North Starr Postacute Care

Inspectors wroteBased on observation, interview and record review the facility failed to revise Resident 11's comprehensive care plan to address a significant change in condition following hospitalization for suspected infected dialysis access (the site used to connect the resident to dialysis, a treatment that cleaned the blood when the kidneys could not do so), treatment with intravenous (IV) antibiotics (medicine given through a vein directly into the blood stream to treat infection), and replacement of the dialysis catheter (a flexible tube placed into a large vein to allow dialysis treatments). This failure had the potential to result in the residents' care needs not being identified, communicated and addressed through coordinated interdisciplinary care planning upon the residents' return to the facility.

Inspectors wroteBased on interview, and record review the facility failed to ensure one (Resident 3) out of ten residents received a level II Pre-admission Screening and Resident Review (PASRR- evaluation for individuals suspected of having a Serious Mental Illness (SMI) or Intellectual/Developmental Disability (I/DD)/Related Condition (RC), triggered by a positive Level I screen, to determine if they need specialized services, ensuring placement in the least restrictive setting) evaluation by the designated entity to determine if SMI, ID/DD/RC conditions were present when Resident 3 had a PASSRR level I screening result positive for SMI and the facility did not ensure a PASRR level II screening was completed. This failure resulted in Resident 3 not receiving a required PASRR level II screening which could result in delayed treatment, identification of care or services. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen therapy (a colorless, tasteless gas essential to living organisms) professional standards of practice were followed for one (Resident 20) of ten residents when Resident 20 did not have oxygen therapy signage posted. This failure resulted in Resident 20's oxygen concentrator (medical device that helps residents breathe) being on with no oxygen therapy signage posted in or outside her room which could result in fire, hazards or injuries. During an observation on 5/5/26 at 10:01 a.m. in Resident 20's room, Resident 20 was observed lying in bed. Resident 20's oxygen concentrator was observed on at 5 LPM (liter per minute-a unit of measurement for the flow rate of oxygen). Resident 20's nasal cannula (a thin, flexible tube with two prongs that fit into the nostrils and deliver oxygen) was on the floor. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure care and services were provided to maintain the highest practicable physical well-being for one of seven sampled residents (Resident 4) by failing to ensure an order for monitoring Resident 4's anticoagulant (a medication that helped prevent blood from clotting too easily, which could increase the risk of bleeding) adverse effects (unwanted or harmful side effects from a medication) was in place following readmission to the facility. This failure had the potential to delay identification of signs and symptoms of bleeding, placing Resident 4 at risk for adverse outcomes related to anticoagulant therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to post actual direct care staffing hours worked for public review for 21 of 21 residents in the facility, as required, by posting projected DHPPD (Direct Hours Per Patient Day) staffing information instead of actual hours worked for the prior day. This failure had the potential to prevent residents' family members and visitors from having accurate information regarding the actual nursing staffing levels providing care in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, handled, and served in accordance with professional standards for food service safety when the ice machine was not secured and accessible to all residents, visitors, and staff. This failure resulted in the ice machine being improperly accessed and handled by Family Member (FM) 1 resulting in the contamination of ice which could lead to food borne illness for 22 out of 22 residents receiving food from the facility. During an observation on 5/5/26 at 9:19 a.m. the ice machine was observed at the end of the hall, near the kitchen and room [ROOM NUMBER]. The ice machine was observed in a closet with no door. The ice machine was observed with no lock. The ice machine was observed with no signage posted. The ice machine was observed with a designated ice scoop on the right side of the wall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program to help prevent the development and transmission of infections for one of ten sampled residents (Resident 30) when Resident 30 had a midline catheter (thin, flexible tube inserted into a vein in the upper arm used for intravenous treatments) dressing that was not changed for 8 days and then was not labeled or recorded in the medical record accurately after a dressing change. This failure resulted in Resident 30's midline catheter dressing not being changed per provider orders or facility policy and procedures which had the potential to result in catheter-related infections and illness. During an observation on 5/5/26 at 9:53 a.m. with Resident 30, in Resident 30's room, Resident 30's midline catheter dressing was observed dated 4/27/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents skin assessments were completed to prevent pressure injuries (a wound or sore that develops from prolonged pressure on the skin, usually over a bony prominence such as heels, knees, elbows, hips, shoulders, and tailbone) for one of four sampled residents (Resident 1) when Resident 1's stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) pressure injury was identified on 6/3/25, 31 days after being admitted to the facility. This failure resulted in Resident 1 developing a stage 3 pressure injury, which prolonged his stay in the facility because the facility he was to be discharged to would not accept him with a pressure injury. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure titled Medication Storage in the Facility when the medication room and medication refrigerator temperature which stored drugs and biologicals were not monitored and documented on 9/8/24 and 9/9/24. This failure had the potential for drugs and biologicals stored inside the medication room and medication refrigerator to decrease their effectiveness.

