitted with diagnoses including acute pyelonephritis, hypothyroidism, and type 2 diabetes mellitus, but the medical record did not document a baseline care plan. R #25 was admitted with urinary tract infection, vascular dementia, and difficulty walking; the record showed a baseline care plan dated 06/09/26, but it was not documented within 48 hours of admission. During interview, the DON confirmed that staff did not document a baseline care plan for R #24 and did not document a baseline care plan for R #25 within 48 hours of admission, and stated that the expectation was for staff to complete a baseline care plan within 48 hours upon admission.
Care plan not updated to reflect independent bathing ability
Penalty
Summary
The facility failed to ensure that R #1’s care plan was revised to reflect the most current resident information within 7 days of the comprehensive assessment and prepared, reviewed, and revised by a team of health professionals. Record review showed that the facility’s Care Planning Policy required a licensed nurse to initiate the care plan and update it as indicated for changes in condition, new problems, resolution of current problems, and as clinically appropriate. R #1 was admitted to the facility with a diagnosis of difficulty in walking not elsewhere classified and was later discharged on 05/28/26. Occupational therapy documentation showed that R #1 was able to bathe or shower independently and transfer in and out of the tub or shower independently. The OT evaluation, OT treatment note, and OT discharge summary all documented this level of function, and the OT confirmed during interview that R #1 did not require assistance to shower or bathe. However, R #1’s care plan, dated 05/15/26, still stated that R #1 required physical assistance of one staff member for bathing/showering. The DON confirmed that the care plan did not reflect R #1’s current bathing and showering ability and should have been revised to accurately reflect independent function.
Failure to Follow Hospital UTI Antibiotic Orders
Penalty
Summary
The facility failed to ensure appropriate treatment for a resident admitted with acute pyelonephritis and a diagnosis of UTI. The resident’s hospital discharge instructions from 04/17/26 directed continuation of Augmentin 500 mg by mouth twice daily for six more days, with an end date of 04/26/26. However, the resident’s April 2026 MAR did not document an order for Augmentin, and instead showed an order dated 04/28/26 for Levaquin 500 mg by mouth one time a day for UTI. The resident’s skilled evaluation progress note dated 04/22/26 documented dark yellow urine, cloudy urine, foul odor, and that a urinalysis was ordered. During interview, the physician stated that if the resident was admitted with orders to continue a medication for UTI from the hospital, it should have been followed on admission, and that staff should call the physician when urinalysis results are received and get the order entered. The DON confirmed that the convalescent order to continue Augmentin was not placed in the system, that the admission nurse should have caught it, that staff were to follow hospital orders unless changed by the doctor, that there was no documentation of contacting the physician to change Augmentin to Levaquin, and that the urine sample was taken on 04/22/26 but orders for Levaquin were not obtained until 04/28/26.
Incomplete wound documentation and missing order for coccyx shear
Penalty
Summary
The facility failed to ensure resident records were complete and accurate for one resident reviewed for pressure ulcers when no physician order or treatment documentation was obtained for a small open shearing area on the resident’s coccyx. The facility’s Wound Management policy required a licensed nurse to assess new wounds, measure them, initiate a wound monitoring record, and implement wound treatment per physician’s order. The resident was admitted with diagnoses including acute pyelonephritis, hypothyroidism, and type 2 diabetes mellitus without complications. Record review showed an admission evaluation documenting a small open shearing area on the coccyx, but the physician orders contained no order for the area and the treatment record contained no wound care treatments. The 5-day MDS assessment also did not document the small open shearing area. During interview, the Wound Care Nurse stated the resident had shear and blanching tissue on the coccyx and had only barrier cream, which was not ordered, and that the resident should have had an order for treatment. The DON confirmed there was a small shearing area on admission and that the admission nurse did not obtain orders for it.
Missing EBP Training for Nursing Staff
Penalty
Summary
The facility failed to provide infection control training for 4 of 4 staff sampled for enhanced barrier precautions, including LPN #1, LPN #2, LPN #3, and CNA #1. Record review showed no documentation of EBP training for any of these staff members. During an interview on 05/05/26 at 3:25 PM, the Regional Clinical Nurse stated that they did not have access to the training curriculum for these staff and could not determine that they had received EBP training. The deficiency was identified in relation to the facility’s infection prevention and control program, which includes mandatory training with written standards, policies, and procedures.
Incomplete Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement accurate, person-centered comprehensive care plans for 8 residents reviewed for comprehensive care plans. Record review and staff interviews showed that multiple resident care plans did not reflect current diagnoses, treatments, preferences, or ordered interventions that were documented elsewhere in the medical record. For one resident, physician orders and the admission MDS showed use of high-risk medications, including anticoagulant therapy with Lovenox and opioid pain medication with hydrocodone-acetaminophen, but the care plan did not document either medication. For another resident, the record showed an order for Lantus insulin for diabetes mellitus and the resident stated a plan to go home with home health services, but the care plan did not document insulin use or the discharge plan. The DON confirmed both omissions. Additional records showed a resident admitted with pressure ulcers on the bilateral buttocks and orders for wound care and later zinc barrier cream, but the care plan did not identify the wounds or interventions to treat or prevent worsening. Another resident had an order for enhanced barrier precautions and stated staff had not discussed discharge planning, yet the care plan did not include the discharge plan or EBP interventions. A resident’s admission MDS identified activity preferences such as reading, music, animals, news, group activities, favorite activities, going outside, and religious services, but the care plan did not include those preferences or the ordered weekly weights. Another resident had repeated documentation of bilateral lower extremity edema and refused to elevate his legs, but the care plan did not include the edema or the refusal. One resident used oxygen intermittently and at night, but the care plan did not document oxygen use or related interventions. Another resident went to dialysis, but the care plan did not document where or how often dialysis was received.
