Waters of Rising Sun, The

In the surveyor’s words

From the most serious findings on record at Waters of Rising Sun, The, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 10, 2022

  During observation and interview, the facility failed to perform appropriate hand hygiene in the kitchen for 1 of 2 kitchen observations with the potential to effect 42 of 42 residents that resided in the facility and failed to store food appropriately in the resident snack refrigerator for 1 of 1 snack refrigerators reviewed. Findings include: 1. During a continuous observation on 01/06/22 at 11:23 A.M., there were no paper towels at the hand washing sink. Cook 11 indicated they had just run out of paper towels and the housekeepers would have to come and replace them as the kitchen staff did not have a key to unlock the paper towel dispenser. A clean hand towel was provided to dry hands. Cook 12 walked into the kitchen without washing her hands. […]

• No harm, potential for more than minimal, patternF641Feb 22, 2024

  Based on record review and interview, the facility failed to accurately complete MDS (Minimum Data Set) assessments related to residents' discharge status and diagnoses for 4 of 14 residents reviewed for accuracy of assessments. (Residents 49, 7, 38, and 50) Findings include: 1. The clinical record for Resident 49 was reviewed on 02/22/24 at 10:21 A.M. A Discharge MDS assessment, dated 12/18/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, anxiety, malnutrition, and heart failure. The assessment indicated this was a planned discharge and the resident's return was not anticipated. […]

• No harm, potential for more than minimal, isolatedF554Mar 3, 2026

  Based on observation, interview, and record review, the facility failed to ensure a resident that self-administered medications was appropriately assessed for self-administration prior to being left alone to administer the complete breathing treatment for 1 of 5 residents observed for medications. (Resident B)Findings include:During an observation on 02/26/2026 at 9:24 A.M., Resident B was in her room sitting up in her bed. Licensed Practical Nurse (LPN) 4 obtained the resident's blood pressure, heart rate, and oxygen saturation level. The nurse placed the nebulizer medication in the reservoir of the nebulizer, held the mask to the resident's face, and placed the straps to hold the mask around the back of the resident's head. […]

• No harm, potential for more than minimal, isolatedF580Mar 3, 2026

  Based on record review and interview, the facility failed to notify the physician of a change in resident's condition related to blood glucose levels for 1 of 15 residents reviewed for notification of change. (Resident 12) Findings include: The clinical record for Resident 12 was reviewed on 03/02/2026 at 9:54 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/21/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, end stage renal disease, anemia, heart failure, hypertension, diabetes, anxiety, and depression. […]

• No harm, potential for more than minimal, isolatedF641Mar 3, 2026

  Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately documented a resident's diagnoses (Resident 17) and a resident's discharged location (Resident 55) for 2 of 15 residents reviewed accuracy of assessments.Findings include:1.The clinical record for Resident 17 was reviewed on 02/26/2026 at 10:38 A.M. The Medications section of the resident's Quarterly MDS assessment, dated 12/31/2025, indicated the resident received insulin, antianxiety, and antidepressant medications during the assessment review period. The Active Diagnoses section of the assessment indicated the resident did not have the current diagnoses of diabetes, anxiety, or depression. […]