The Vardell Report.Northstar Post Acute

Across 5 inspections from October 2023 to February 2026, state surveyors documented 77 findings at Northstar Post Acute; 77 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections

5

2023–2026, standard and complaint

Findings

77

Deficiencies cited by state inspectors

Corrected

77

Of 77 findings, with a recorded correction date

Penalties

1

1 fine; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Feb 22026

   Standard health inspection

   30 findings

   The same visit included a complaint investigation.

   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level FNo actual harm, potential for moreCorrected Mar 17, 2026
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level FNo actual harm, potential for moreCorrected Mar 17, 2026
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level ENo actual harm, potential for moreCorrected Mar 17, 2026
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Mar 17, 2026
   • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Mar 17, 2026
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel ENo actual harm, potential for moreCorrected Mar 17, 2026
   • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level ENo actual harm, potential for moreCorrected Mar 17, 2026
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F606Not hire anyone with a finding of abuse, neglect, exploitation, or theft.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F946Provide training in compliance and ethics.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level DNo actual harm, potential for moreCorrected Mar 17, 2026
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Mar 17, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Dec 192024

   Standard health inspection

   7 findings

   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level ENo actual harm, potential for moreCorrected Jan 29, 2025
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Jan 29, 2025
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jan 29, 2025
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jan 29, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jan 29, 2025
   • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level DNo actual harm, potential for moreCorrected Jan 29, 2025
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Jan 29, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Aug 92024

   Complaint investigation

   1 finding

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 3, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Feb 202024

   Standard health inspection

   38 findings

   The same visit included a complaint investigation.

   • F697Provide safe, appropriate pain management for a resident who requires such services.Level GActual harmCorrected Apr 7, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level FNo actual harm, potential for moreCorrected Apr 7, 2024
   • F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level FNo actual harm, potential for moreCorrected Apr 7, 2024
   • F583Keep residents' personal and medical records private and confidential.Level ENo actual harm, potential for moreCorrected Apr 7, 2024
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level ENo actual harm, potential for moreCorrected Apr 7, 2024
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F635Provide doctor's orders for the resident's immediate care at the time the resident was admitted.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F881Implement a program that monitors antibiotic use.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F946Provide training in compliance and ethics.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level DNo actual harm, potential for moreCorrected Apr 7, 2024
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level CPotential for minimal harmCorrected Apr 7, 2024

   Enforcement Action

   Civil money penalty, $70,296 imposed February 20, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 20, 2024, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Oct 162023

   Complaint investigation

   1 finding

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Nov 29, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Medication Error Rate, Cited in Three Inspections

   Inspectors cited F759 in February 2024, December 2024 and February 2026. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242426F759 across all 5 inspections, oldest to newest
2. 2

   Infection Control, Cited in Three Inspections

   Inspectors cited F880 in February 2024, December 2024 and February 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242426F880 across all 5 inspections, oldest to newest
3. 3

   Citation F943, Cited in Three Inspections

   Inspectors cited F943 in February 2024, December 2024 and February 2026. The agency describes it this way: Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242426F943 across all 5 inspections, oldest to newest
4. 4

   Citation F552, Cited in Two Inspections

   Inspectors cited F552 in February 2024 and February 2026. The agency describes it this way: Ensure that residents are fully informed and understand their health status, care and treatments. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242426F552 across all 5 inspections, oldest to newest
5. 5

   A Clean, Homelike Setting, Cited in Two Inspections

   Inspectors cited F584 in February 2024 and February 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242426F584 across all 5 inspections, oldest to newest
6. 6

   Protection From Abuse and Neglect, Cited in Two Inspections

   Inspectors cited F600 in October 2023 and February 2026. This citation covers whether residents are protected from abuse and neglect by anyone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242426F600 across all 5 inspections, oldest to newest
7. 7

   Reporting Suspected Abuse, Cited in Two Inspections

   Inspectors cited F609 in February 2024 and February 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242426F609 across all 5 inspections, oldest to newest
8. 8

   Care Plans, Cited in Two Inspections

   Inspectors cited F656 in February 2024 and February 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242426F656 across all 5 inspections, oldest to newest
9. 9

   Care Plan Timing and Review, Cited in Two Inspections

   Inspectors cited F657 in February 2024 and February 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242426F657 across all 5 inspections, oldest to newest
10. 10

    Quality of Care, Cited in Two Inspections

    Inspectors cited F684 in February 2024 and August 2024. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242426F684 across all 5 inspections, oldest to newest
11. 11

    Accident Hazards and Supervision, Cited in Two Inspections

    Inspectors cited F689 in February 2024 and February 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242426F689 across all 5 inspections, oldest to newest
12. 12

    Post nurse staffing information every day, Cited in Two Inspections

    Inspectors cited F732 in December 2024 and February 2026. The agency describes it this way: Post nurse staffing information every day. None rose above level C (potential for minimal harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242426F732 across all 5 inspections, oldest to newest
13. 13

    Pharmacy Services, Cited in Two Inspections

    Inspectors cited F755 in February 2024 and February 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242426F755 across all 5 inspections, oldest to newest
14. 14

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in December 2024 and February 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242426F761 across all 5 inspections, oldest to newest
15. 15

    Medical Records, Cited in Two Inspections

    Inspectors cited F842 in February 2024 and December 2024. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242426F842 across all 5 inspections, oldest to newest
16. 16