Missing discharge, transfer, and bed-hold documentation
Penalty
Summary
The facility failed to provide required discharge or transfer documentation for three residents who were discharged or transferred to the hospital. For one resident, the transfer form documented chest pain radiating to the left arm, but the form did not include appeal rights information or the name and contact information for the Office of the State Long-Term Care Ombudsman. The medical record also did not document a Bed Hold Notification for that hospital transfer. The DON confirmed that staff did not document a transfer notification with appeal rights or Ombudsman contact information and did not document a Bed Hold Notification when the resident was transferred. For another resident, the medical record did not contain a discharge notice, a discharge summary, a recapitulation of stay, a final summary of status, medication reconciliation, home health contact information, DME orders, medications provided at discharge, or follow-up appointments. The DON confirmed that staff did not provide a discharge notice and did not document a discharge summary with the required elements before discharge. The record also did not show that a home health agency was contacted or that any DME was ordered. For the third resident, the medical record did not contain a discharge notice or discharge summary, and it did not document when the resident left the facility, who the resident left with, the information provided to the resident or family, the resident’s status at discharge, a recapitulation of stay, home health contact, DME orders, medications provided, or follow-up appointments. The DON confirmed the resident discharged from the facility, that home health was contacted after discharge, and that staff did not document this information in the medical record. The DON also stated that staff did not complete a discharge notice or discharge summary and that she did not send copies of discharge or transfer notices to the Ombudsman, although she did email a weekly list of discharged or transferred residents.
Missing Baseline Care Plans After Admission
Penalty
Summary
The facility failed to create an accurate baseline care plan within 48 hours of admission for 5 of 5 residents reviewed: R #20, R #38, R #46, R #47, and R #49. Record review showed each resident had an admission record documenting admission to the facility, but the medical record did not contain a baseline care plan completed within the required 48-hour timeframe after admission. During interviews, the DON confirmed the missing baseline care plans for each resident. For R #20, R #38, R #46, R #47, and R #49, the DON stated that staff should have completed a baseline care plan within 48 hours of admission and acknowledged that this was not done.
Failure to Hold Timely IDT Meetings and Update Care Plan for PEG Tube/EBP
Penalty
Summary
The facility failed to ensure care plan revisions occurred for 3 of 9 residents reviewed for care plan accuracy, and failed to ensure the interdisciplinary team participated in care plan meetings within 7 days of completion of the admission MDS assessment for three residents. For one resident, the admission MDS was completed on 03/25/26, but no IDT meeting was documented, and the resident stated she had not attended a meeting to discuss her care plan. For another resident, the admission MDS was completed on 04/14/26, but staff did not document an IDT meeting and the resident stated he had not attended one. For a third resident, the admission MDS was completed on 04/21/26, but staff did not document an IDT meeting and the resident's family member stated he had not attended a meeting to discuss the care plan. The DON and Regional Clinical Nurse confirmed that IDT meetings were not conducted for these residents and that staff were expected to hold them within 7 days of completion of the admission MDS. The facility also failed to revise one resident's care plan with current information after a PEG tube was placed. Provider notes documented that the resident had a PEG tube appointment and later had a PEG tube in place, and a physician order was written for Enhanced Barrier Precautions related to the PEG tube. However, the resident's care plan, revised on 04/29/26, did not include that staff were expected to follow EBP when providing high-contact care after the PEG tube was placed. The DON confirmed the resident had a PEG tube while in the facility, should have been on EBP after returning with the PEG tube, and that the care plan did not document the need for EBP during high-contact care.
Delayed Documentation of Resident Code Status
Penalty
Summary
The facility failed to ensure there was a system in place for nursing staff to immediately determine code status for 3 of 3 residents reviewed for code status. For each of the three residents, the record showed that full code status was documented in the Convalescent Care Orders, but that status was not entered into the medical record at the time of admission. The deficiency involved residents who were admitted to the facility and whose code status was not immediately documented in the medical record. For one resident, the full code status was not documented until four days after admission. For a second resident, the full code status was not documented until two days after admission. For the third resident, the full code status order was not entered into the medical record until two days after admission. During interviews, the DON confirmed that the residents' code status was documented in the CCOs but was not documented in the medical record upon admission, and stated that code status should be verified upon admission and documented in the medical record.
Activities Program Did Not Reflect Resident Preferences
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests of 2 residents reviewed for activities by not providing meaningful individualized activities based on their stated preferences. One resident stated there were not any activities she was interested in and reported there were no church services at all. Her annual MDS assessment identified activity preferences as very important, including having books, newspapers, and magazines; having music; being around animals; keeping up with the news; doing things with groups of people; doing favorite activities; going outside for fresh air; and participating in religious services. Her care plan did not include these personal preferences from the annual MDS assessment. A second resident, who is Spanish speaking only, stated he had not been made aware of activities in the facility. During interview, the AD stated activities were offered at 9:30 AM and 2:00 PM, including daily chronicles with puzzles and coloring pages, crafts, going outside, and BINGO, and that the chronicles were printed in Spanish. The AD also stated a church group visited once a month, themed activities were based on current events, activities were not planned based on assessments, and there were no evening or weekend activities. The AD stated she did not speak Spanish and there were no activity staff who spoke Spanish.
Activities Director Lacked Required Qualifications
Penalty
Summary
The facility failed to have a qualified activity professional direct an ongoing program of activities for 2 sampled residents, identified in the report as R31 and R59, because staff did not ensure the Activities Director had the qualifications required to perform the duties of that position. Record review of the AD personnel file showed a hire date of 11/06/25, and the resume did not include a license or registration as a therapeutic recreation specialist or eligibility for such licensure, two years of experience in a social or recreational program within the last five years, qualifications as an occupational therapist or occupational therapy assistant, or completion of a state-approved training course for activities professionals. The AD job description dated December 2023 listed qualifications including accreditation as a Certified AD, completion of a state-approved AD training course, a bachelor's degree in recreation therapy or a related area with licensure or registration, one year of experience as an AD in LTC, and two years of experience conducting social or recreational programs within the past five years. During interview, the Administrator stated the AD was recently hired and did not have a license or experience in activities, and that the AD was scheduled to attend a 40-hour AD course in July 2026. The Administrator also stated the AD was supervised by the Administrator and that the Corporate AD oversaw the AD's work at the facility. The Corporate AD stated she had recently started with the company, was mostly a consultant for the AD, and had never been to the facility.
