Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 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.
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.
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.
The facility failed to report investigation results of alleged medication diversion and injuries of unknown origin to the State Agency within five days. A resident with unexplained fractures and missing narcotics from the Emergency Kit were not properly documented or reported, as confirmed by the DON.
The facility did not post daily nurse staffing data, omitting the total number and actual hours worked by RNs, LPNs, and CNAs. An observation revealed missing information at the entrance, and the DON confirmed the night shift nurse's responsibility for posting complete data.
The facility failed to develop care plans addressing the individualized discharge goals and needs for three residents reviewed for discharge planning. Record reviews and an interview with Social Services staff confirmed the absence of such documentation in the residents' care plans and charts.
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.
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.
Failure to Timely Report Investigation Results
Penalty
Summary
The facility failed to report the results of investigations regarding alleged medication diversion and injuries of unknown origin to the State Agency within the required five-day period. This deficiency was identified through record reviews and interviews. In one case, a resident was sent to the emergency room due to a nosebleed and was found to have rib fractures and a compression fracture of the Thoracic 10 vertebrae. Despite efforts to determine the cause, no explanation was found, and the facility did not document that a follow-up report was submitted to the State Agency within the required timeframe. In another incident, the facility reported missing narcotics, with the initial incident occurring on a specified date. The medication count on the Emergency Kit was found to be inaccurate, and new interventions were developed to secure the kit. However, the facility again failed to document that a follow-up report was submitted to the State Agency within five days of the incident. The Director of Nursing confirmed the lack of documentation for both incidents during an interview.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post daily nurse staffing data that included the total number and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides responsible for resident care per shift. During an observation on January 30, 2025, it was noted that the nurse staffing data posted at the front entrance did not include the required information for the day. In an interview, the Director of Nursing (DON) confirmed that the night shift nurse is responsible for posting this data, which should include the total number of staff scheduled for each shift and the number of hours each nursing staff member is scheduled to work.
Failure to Develop Individualized Discharge Plans
Penalty
Summary
The facility failed to develop care plans addressing the individualized discharge goals and needs for three residents (R #11, R #12, and R #13) reviewed for discharge planning. Record reviews revealed that the care plans for these residents, dated 01/19/24, 03/06/24, and 04/01/24 respectively, did not include documentation of their discharge goals and needs. During an interview on 05/01/24, the Social Services (SS) staff confirmed the absence of such documentation in the residents' care plans and charts.
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 58 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 | ★★★★★ | 14 | 0 |
| Casa De Oro Center | 7.9 mi | ★★★★★ | 21 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.