Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Rising Star Nursing Center during CMS and state inspections, most recent first.
Failure to develop comprehensive person-centered care plans for 3 residents. One resident had a scalp wound with ordered wound care, but no care plan addressed the wound or related treatment. Two residents had significant psychosocial needs: one expressed grief, loneliness, and a desire to die, and another reported trauma/PTSD triggers during incontinent care, yet neither had a care plan addressing those needs. The ADON acknowledged the missing care plans.
Failure to Address Behavioral Health and Trauma Needs: Two residents did not receive individualized psychosocial care. One resident, who was cognitively intact and had no psychotropic meds, repeatedly expressed wanting to die, feeling useless, lonely, and forgotten, but had no care plan for those concerns. Another resident with TBI and MDD reported that incontinent care triggered past physical, emotional, and sexual abuse, causing panic attacks, yet her trauma history and triggers were not included in the care plan; the COTA knew of the history but did not report it because it was historical.
A CNA failed to complete female peri-care during incontinent care for a resident with dementia, severe cognitive impairment, and frequent bladder and bowel incontinence. The aide wiped the buttocks and rectal area but did not cleanse the vaginal area before applying a new brief, and later stated she got nervous and forgot some steps. The ADON, DON, and Administrator confirmed that vaginal peri-care was expected, and the facility policy required cleansing the perineal area from front to back.
A resident with an unstageable pressure ulcer on the left heel did not receive the required weekly skin assessments and wound care documentation as outlined in their care plan. Despite being at high risk for skin breakdown due to conditions like malnutrition and cognitive deficits, the facility's electronic system failed to trigger necessary reminders, leading to a lapse in care. The DON confirmed the oversight, acknowledging the absence of documented assessments after the resident's skilled nursing services ended.
A facility failed to post an 'Oxygen in Use' sign on a resident's door, who required oxygen for conditions like COPD and asthma. Despite the facility's policy, observations showed the sign was missing, and interviews with the ADON and DON revealed no specific responsibility for posting the sign, attributing the oversight to staff being rushed during the resident's admission.
The facility failed to maintain proper infection control practices, as observed with an LVN not sanitizing an insulin pen's rubber stopper before use and a CNA not sanitizing a catheter bag's drain after emptying it. Additionally, a resident's catheter bag was found on the floor, contrary to facility policy. These actions could lead to infections.
A facility failed to develop a comprehensive baseline care plan within 48 hours of a resident's admission, omitting critical information such as oxygen use, smoking status, and discharge goals. Despite the resident's cognitive status and existing physician orders, the ADON and DON acknowledged the potential for a gap in care. The facility's policy mandates a complete baseline care plan within 48 hours, which was not followed.
A facility failed to develop a comprehensive care plan within 7 days for a resident with multiple health conditions, including Acute Transverse Myelitis and Chronic Kidney Disease. The delay was due to oversight by the ADON, who had recently returned from medical leave, and the DON. The care plan was initiated significantly later than required by the facility's policy.
A facility failed to maintain accurate medical records for a resident, leading to confusion over medication parameters. The resident's cardiac medication orders were incorrectly entered, using 'and' instead of 'or', causing an LVN to hold medications unnecessarily. The DON acknowledged the transcription error, and the ADMN could not provide a specific policy on record accuracy.
Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 3 of 8 residents reviewed. Resident #6 had an open scalp wound and was admitted with diagnoses including an open wound of the scalp and presence of other bone and tendon implants. His quarterly MDS showed moderate cognitive impairment and that he received skin treatments, and the order summary included wound care for a right scalp lesion with cleansing and a protective dressing. During observation, wound care was provided to the resident’s scalp skin graft, but the care plan report initiated in April and last revised in May contained no care plan for the scalp wound or related wound care. Resident #25 was admitted with arthritis, had moderate hearing difficulty, was cognitively intact, and required moderate assistance with most ADLs. During interview, she stated she was mourning her family and loss of independence, felt she had no choices, felt forgotten, and said she wanted to die because everyone she knew was gone. She also stated her children visited but did not need her anymore. Her care plan included chronic pain and pain due to age, but there was no care plan addressing her acute unhappiness, desire to die, loneliness, feelings of uselessness, or loss of independence. Resident #26 was admitted with arthritis, traumatic brain injury, and major depressive disorder. Her quarterly MDS showed she was cognitively intact, did not report depression indicators, exhibited delusions, and was receiving an antidepressant and an anti-convulsant. Her order summary included citalopram, clonazepam for anxiety, and venlafaxine for depressive disorder. During interview, she stated that incontinent care by a CNA triggered her trauma history, that she told the aide to stop and get out, and that she rolled to punch the aide. The ADON stated the resident had disclosed a history of PTSD and wanted therapy, but the care plan contained no plan for trauma history, PTSD, or trigger management.