Incomplete Documentation of PEG Feedings, Hospital Transfer, and Discharge
Penalty
Summary
Medical records were incomplete and inaccurate for a resident who had a PEG tube inserted and began enteral feedings after returning from the hospital. The record did not document when the resident left the facility for the PEG placement, when she returned, or an assessment of her status after the procedure. Orders required staff to hold tube feedings for resident care and activities, document how long feedings were held, document total enteral feed volume every 24 hours, and check and document residual volume before medication administration, but these entries were not consistently recorded. Observation and interview showed the resident was frequently disconnected from the feeding pump during the day, including times when she was in the common area or eating breakfast, and at other times was connected to the pump in bed. Staff did not document enteral feeding administration and water flushes for multiple shifts across several days, did not document total enteral feed volume infused, and did not document residual volumes on several dates. An LPN confirmed she disconnected the resident in the morning and reconnected her after lunch, but did not document how long the resident was off the pump, the amount of feed received, or the residual volume checked before reconnecting. The facility also failed to document the circumstances surrounding another resident’s transfer to the hospital for chest pain radiating to the left arm, including the situation leading to the transfer, who was contacted, and who was notified. In addition, the record for a third resident discharged from the facility did not document the time of discharge, the resident’s status at discharge, who the resident left with, what education was provided, or whether any medications or equipment were sent with the resident. The DON confirmed these items were expected to be documented but were not found in the medical record.
Failure to Maintain EBP and PPE for Residents with Wounds and Indwelling Devices
Penalty
Summary
The facility failed to maintain an infection prevention and control program for residents on Transmission Based Precautions, specifically Enhanced Barrier Precautions (EBP), when staff did not consistently use gowns and gloves during high-contact care and did not keep PPE available outside affected residents’ rooms. The report identified 4 of 5 reviewed residents with EBP-related concerns: residents with a PEG tube, an open wound, a Foley catheter and wound dressing, and a PICC line for IV antibiotics. The Infection Preventionist confirmed that residents with wounds, Foley catheters, or PICC lines should have an EBP sign and PPE outside the room and that staff were expected to wear a gown and gloves for close contact care such as transferring, showering, wound care, and handling indwelling devices. For one resident with a PEG tube, an EBP order was in place, an EBP sign was posted, and PPE was located about 8 feet away from the room rather than outside the door. The resident stated staff did not wear a gown when transferring her to a wheelchair, showering her, or connecting enteral feedings to the feeding tube. For another resident with an open wound to the right foot and IV daptomycin for osteomyelitis, an EBP sign was posted near the room, but PPE was not observed outside the room. The resident stated staff wore gloves when administering IV antibiotics and during wound care, but did not wear gowns. A third resident had a Foley catheter draining reddish urine and a wound dressing to the left great toe, but no EBP order was documented and no sign or PPE was set up outside the room. A fourth resident had a PICC line for IV antibiotics due to a foot infection, but no EBP sign or PPE was observed outside the room at the time of one observation. The resident stated staff did not wear a gown when administering antibiotics through the PICC line or changing the catheter. During another observation, the ADON entered and exited the room wearing a mask and gloves but not a gown, and the resident confirmed the ADON changed the PICC dressing without wearing a gown. The report also noted that the resident’s nasal cannula was not dated, and the ADON could not determine when it had last been changed.
Resident Grievance Process Not Explained
Penalty
Summary
The facility failed to ensure that residents were aware of the process to file a grievance for one resident sampled for missing items. During an interview on 04/29/26, the resident stated that staff did not tell her how to file a grievance. During an interview on 05/01/26, the Administrator stated the grievance process is reviewed during resident council meetings, and if residents do not attend resident council, the SSD would go over how to file a grievance with them; however, the Administrator also stated the facility did not currently have an SSD. The Administrator further stated that if a resident reported missing items, he would talk to the resident and file a grievance for them. During a separate interview on 05/01/26, the AD stated she thought she was supposed to file grievances for residents, that she would tell a resident she would file a grievance if they reported a missing item, and that she had not gone over how to file a grievance during resident council or with residents individually.
PRN Alprazolam Orders Continued Without Required Provider Rationale
Penalty
Summary
The facility failed to ensure that two residents did not receive PRN psychotropic medications unless the medications were medically necessary, because PRN alprazolam orders were written without an end date and without a documented clinical rationale for use beyond 14 days. For one resident, the physician's order dated 04/27/26 included alprazolam 1 mg every 8 hours PRN for anxiety/agitation, and the record did not contain a provider rationale for continuing the PRN medication longer than 14 days. For the second resident, the physician's order dated 04/22/26 included alprazolam 0.25 mg PRN every 24 hours at bedtime for anxiety, also without an end date and without a documented rationale for extended PRN use. During interviews on 05/04/26 and 05/05/26, the DON and Regional Clinical Nurse confirmed that both residents had PRN alprazolam orders that were ordered indefinitely and that the medical record did not include a provider rationale for use beyond 14 days. The record review showed that the facility had five residents reviewed for unnecessary medications, and the deficiency was identified for two of those residents.
Failure to Complete Discharge Planning for Two Residents
Penalty
Summary
The facility failed to implement an effective discharge planning process for 2 residents, R #40 and R #57, by not conducting IDT discharge planning, not updating comprehensive care plans and discharge plans with treatment preferences and needs, and, for R #57, not documenting a discharge plan of care that included treatment preferences and needs. For R #40, the record showed the resident was admitted to the facility and later discharged after the resident was insistent on going home and the provider approved the discharge. However, the care plan did not document a discharge plan, and the medical record did not include discharge plans, conversations with the resident about discharge, or a post-discharge plan of care. The DON confirmed staff did not have R #40's discharge plan and did not conduct an IDT meeting to plan for discharge. For R #57, the record showed the resident was admitted to the facility and later discharged after family discussions about insurance coverage and payment. The resident's family member stated staff had asked him to come for a meeting about care, but no staff were available when he arrived, and later he was told the resident's insurance would not cover care after a certain point unless he paid privately. He also stated staff had not met with him to discuss discharge plans or what was needed for a safe discharge home. The care plan did not document a discharge plan, and the medical record did not include discharge plans, conversations with the resident or family about discharge, or a post-discharge plan of care. The DON confirmed an IDT meeting did not take place to discuss discharge and that staff were expected to document discharge plans in the resident's care plan.
Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to ensure a comprehensive MDS assessment was completed within 14 calendar days after admission for one resident who was reviewed for pressure ulcers. Record review showed the resident was admitted to the facility on an unspecified date, and the admission MDS assessment was dated 03/31/26 but completed on 04/14/26, which was not within 14 days of admission. During a joint interview on 05/04/26 at 2:48 PM, the DON and Regional Clinical Nurse confirmed that the resident's admission MDS assessment was not completed within 14 days of admission. Staff were expected to complete admission MDS assessments within 14 days of admission.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a Discharge MDS assessment for one resident after the resident was discharged from the facility. Record review showed the resident was admitted on an unspecified date and discharged on 12/06/25, but the medical record did not contain a Discharge MDS Assessment after the discharge. During a joint interview on 05/04/26 at 2:55 PM, the DON and Regional Clinical Nurse confirmed that the resident had been discharged on 12/06/25, that the medical record did not include a Discharge MDS Assessment, and that staff were expected to complete a Discharge MDS Assessment after residents were discharged.
Inaccurate MDS Documentation for Insulin Use
Penalty
Summary
The facility failed to ensure the MDS was accurate for one resident reviewed for accurate MDS assessments. Record review showed the resident was admitted to the facility and had a physician order for Lantus 15 units subcutaneously once daily for diabetes mellitus. The admission MDS, dated [DATE], documented that the resident received insulin for the previous two days since admission under the insulin section, but staff did not document that the resident was receiving insulin in the high-risk drug classes section. During an interview on 05/05/26 at 4:26 PM, the MDS Coordinator confirmed that the resident was receiving insulin and that it should have been documented in the high-risk drug section of the MDS.
Failure to Monitor Ordered Weights
Penalty
Summary
The facility failed to provide services that met professional standards of practice for 2 residents who were both identified as being at risk for malnutrition. For one resident, the physician ordered weekly weights for four weeks and then monthly weights, but the weight summary showed only two documented weights, and no other weights were recorded. For the second resident, the physician also ordered weekly weights for four weeks and then monthly weights, but the weight summary showed only two documented weights, with no additional weights documented. During interviews on 05/04/26, the DON confirmed that staff did not perform the weekly weights for either resident and stated that her expectation was that both residents would be weighed as ordered.
Failure to Assess and Document Bilateral Leg Edema
Penalty
Summary
The facility failed to ensure appropriate treatment and care were provided for a resident with bilateral leg edema. The resident was admitted after a hospital stay that included severe acute kidney injury and three dialysis treatments. During observations on 04/29/26 and 05/01/26, the resident’s legs were noted to appear swollen, and the resident stated the swelling had been present since the hospital stay and that he did not know what staff were doing for the edema. Record review showed the admission assessment dated 04/27/26 documented no edema, and nursing progress notes did not include an assessment of the resident between 04/28/26 and 05/01/26. On 05/01/26, the provider documented 3+ pitting edema in both legs and ordered furosemide 20 mg daily for edema. During interview, an LPN confirmed she had not been aware of the edema, assessed the resident, and found 3+ pitting edema in the left leg and closer to 4+ pitting edema in the right leg and foot. The DON confirmed nursing staff had not documented assessments during that period and that staff were expected to complete and document a daily head-to-toe assessment.
Failure to Monitor PEG Tube Feedings and Weights
Penalty
Summary
Failure to provide enough food and fluids to maintain nutritional status occurred for a resident with a PEG tube who was admitted to the facility on [DATE] and later had tube feeding orders entered after hospital discharge. The resident stated that staff administered feedings through the PEG tube twice a day and that she was unsure how long she was supposed to remain connected to the feeding pump each day. Hospital discharge documents showed the PEG tube was inserted on 04/21/26 and could be used for feeding and medications that same day. Physician orders required continuous enteral feedings and water flushes for 20 hours a day, documentation of the total enteral feed volume infused every 24 hours, documentation of residual volume before medication administration, and weekly weights for 4 weeks and monthly thereafter. Record review showed the resident’s weight decreased from 131 pounds on 03/15/26 to 114.5 pounds on 04/05/26 and 113 pounds on 04/19/26. Staff did not weigh the resident as ordered on multiple dates, including entries marked as hold, other, or not administered, and progress notes showed weight pending or no documentation. Staff also did not document the resident’s total time off the feeding pump daily as ordered. After PEG placement, staff did not document enteral feeding administration and water flushes on multiple dates and times between 04/23/26 and 04/30/26, did not document total enteral feed volume infused during that period, and did not document residual volume checks on several dates. During interview, the DON, Dietitian, and Regional Clinical Nurse confirmed the resident had lost 16.5 pounds between admission and 04/05/26, that staff did not weigh the resident upon admission or weekly as ordered, and that staff did not document enteral feeding administration, volumes, residuals, or time off the pump as expected.
Missing Oxygen Order for Resident Using Oxygen at Night
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for one resident. R #54 was admitted to the facility and, during observation, an oxygen concentrator was found sitting next to the resident’s bed. The resident stated she used oxygen when she lay down in bed. The resident’s Convalescent Care Orders dated 04/15/26 included an order for oxygen by nasal cannula PRN, and the admission MDS dated 04/24/26 documented that the resident used oxygen intermittently. However, the medical record did not contain an order for the resident to use oxygen. During interview, the DON and RCN confirmed that the resident used oxygen at night, that staff did not document an oxygen order in the medical record, that the resident had a CCO for PRN oxygen use, and that staff were expected to document CCOs for oxygen use in the medical record when a resident arrived.