Inspectors wroteBased on interview and record review, the facility failed to follow the policy and procedure titled Staff Development Program to ensure Licensed Nurses (LNs), Certified Nursing Assistants (CNAs) and ancillary (additional) support staff received and demonstrated competency to prevent and recognize resident abuse and had the necessary skills and techniques necessary to care for residents who were identified as high risk for fall when: 1. 11 of 28 facility staff had not attended and completed the 2024 annual mandatory in-service training for Abuse Prevention. 2. 16 of 28 facility staff had not attended and completed the 2024 annual mandatory in-service training for Fall Prevention. These failures had the potential to place residents at risk for care not being provided in a safe and competent manner.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean, safe, and sanitary homelike environment for two of five sampled residents (Residents 16 and 22) when the west hall shower room remained accessible for use with missing floor tiles, and the existing floor tiles were black with yellow areas in the tile grout. This failure resulted in an unclean, unsafe, unsanitary and non-homelike environment for Residents 16 and 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for three of 16 sampled residents (Residents 1, 6, 10 ) when: 1. Resident 1's care plan was not developed to reflect interventions to address her use of a left shoulder sling after an unwitnessed fall with injury. This failure had the potential for Resident 1's left upper arm's injury to worsen. 2. Resident 10's care plan was not developed to reflect interventions to address her refusal of medications. This failure had the potential for Resident 10's medical needs to not be met. 3. Facility failed to implement the care plan for monitoring and assisting Resident 6 during meals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment for two of nine sampled residents (Residents 20 and 22) when Residents 20 and 22's wheelchairs wheel locks were loose and not locking properly. This failure had the potential to put Resident 20 and Resident 22's safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of abuse as per the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting policy for one resident (Resident 1), when Resident 1 had an unwitnessed fall with injury. In addition, the facility failed to report the results of the facility's investigation to the State Survey Agency within five working days of the alleged incident. This failure had the potential to place Resident 1 and other vulnerable residents at increased risk of abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide services which met professional standards of practice for one of 16 sampled residents (Residents 10) when the facility failed to notify the Attending Physician of Resident 10's ongoing refusal of Fluticasone-Salmeterol (medication to prevent inflammation and narrowing of airway) inhaler. This failure had the potential to place Resident 10 at risk of not receive appropriate care and attain her highest well-being.

Inspectors wroteBased on observation during the survey period of 9/10/24 to 9/13/24, the facility failed to provide the minimum of at least 80 square feet per resident in 15 out of 16 rooms (Rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16). This failure had the potential for residents in Rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16 to not have reasonable privacy or adequate space.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than five percent when 10 medication errors were observed during 35 medication administration opportunities, which resulted in an error rate of 28.57 percent. These failures resulted in Resident 21 not being informed of the medications being administered and had the potential for unsafe medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety when: 1. Two of two five-pound packs of ground beef were placed in the kitchen refrigerator to thaw without a documented pulled date (the date the frozen meat was removed from the freezer and placed in the refrigerator) or use-by date (the date the meat should be discarded); 2. The temperature of the water for the hand-washing sink in the kitchen was measured at 84 degrees Fahrenheit (F), below the expected temperature range of 100 to 108 degrees F per the facility policy and procedure. 3. The green salad on the kitchen assembly line on 5/4/22 had an internal temperature of 50 degrees F, rather than the expected temperature of 41 degrees or less per the Food Code. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control and prevention program when: 1. One of four staff (Certified Nurse Assistant [CNA] 2) failed to follow the facility's policy titled, Scope of Infection Control Program, when CNA 2 did not wear a face mask before entering the facility's screening area and main lobby. This failure had the potential to place residents, visitors, and staff at increased risk for transmission (a process on how an infectious agent can be transferred from one person to another) of SARS-CoV-2 (the virus that causes a respiratory disease called Coronavirus disease 19 [COVID-19]. The virus is spread from person to person through droplets released when an infected person coughs, sneezes, or talks). 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat one of 12 sampled residents (Resident 19) with dignity and respect when Resident 19's fingernails were untrimmed and covered with black and brown matter. This failure resulted in the potential harm of Resident 19 not reaching her highest practicable well being.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a person-centered comprehensive care plan for one of 24 sampled residents (Resident 19) when Resident 19's personal hygiene care plan was not implemented. This failure resulted in Resident 19's fingernails on both hands to be untrimmed and dirty, covered by brown and black substance and had the potential to result in Resident 19 to develop skin infection and or stomach problems such as nausea, vomiting, diarrhea or stomach infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals (substances such as vaccines, drugs, or supplements) were stored in accordance with the facility's policy and procedure, titled, Medication Storage in the Facility, for one of 12 sampled residents (Resident 21), when Resident 21's therapeutic nutritional shake (an oral formula for those with kidney disease [damaged kidneys causing difficulty and inability to create urine]) was opened and placed inside the medication cart for storage, instead of the refrigerator. This failure had the potential for Resident 21's therapeutic nutritional shake to not be stored per manufacture's recommendation, which had the potential to reduce efficacy of the shake and for adverse reactions such as nausea, vomiting, or diarrhea.

Inspectors wroteBased on observation during the survey period of 5/3/22 to 5/6/22, the facility failed to provide the minimum of at least 80 square feet per resident in 15 out of 16 rooms (Rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16). This failure had the potential for residents in Rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16 to not have reasonable privacy or adequate space.