Failure to Address Residents’ Behavioral Health and Trauma Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to maintain the highest practicable physical, mental, and psychosocial well-being for 2 of 6 residents reviewed for psychosocial adjustment. For Resident #25, the record showed she was cognitively intact, had moderate hearing difficulty, required moderate assistance with most ADLs, and had no psychotropic medication ordered. Her care plan addressed chronic pain and pain due to age, but there was no care plan for her acute unhappiness related to wanting to die, feeling lonely for family, feeling useless, and loss of independence. Resident #25’s social service documentation and interviews showed repeated expressions of distress. She told the social worker that outliving her siblings was “my punishment here on earth,” and later stated, “Why he keeps leaving me here,” while also having a history of acute anxiety requiring medication intervention. During interview, she said she was sad because she was not her mother’s favorite, had a loss of independence, had no choices in the facility, felt forgotten, and wanted to die because everyone she knew was gone. Facility leadership acknowledged she had been discussed with the doctor and that she was focused on everyone she knew being gone, but there were no notes documenting those discussions. For Resident #26, the record showed diagnoses including arthritis, traumatic brain injury, and major depressive disorder. She was cognitively intact, exhibited delusions, and was receiving antidepressant and anti-anxiety medications. Her care plan did not include a plan for her history of trauma. During interview, Resident #26 stated that incontinent care by a CNA triggered her history of trauma, caused panic attacks, and brought up unpleasant memories from her first marriage. She said she had to return to therapy to address the trauma and had requested help setting up therapy herself because it was too slow. The COTA stated Resident #26 had shared a history of physical, emotional, and sexual abuse and that the incident really triggered her, but the COTA did not report it because it was historical. The DON stated Resident #26 did not reveal her history until after she reported the event, and the facility policy required comprehensive person-centered care planning that included trauma-informed care and trigger identification.
Incomplete Perineal Care During Incontinent Care
Penalty
Summary
The facility failed to ensure that a certified nurse aide demonstrated competency in perineal care during incontinent care for a resident with dementia and muscle weakness who was frequently incontinent of bladder and bowel and had a BIMS score of 5 indicating severe impairment. During an observation, CNA A and NA B provided incontinent care after the resident’s brief was found wet with urine. CNA A removed the brief and wiped the resident’s buttocks and rectal area, while NA B assisted and then applied a new pull-up brief. CNA A did not perform peri-care to the resident’s vaginal area before the brief was fastened. During interview, CNA A stated she had mostly wiped the resident’s bottom and should have turned the resident on her back to perform more thorough peri-care of the vaginal area, but said she got nervous and forgot some steps. The ADON, DON, and Administrator each stated that peri-care to the vaginal area was expected and that the CNA likely failed to complete the care because she became nervous. Record review showed CNA A had passed a competency check for female perineal/incontinent care, and the facility’s policy required cleansing the perineal area from front to back, separating the labia, and cleaning the rectal area thoroughly.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, identified as Resident #27, who was admitted with an unstageable pressure ulcer on the left heel. The resident's medical history included conditions such as unspecified protein-calorie malnutrition, cognitive communication deficit, and muscle weakness, which increased the risk of skin breakdown. Despite these risk factors, the facility did not conduct weekly skin assessments or document wound care as required by their care plan and facility policy. The resident's care plan, initiated in March 2024, outlined specific interventions to prevent further skin breakdown and promote healing of the existing ulcer. These interventions included weekly wound assessments and maintaining pressure off the affected area. However, a review of the resident's assessment records revealed that the last documented weekly skin assessment occurred in March 2024, with no evidence of subsequent wound care documentation. This lack of consistent monitoring and documentation could potentially lead to infections and worsening of the resident's condition. Interviews with the Director of Nursing (DON) revealed that the facility's electronic system failed to trigger reminders for weekly skin assessments after the resident was removed from skilled nursing services in May 2024. The DON acknowledged the oversight and stated that no proof was available to confirm that nurses performed the required assessments after this period. The facility's policy required comprehensive head-to-toe skin assessments and completion of wound care sheets for residents with pressure ulcers, but these procedures were not followed, resulting in a deficiency in care for Resident #27.