Inconsistent pain assessment and documentation for two residents
Penalty
Summary
The facility failed to effectively manage pain for 2 residents by not consistently assessing and documenting pain levels before and after administration of ordered pain medications. For one resident with a wedge compression fracture of the third lumbar vertebra, the record showed repeated administration of acetaminophen, ibuprofen, and Percocet, but nursing documentation often did not include a numerical pain score at the time the medication was given or when its effectiveness was later recorded. The resident stated during interview that she had severe pain, including reporting pain as 50 on a zero to ten scale on one occasion and 100 on a zero to ten scale on another occasion. For that same resident, the Nurse Administration Record for April 2026 showed no documented numerical pain assessments between 04/21/26 and 04/30/26. Progress notes reflected multiple doses of ibuprofen and Percocet given for back pain, but the entries frequently omitted the resident’s pain level. The Percocet order was later discontinued, and during interview the resident stated she was not aware of the discontinuation because no one had discussed it with her. For the second resident, who had multiple rib fractures, the record showed repeated administration of hydrocodone-acetaminophen and acetaminophen for rib pain, but pain assessments were inconsistently documented. Some entries included pain scores such as 9, 8, 10, 6, 5, and 8, while other medication administrations and effectiveness notes did not include a pain level. The record also showed gaps of over 4 hours, over 5 hours, over 7 hours, over 9 hours, and over 11 hours without reassessment of pain after medication administration. The DON later confirmed that staff did not assess and document the residents’ pain levels and that the numerical pain level should be documented to determine whether pain is adequately managed.
Failure to Coordinate Dialysis Care
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care and services for a resident with end stage renal disease. The resident was admitted with a diagnosis of end stage renal disease and was observed leaving for a dialysis appointment during an interview. Review of the physician orders showed there was no order for the resident’s dialysis treatment. Record review of the dialysis communication sheet showed the facility completed pre-dialysis information on one occasion, but the form did not include post-dialysis information, monitoring, or assessments. On other dialysis dates, the facility did not complete the dialysis communication sheet. The resident’s medical record also did not document how communication with the dialysis provider would occur, who was responsible for communicating, or where communication and responses would be documented. The DON confirmed there was no dialysis order, the post-dialysis communication was not completed, and there was no other documentation of communication, coordination, or collaboration between the facility and the dialysis provider.
Controlled Substance Log Not Updated for Resident Oxycodone
Penalty
Summary
The facility failed to ensure drug records were in order and that all controlled drugs were accounted for for one resident, R #54, when staff did not document dispensed narcotics. R #54 was admitted to the facility on an unspecified date and had a physician order dated 04/22/26 for oxycodone 5 mg, one tablet every 4 hours for pain. During observation on 05/04/26 at 2:32 PM, the controlled substance log for oxycodone 5 mg showed 50 capsules should have been present, but only 48 capsules were in the medication card. During interview, an LPN stated she had given R #54 two doses of oxycodone 5 mg before the resident’s 1:06 PM appointment and said she got busy and did not document that she had administered the medication. The DON stated the controlled substance log should be updated and current at the time narcotics are dispensed.
Failure to Set an End Date for Antibiotic Therapy
Penalty
Summary
Implementing a program that monitors antibiotic use failed when staff did not ensure comprehensive antibiotic stewardship practices were followed for one resident reviewed for antibiotic use. Record review showed an order dated 04/14/26 for amoxicillin 500 mg by mouth three times daily for a tooth infection, with the end date entered as indefinite and no stop date documented. The medication was later discontinued on 04/30/26, and the MAR showed the resident received amoxicillin from 04/14/26 through 04/30/26. Review of the resident’s April 2026 progress notes found no documentation determining the need for the resident to remain on amoxicillin indefinitely. During interview on 05/05/26, the DON and Regional Clinical Nurse confirmed the antibiotic was given longer than the typical standard order of 7-10 days, should have had an end date, and that staff reviewing new antibiotic orders should have identified the need for an end date.
Failure to Honor POA-Requested DNR Due to Lack of Documentation and Orders
Penalty
Summary
The deficiency involves the facility’s failure to have a functional system to ensure staff could correctly initiate or withhold CPR in accordance with a resident’s code status and the POA’s expressed wishes. During admission, the ADON documented that the resident had a POA and that the POA stated the resident wished to be DNR, and the POA reported having a DNR form in his car but did not return with it. The ADON did not document the POA’s DNR request in the medical record and did not contact the provider to obtain a DNR order, resulting in the absence of any DNR order in the physician’s orders or medical record. The DON later confirmed that the admitting nurse should have contacted the physician and that staff should have entered the DNR status in the medical record. Subsequently, staff went to check on the resident and found her unresponsive. EMS was called, AED pads were applied with no shock advised, and EMS initiated CPR and transported the resident to the hospital. An intake report documented that CPR was initiated against the POA’s DNR wishes. Because the resident’s DNR request, as communicated by the POA, was never documented or converted into a physician’s order, staff and EMS proceeded with CPR as if the resident were Full Code, contrary to the POA’s expressed wishes.
Failure to Accurately Care Plan Admission Pressure Ulcer Within 48 Hours
Penalty
Summary
The facility failed to develop an accurate baseline care plan within 48 hours of admission for one resident, resulting in omission of critical wound information. Record review showed the resident was admitted on an unspecified date, and the Admission MDS documented that the resident had one unstageable pressure ulcer present on admission and required pressure ulcer/injury care. However, review of the resident’s baseline care plan, dated 02/19/26, revealed that staff did not document the presence of the pressure ulcer or the need for wound care. In an interview on 02/20/26 at 1:31 PM, the DON confirmed that the resident’s care plan did not indicate the pressure ulcer or wound care needs and stated that her expectation was for nurses to care plan wounds and necessary wound care within the first 48 hours of admission. This deficient practice could likely result in residents not receiving appropriate care and may place residents at risk of an adverse event or worsening of their condition after admission.