    Citation F868, Cited in Two Inspections

    Inspectors cited F868 in February 2024 and February 2026. The agency describes it this way: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242426F868 across all 5 inspections, oldest to newest
17. 17

    Citation F883, Cited in Two Inspections

    Inspectors cited F883 in February 2024 and February 2026. The agency describes it this way: Develop and implement policies and procedures for flu and pneumonia vaccinations. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242426F883 across all 5 inspections, oldest to newest
18. 18

    Citation F887, Cited in Two Inspections

    Inspectors cited F887 in February 2024 and February 2026. The agency describes it this way: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242426F887 across all 5 inspections, oldest to newest
19. 19

    Citation F941, Cited in Two Inspections

    Inspectors cited F941 in February 2024 and February 2026. The agency describes it this way: Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242426F941 across all 5 inspections, oldest to newest
20. 20

    Citation F942, Cited in Two Inspections

    Inspectors cited F942 in February 2024 and February 2026. The agency describes it this way: Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242426F942 across all 5 inspections, oldest to newest
21. 21

    Citation F944, Cited in Two Inspections

    Inspectors cited F944 in February 2024 and February 2026. The agency describes it this way: Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242426F944 across all 5 inspections, oldest to newest
22. 22

    Citation F945, Cited in Two Inspections

    Inspectors cited F945 in February 2024 and February 2026. The agency describes it this way: Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242426F945 across all 5 inspections, oldest to newest
23. 23

    Provide training in compliance and ethics, Cited in Two Inspections

    Inspectors cited F946 in February 2024 and February 2026. The agency describes it this way: Provide training in compliance and ethics. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242426F946 across all 5 inspections, oldest to newest
24. 24

    Citation F949, Cited in Two Inspections

    Inspectors cited F949 in February 2024 and February 2026. The agency describes it this way: Provide behavior health training consistent with the requirements and as determined by a facility assessment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242426F949 across all 5 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How are medication passes checked, and what happens when an error is found?

   Medication Error Rate: cited in three inspections, most seriously at level E.

2. 02

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in three inspections, most seriously at level D.

3. 03

   What changed after F943 was cited, and how do you check it now?

   Citation F943: cited in three inspections, most seriously at level E.

4. 04

   What changed after F552 was cited, and how do you check it now?

   Citation F552: cited in two inspections, most seriously at level D.

5. 05

   What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

   A Clean, Homelike Setting: cited in two inspections, most seriously at level D.

6. 06

   What happened after the abuse or neglect citation, and what changed in training or supervision?

   Protection From Abuse and Neglect: cited in two inspections, most seriously at level D.

7. 07

   How are staff trained to report suspected abuse or neglect, and who reports it to the state?

   Reporting Suspected Abuse: cited in two inspections, most seriously at level D.

8. 08

   How is a care plan written and reviewed here, and how do families take part in it?

   Care Plans: cited in two inspections, most seriously at level F.

9. 09

   How often are care plans revised, and who takes part in the review?

   Care Plan Timing and Review: cited in two inspections, most seriously at level D.

10. 10

    How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

    Quality of Care: cited in two inspections, most seriously at level D.

11. 11

    What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

    Accident Hazards and Supervision: cited in two inspections, most seriously at level D.

12. 12

    What changed after F732 was cited, and how do you check it now?

    Post nurse staffing information every day: cited in two inspections, most seriously at level C.

13. 13

    How often does the consultant pharmacist review each resident’s medications?

    Pharmacy Services: cited in two inspections, most seriously at level E.

14. 14

    How are medications stored and secured, and who checks the medication carts?

    Medication Labeling and Storage: cited in two inspections, most seriously at level E.

15. 15

    How can a family request a resident’s records, and how are they kept accurate?

    Medical Records: cited in two inspections, most seriously at level D.

16. 16

    What changed after F868 was cited, and how do you check it now?

    Citation F868: cited in two inspections, most seriously at level E.

17. 17

    What changed after F883 was cited, and how do you check it now?

    Citation F883: cited in two inspections, most seriously at level F.

18. 18

    What changed after F887 was cited, and how do you check it now?

    Citation F887: cited in two inspections, most seriously at level D.

19. 19

    What changed after F941 was cited, and how do you check it now?

    Citation F941: cited in two inspections, most seriously at level F.

20. 20

    What changed after F942 was cited, and how do you check it now?

    Citation F942: cited in two inspections, most seriously at level D.

21. 21

    What changed after F944 was cited, and how do you check it now?

    Citation F944: cited in two inspections, most seriously at level E.

22. 22

    What changed after F945 was cited, and how do you check it now?

    Citation F945: cited in two inspections, most seriously at level D.

23. 23

    What changed after F946 was cited, and how do you check it now?

    Provide training in compliance and ethics: cited in two inspections, most seriously at level D.

24. 24

    What changed after F949 was cited, and how do you check it now?

    Citation F949: cited in two inspections, most seriously at level D.

25. 25

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Insufficient nursing staff was cited in February 2024.

26. 26

    What led to the 2024 fine, and has it been paid?

    A $70,296 civil money penalty was imposed February 20, 2024. CMS publishes the fine, not whether it has been paid.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Nevada state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Nevada state survey agency

  Inspection Oct 16, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Nevada state survey agency

  Inspection Feb 20, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Nevada state survey agency

  Inspection Aug 9, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Nevada state survey agency

  Inspection Dec 19, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Nevada state survey agency

  Inspection Feb 2, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 295023

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.