Failure to Post Oxygen in Use Sign
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen administration, as evidenced by the absence of an 'Oxygen in Use' sign on the resident's door. The resident, a female with diagnoses including Chronic Obstructive Pulmonary Disease and asthma, was admitted to the facility with physician orders for oxygen administration as needed for shortness of breath. Observations on multiple occasions revealed that the required signage was not posted, which is a deviation from the facility's policy on oxygen administration. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that there was no specific individual responsible for ensuring the sign was posted, and it was expected that the person setting up the concentrator would do so. Both the ADON and DON acknowledged that all staff should monitor for the presence of these signs. The oversight was attributed to staff being rushed during the resident's admission process, which led to the failure to adhere to the facility's policy, potentially compromising safety by not indicating the presence of oxygen in use.
Infection Control Deficiencies in Insulin and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two staff members, LVN A and CNA B. LVN A did not sanitize the rubber stopper of an insulin flex pen with an alcohol swab before attaching a pen needle, which is a necessary step to prevent infection. LVN A admitted to forgetting this step due to nervousness from being observed. The facility's policy on insulin pen administration clearly states that the rubber stopper should be wiped with an alcohol wipe before attaching a new pen needle. CNA B failed to sanitize the drain of a catheter bag after emptying it, which is a critical step to prevent contamination and infection. Additionally, Resident #183's catheter bag was observed on the floor and later touching the floor while hanging from the bed railing, contrary to the facility's policy that requires catheter bags to be kept off the floor. CNA B acknowledged not having an alcohol swab during the procedure, which led to the oversight. The Director of Nursing, who is also the infection preventionist, confirmed that these practices could lead to infections and that the facility's policies were not followed in these instances.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, which is a requirement to ensure effective and person-centered care. The baseline care plan for the resident did not include critical information such as oxygen use, smoking status, and discharge goals. This omission was identified during a review of the resident's records, which showed that the resident had been admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Asthma, and hypertension. Despite having physician orders for oxygen use, these details were not incorporated into the baseline care plan. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that it was the ADON's responsibility to complete the baseline care plan, and both the ADON and DON were responsible for monitoring its accuracy. The ADON admitted that the omission might have been due to being in a hurry, while the DON acknowledged the potential for a gap in comprehensive care. However, both believed that the resident's cognitive status and existing orders mitigated the impact of the oversight. The facility's policy requires that a baseline care plan be developed within 48 hours of admission, including initial goals and physician orders, which was not adhered to in this case.
Failure to Develop Timely Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident within 7 days after the completion of the comprehensive assessment, as required by their policy. The resident, a female with a history of Acute Transverse Myelitis, Rheumatoid Arthritis, Bartter's Syndrome, Chronic Kidney Disease, and high blood pressure, was admitted with a completed Admission MDS on February 16, 2024. However, the comprehensive care plan was not initiated until April 16, 2024, well beyond the 7-day requirement. Interviews with the ADON and DON revealed that the delay was due to oversight. The ADON, who was responsible for completing and monitoring the care plan, had returned from medical leave and was catching up on tasks, which led to the oversight. The DON also acknowledged the oversight and stated that both she and the ADON were responsible for the lapse in completing the care plan. The facility's policy clearly states that comprehensive care plans should be developed within 7 days after the comprehensive assessment, which was not adhered to in this case.
Inaccurate Medication Parameters in Resident Records
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the parameters for administering cardiac medications. The resident, a female with a history of heart failure, dementia, and other conditions, had physician orders for medications including carvedilol, hydralazine, and losartan potassium. These orders included specific parameters for holding the medication based on blood pressure and heart rate readings. However, the orders were incorrectly entered into the electronic medical system, using 'and' instead of 'or', which led to confusion about when to hold the medications. During an observation, an LVN held the medications because the resident's blood pressure and pulse did not meet the parameters as entered. The LVN later stated she was unsure if the order needed to be changed to reflect that only one parameter needed to be met to hold the medication. The DON acknowledged the transcription error and stated that the order was entered incorrectly, which could have led to medication errors. The ADMN was unable to provide a specific policy on the accuracy of records, only a general medication policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rising Star
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Cisco | 19.7 mi | ★★★★★ | 9 | 0 |
| Avir At Woodlands | 22.3 mi | ★★★★★ | 15 | 0 |
| Care Nursing & Rehabilitation | 23.5 mi | ★★★★★ | 3 | 0 |
| Western Hills Healthcare Residence | 24.2 mi | ★★★★★ | 0 | 0 |
| Legacy Estate Long Term Care | 24.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.