Failure to Develop Comprehensive Care Plans for Residents With Pressure Ulcers
Penalty
Summary
Surveyors identified a deficiency in the development and implementation of accurate, person-centered comprehensive care plans related to pressure ulcers for two residents. For one resident, the admission MDS dated 01/15/26 documented one unstageable pressure ulcer present on admission and two additional unstageable pressure injuries presenting as deep tissue injuries, also present on admission. The Care Area Assessment dated 01/21/26 indicated a need for pressure ulcer care. However, review of this resident’s care plan dated 01/16/26 showed that no care plan addressing pressure ulcers or the need for wound care had been developed. For the second resident, the admission MDS documented one unstageable pressure ulcer present on admission, and the Care Area Assessment dated 01/06/26 indicated a need for pressure ulcer care. The resident’s care plan, initiated on 12/28/25, did not include a care plan for pressure ulcers at that time; a pressure ulcer care plan was not added until 02/20/26. During an interview on 02/20/26 at 1:33 PM, the DON confirmed that comprehensive care plans for both residents did not include plans for their pressure ulcers and the need for wound care, despite the facility’s expectation that staff complete comprehensive care plans to include pressure ulcers and wound care needs.
Incomplete and Inaccurate Wound Care Documentation on TAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records related to wound care treatments for two residents. For one resident with a physician’s order dated 01/15/26 for daily wound care to the right buttock using normal saline, Medihoney, calcium alginate gauze, and a silicone bordered dressing, the Treatment Administration Record (TAR) for January 2026 showed no documentation that wound care was completed on 01/19/26, 01/21/26, and 01/23/26. For another resident with a physician’s order dated 01/01/26 for wound care to bilateral buttocks, including cleansing with normal saline, application of Sureprep to surrounding tissue, Medihoney to the wound bed, and coverage with a sacral silicone bandage, the January 2026 TAR contained no documentation of wound care from 01/02/26 through 01/23/26. During an interview on 02/20/26, the Wound Care Nurse stated she worked Monday through Friday and completed all wound care on those days. She reported that she did perform wound care for the first resident on 01/19/26, 01/21/26, and 01/23/26 but did not document these treatments on the TAR. She also stated she completed wound care for the second resident on 01/01/26, 01/02/26, 01/05/26 through 01/09/26, 01/12/26 through 01/16/26, and 01/19/26 through 01/23/26, but again did not document these treatments on the TAR. The Wound Care Nurse indicated that sometimes the unit nurse documented completion of wound care on the TAR, and acknowledged she should ensure that either she or the unit nurse documented the wound care as completed. The survey findings state that this failure to accurately document wound care had the potential to negatively impact the care staff provide due to inaccurate records.
Unlicensed Staff Member Provided Nursing Care and Demonstrated Incompetence
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and valid credentials to provide nursing services to all residents. An individual, identified as SM #1, was employed and worked as an LPN without holding a valid license, using false credentials that initially passed through the facility's background and license verification systems. During her employment, SM #1 demonstrated significant lapses in nursing skills, including improper handling of a resident's Foley catheter, which caused the resident pain, and multiple instances of incomplete documentation and medication errors. Staff interviews and disciplinary records revealed that SM #1 required extended orientation and frequent supervision due to her inability to complete competencies and perform basic nursing tasks independently. Further review showed that SM #1 was involved in several incidents, such as presenting a resident with unrecognized medications, attempting blood sugar checks on a non-diabetic resident, and being perceived as unskilled in IV administration. Other staff members reported that SM #1 often failed to perform her duties, required assistance from other nurses, and was frequently inattentive to resident care. Documentation issues, improper medication handling, and incomplete assessments were noted during her tenure. Staff expressed concerns about her proficiency and reported these issues to supervisors. The facility's investigation confirmed that SM #1 had worked for several months under false pretenses, and her lack of skills and credentials directly impacted the care provided to residents. The facility only discovered the falsification after multiple disciplinary actions and an incident involving improper Foley catheter care. SM #1 resigned when confronted with the investigation and refused to cooperate further.
Failure to Report Alleged Neglect and Medication Errors
Penalty
Summary
The facility failed to report allegations of neglect involving a resident who was affected by improper medication administration and incomplete care by a staff member who was later found to be working under false credentials. Specifically, the staff member left medications at the resident's bedside, administered medications that were not recognized by the resident, and attempted to perform procedures such as IV administration incorrectly. Documentation and required assessments for the resident were also incomplete, and concerns about the staff member's competence and actions were raised by both nursing and CNA staff to supervisors. Despite these incidents and staff concerns, the facility did not report the allegations of neglect to the State Agency as required. The Director of Nursing confirmed during an interview that the allegations related to the staff member's neglectful actions were not reported. The resident involved was receiving intravenous antibiotics and had incomplete admission and discharge documentation during their stay.
Failure to Implement Water Management Program for Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically lacking a water management program to minimize the risk of Legionella and other opportunistic pathogens in the building's water system. This deficiency could potentially affect all 27 residents living in the facility. The facility's Water Management Policy, revised in September 2024, outlined the need for a Water Management Plan overseen by a team including center leadership, infection preventionist, maintenance employees, safety officers, risk and quality management staff, and the Director of Nursing. However, interviews revealed that key personnel, including the Director of Maintenance and the Director of Nursing, were not aware of or involved in any activities or meetings related to water management and the prevention of Legionella growth. The Director of Maintenance, who has been in the position since October 2023, stated he was unaware of any responsibilities related to preventing the growth of Legionella or other waterborne pathogens, as these tasks were previously handled by an administrator who left in mid-2024. The Director of Nursing also confirmed a lack of involvement in meetings or actions regarding waterborne pathogen management. The current Administrator acknowledged that the Director of Maintenance should have a diagram of the water system and be aware of potential growth areas for pathogens, but he was not aware of the Water Management Plan team or involved in any related meetings. This lack of awareness and involvement among key staff members contributed to the facility's failure to implement an effective infection control program.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified, trained, or certified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program (IPCP). This deficiency was identified during an interview and record review. The Director of Nursing (DON) revealed that the current IP had issues with her nursing license and has been on leave since January 10, 2025, due to these issues. Consequently, the DON has been performing the IP duties and is working towards obtaining her IP certification. A review of the former IP's time sheet confirmed that she last worked at the facility on January 10, 2025. This failure could potentially affect all 27 residents in the facility, as identified by the resident matrix provided by the Administrator.
Deficient Care Planning for Residents
Penalty
Summary
The facility failed to develop accurate, person-centered comprehensive care plans for three residents, which could result in staff being unaware of the residents' current and actual needs. For one resident, the care plan did not document the severe vision impairment and how staff would assist the resident, despite the admission record and Minimum Data Set (MDS) assessment indicating a severe vision impairment. Another resident's care plan failed to include their activity preferences, which were identified as very important during the MDS assessment interview. Additionally, the care plan for a third resident did not document the resident's functional level and the assistance needed to complete Activities of Daily Living (ADLs), even though the MDS assessment detailed substantial or maximal assistance required for various ADLs. The MDS Coordinator confirmed that the care plan should have included the resident's functional abilities, highlighting a gap in documentation and care planning.
Inadequate IDT Participation and Care Plan Updates
Penalty
Summary
The facility failed to meet care plan requirements for several residents due to inadequate participation of the Interdisciplinary Team (IDT) and failure to update care plans with current resident information. For one resident, the care plan meeting was attended only by the resident and a social services worker, lacking input from other essential team members. Another resident's care plan meeting included the dietary manager, family member, nurse navigator, social services staff, rehabilitation staff, and recreation staff, but no further meetings were held to ensure ongoing interdisciplinary input. Similarly, another resident's care plan meetings were inconsistently attended by necessary team members, with some meetings missing key participants such as the CNA and providers. Additionally, the facility did not revise a resident's care plan to reflect a new medical condition. The resident developed a stage I pressure ulcer on the right heel, which was documented in the nursing progress notes but not updated in the care plan. This oversight indicates a failure to ensure that the care plan accurately reflected the resident's current health status and necessary interventions, potentially impacting the quality of care provided.
Unlocked Treatment Carts Pose Safety Risk
Penalty
Summary
The facility failed to ensure the safety of residents on the East Unit by not securing treatment carts when not supervised by staff. During an observation, an IV treatment cart was found unlocked and open, containing sterile needles and intravenous catheters, with no staff present. This was confirmed by an RN who acknowledged that the cart should be locked when not in sight or control. Additionally, another treatment cart was observed unlocked and open, containing medications such as diclofenac, bacitracin, nystatin, mupirocin, silvasorb, and scissors, again with no staff present. An LPN confirmed that this cart was also supposed to be locked.
Expired Medication Found in Medication Cart
Penalty
Summary
The facility failed to properly store medications, as observed on the East Unit's medication cart, where a fish oil supplement, 1000 mg, was found to be expired since December 2024. This medication was intended to help reduce pain, improve morning stiffness, and relieve joint tenderness in people with rheumatoid arthritis. During an interview, RN #16 confirmed the expiration of the fish oil supplement and acknowledged that it should not have been present in the medication cart. Additionally, the Director of Nursing (DON) confirmed that expired medications should not be in the medication carts and that nurses are responsible for checking for expired medications during each shift.
Inadequate Call Light System in Resident Rooms
Penalty
Summary
The facility failed to ensure that the call light pull cords in residents' rooms were adequately equipped to allow residents to call for help. This deficiency was observed in the rooms of three residents, where the pull cords were not reachable unless the residents were in bed. One resident's wife reported that her husband was not cognizant enough to pull the cord, leaving him without an option to call for help. Another resident had a trash bag tied to the end of the call light cord, which was too short for him to reach, and he was unsure why the bag was there, except possibly to make the cord longer. A third resident was observed to be unable to reach the call light from his bed, and the Maintenance Director confirmed that the pull cords could not be reached if residents were not in bed. The Maintenance Director explained that the cords were shortened to prevent tangling, and there was no alternative method for residents who were not cognizant enough to pull the cord. The director also confirmed that the facility did not have a way to modify the pull cords for such residents, and some cords had bags tied to them to make them easier to grip. This practice could likely result in residents being unable to call for assistance when needed.
Failure to Provide Written Transfer and Discharge Notices
Penalty
Summary
The facility failed to provide timely written notifications to residents and their representatives regarding transfers and discharges, as well as information on appeal rights and contact details for the Ombudsman. Specifically, five residents were affected by this deficiency. For one resident, the Power of Attorney (POA) only received a verbal notice of discharge and was not informed in writing about the discharge plan, appeal rights, or Ombudsman contact information. The POA had to independently seek out information to appeal the discharge, as the facility did not provide the necessary details. Additionally, the facility did not issue written transfer notices for residents who were sent to the hospital. In several cases, residents were transferred due to medical conditions such as altered mental status, gastrointestinal bleeding, low blood pressure, and elevated white blood cell count. The records for these transfers lacked documentation of written notices, and the facility's staff confirmed that they did not provide such notices to residents or their representatives. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed that the facility's practice was to notify families of hospital transfers via phone, without providing written documentation. Furthermore, the Social Services department did not notify the Ombudsman of resident discharges or transfers, which is a required procedure. This lack of proper notification could lead to residents and their representatives being uninformed about their rights and the reasons for transfers or discharges.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide written notices of the bed hold policy to residents or their representatives when residents were transferred to the hospital. This deficiency was identified for four residents who were reviewed for hospitalization. Specifically, the medical records of these residents did not contain any documentation of a written bed hold notice, which is required to inform residents or their representatives of how long their bed would be held during their absence. The deficiency was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the staff did not complete the bed hold notices prior to sending the residents to the hospital. The residents involved were sent to the hospital for various medical reasons, including altered mental status, gastrointestinal bleeding, abdominal pain, low blood pressure, elevated white blood cell count, and uncontrolled pain. The absence of written notices could result in residents or their representatives being unaware of the bed hold policy upon their return from the hospital.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for four residents, which could result in an inaccurate understanding of their needs. Resident #4 was admitted with a Stage II pressure ulcer on the coccyx, but the admission MDS incorrectly documented no unhealed pressure ulcers. Similarly, Resident #7 experienced a fall after admission, yet the MDS inaccurately recorded no falls since admission. Resident #11 was admitted with multiple wounds, including a pressure wound on the left heel and other ulcerations, but the MDS failed to document these conditions. Lastly, Resident #184 had Moisture Associated Skin Damage (MASD) due to incontinence, which was not recorded in the Medicare 5-Day MDS Assessment. Interviews with the Director of Nursing and the MDS Coordinator confirmed the discrepancies in the MDS assessments for these residents. The inaccuracies in the MDS documentation were identified through record reviews and staff interviews, highlighting a pattern of oversight in accurately capturing the residents' medical conditions and care needs upon admission. These deficiencies in documentation could potentially lead to inadequate care planning and interventions for the affected residents.
Failure to Document Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to create accurate baseline care plans within 48 hours of admission for three residents, leading to potential risks of inadequate care. Resident #11 was admitted with multiple wounds, including cellulitis, sepsis, and MRSA infections, but the baseline care plan did not document these wounds or any interventions for their treatment. The MDS Coordinator confirmed that the baseline care plan should have included these details. Resident #184 was admitted with Moisture Associated Skin Damage (MASD) due to incontinence, but the baseline care plan did not document this condition or any interventions. The MDS Coordinator acknowledged that the baseline care plan was not completed within the required 48-hour timeframe and failed to include the MASD diagnosis, which was noted in the resident's progress notes. Resident #185 had several diagnoses, including severe protein-calorie malnutrition, dysphagia, and a PEG tube for enteral feeding. However, the baseline care plan did not document the dysphagia diagnosis, the presence of the PEG tube, or the specific diet and feeding orders. The MDS Coordinator confirmed these omissions, indicating that the baseline care plan should have included all relevant medical information and interventions.
Failure to Obtain and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure that wound care orders were obtained and implemented for a resident with a pressure ulcer. Upon admission, the resident had a Stage II pressure ulcer on the coccyx, as noted in the wound care consultation. Despite this, the facility did not have wound care orders in place for the resident's pressure ulcer from the time of admission until several days later. The Treatment Administration Record for December 2024 and January 2025 showed a lack of orders for the treatment of the pressure ulcer until January 11, 2025. Additionally, the facility's nursing progress notes indicated that staff did not consult with the facility provider to obtain necessary wound care orders for the resident's pressure ulcer, which was present upon admission. The Director of Nursing acknowledged that nursing staff failed to identify wounds upon admission and did not obtain orders for the pressure ulcer, which was against the facility's expectations. This deficiency could lead to inconsistent interventions and worsening of the pressure ulcer.
Lack of Physician Order and Clinical Justification for Condom Catheter Use
Penalty
Summary
The facility failed to ensure that a resident with a condom catheter had a physician's order and a documented clinical condition justifying its use. During an interview, the resident stated that he had a catheter to streamline the process of elimination, despite being continent of bowel and bladder. An observation confirmed the presence of a catheter, but a review of the resident's physician orders and medical record revealed no order or documented clinical condition necessitating the use of a condom catheter. The Director of Nursing confirmed the absence of an order or clinical documentation, acknowledging that the facility's expectation is for all residents to have orders and clinical reasons for catheter use.
Failure to Change Nasal Cannula as Scheduled
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident by not changing the nasal cannula within the required 7-day period. During an observation, it was noted that the resident's nasal cannula was not dated, indicating when it had last been changed. The resident had a physician's order for continuous oxygen at 2 liters via nasal cannula. The Director of Nursing (DON) stated that nasal cannulas are typically changed weekly on Sundays, and a piece of tape with the date is used to document the change. However, a Certified Nursing Assistant (CNA) confirmed that the resident's cannula did not have a date, and she could not verify if it had been changed as per the schedule. This oversight could lead to the nasal cannula becoming obstructed, non-functional, and unsanitary, potentially affecting the resident's oxygen supply.
Inappropriate Use of Psychotropic Medication for a Resident
Penalty
Summary
The facility failed to ensure that a resident did not receive psychotropic medication without a medical necessity. Specifically, a resident was administered Remeron, an antidepressant, for muscle weakness, which is not an appropriate medical diagnosis for the use of this medication. The resident's admission record indicated diagnoses of cognitive communication deficit, other symbolic dysfunctions, and severe dementia without behavioral, psychotic, mood, or anxiety disturbances, none of which justify the use of Remeron. The physician's order dated January 11, 2025, prescribed Remeron 15 mg at bedtime for muscle weakness, and the Medication Administration Record confirmed that the resident received this medication every evening starting from that date. During an interview, the Director of Nursing confirmed the order for Remeron for muscle weakness and acknowledged that the resident did not have a medical diagnosis appropriate for the use of this medication. This oversight could lead to the resident receiving unnecessary medication, increasing the risk of adverse side effects.
Deficiencies in Wound Care and Skin Condition Management
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for two residents, leading to deficiencies in wound care and skin condition management. For one resident, the facility did not implement convalescent care orders for multiple wounds upon admission. The resident had several wounds, including ulcerations and a surgical wound, which required specific wound care treatments. However, the staff did not document any wound care orders or treatments between the resident's admission and several days later, nor did they assess the resident's skin upon admission. This lack of documentation and care could have led to the staff and physician being unaware of changes in the resident's condition. Another resident developed Moisture Associated Skin Damage (MASD) due to incontinence, but the facility failed to notify the provider or document any treatment for this condition. The resident's progress notes consistently recorded the presence of MASD over several days, yet there was no documentation of provider notification or treatment orders in the medical record. Interviews with staff confirmed that the nurse should have assessed the resident's skin, contacted the provider for orders, and documented any communication and treatment. The deficiencies highlight a failure in the facility's processes for implementing care orders and managing changes in residents' conditions. The lack of documentation and communication with providers regarding wound care and skin conditions could lead to worsening of residents' health. The facility's staff did not follow established protocols for assessing and documenting care, which are critical for ensuring residents receive appropriate treatment.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 46 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Las Cruces
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Calibre Post Acute, Llc | 2 mi | ★★★★★ | 11 | 0 |
| Las Cruces Wellness & Rehabilitation Llc | 2.2 mi | ★★★★★ | 3 | 0 |
| Casa Del Sol Center | 3.9 mi | ★★★★★ | 9 | 0 |
| Las Cruces Village Nursing & Rehabilitation Llc | 4.4 mi | ★★★★★ | 7 | 0 |
| Casa De Oro Center | 7.9 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Northrise Wellness & Rehabilitation.
100% money-back within 48 hours.
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.