Cycle 1
Health 2024-12-19 · Fire 2024-12-19
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Carson City, NV
Northstar Post Acute
2-star overall rating with 2-star inspections with $70,296 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2898 Highway 50 East, Carson City, NV
(775) 882-3301
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
73
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Covenant Care
Operator or chain grouping
Approved since
1973-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
24 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.87
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.66
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.14
All reported nurse hours · state 4.34 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.85 · national 3.43
Weekend RN hours
0.88
Weekend registered nurse coverage · state 0.85 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
3.39
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,647
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9840
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.69
Baseline 17.66% · Performance 20.65% · Measure score 1.69 · Achievement 1.69 · Improvement 0
Healthcare-associated infections
5.22
Baseline 4.29% · Performance 6.28% · Measure score 5.22 · Achievement 5.22 · Improvement 0
Total nurse turnover
2.06
Baseline 57.78% · Performance 55.26% · Measure score 2.06 · Achievement 2.06 · Improvement 0.26
Adjusted total nurse staffing
1.48
Baseline 2.82 hours · Performance 3.41 hours · Measure score 1.48 · Achievement 1.17 · Improvement 1.48
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.52% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 207 · Observed rate 12.56% · Lower 95% interval 8.4% |
| Discharge to community | 50.26% |
50.57%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 210 · Observed rate 43.81% · Lower 95% interval 42.16% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 89.52% |
95.27%
5.8 pts worse
|
Numerator 94 · Denominator 105 |
| Falls with major injury | 0.95% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 105 |
| Discharge self-care score | 78.95% |
53.69%
25.3 pts better
|
Numerator 45 · Denominator 57 |
| Discharge mobility score | 75.44% |
50.94%
24.5 pts better
|
Numerator 43 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 105 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.28% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 5.38% · Lower 95% interval 4.15% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 66 |
| Staff flu vaccination coverage | 62.32% |
42%
20.3 pts better
|
Numerator 43 · Denominator 69 |
| Discharge function score | 73.68% |
56.45%
17.2 pts better
|
Numerator 42 · Denominator 57 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 53 · Denominator 53 |
| Transfer of health information to patient | 90.32% |
96.28%
6 pts worse
|
Numerator 28 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 5.88% |
25.2%
19.3 pts worse
|
Numerator 3 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.3 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.5%
8.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 64.4% |
89.6%
25.2 pts worse
|
95.5%
31.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 64.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
2.3%
0.2 pts worse
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.6% · Q3 2.3% · Q4 2.1% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.6% |
4.9%
3.7 pts worse
|
11.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.8% · Q3 4.8% · Q4 20.0% · 4Q avg 8.6% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.6%
0.9 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 13.2% · Q3 0.0% · Q4 0.0% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.9% |
22.2%
5.3 pts better
|
19.6%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 10.3% · Q3 23.1% · Q4 11.6% · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.8% |
18.5%
7.7 pts better
|
16.7%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 12.9% · Q3 12.1% · Q4 10.3% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.6% |
19.1%
8.5 pts better
|
16.3%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 30.6% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.0% |
14.2%
2.8 pts worse
|
14.9%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 26.3% · Q3 0.0% · Q4 25.6% · 4Q avg 17.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
1.8%
0.7 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.3% · Q3 0.0% · Q4 2.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.4% |
16.5%
8.1 pts better
|
19.8%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.5% · Q3 9.2% · Q4 16.7% · 4Q avg 8.4% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
5.5%
1.5 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 8.4% · Q3 6.8% · Q4 6.1% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
84.1%
11.6 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 97.6% · Q3 98.4% · Q4 87.9% · 4Q avg 95.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.0% |
9.8%
5.2 pts worse
|
12.0%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 15.7% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.2% |
80.7%
7.5 pts worse
|
79.7%
6.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.6% |
23.4%
6.2 pts worse
|
23.9%
5.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.6% · Observed 31.4% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-20 · Fire 2024-02-20
39 health deficiencies
Top issue: Resident Rights (9 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2022-12-01 · Fire 2022-12-01
32 health deficiencies
Top issue: Infection Control (8 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-19
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-01-29
E · Potential for more than minimal harm
2024-12-19
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-29
E · Potential for more than minimal harm
2024-02-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-20
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-20
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-20
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-20
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-02-20
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-20
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-01
D · Potential for more than minimal harm
2022-12-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-01-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-19
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-01-29
E · Potential for more than minimal harm
2024-12-19
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-19
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-01-29
C · Minimal harm
2024-12-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-08-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-03
G · Actual harm
2024-02-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-07
F · Potential for more than minimal harm
2024-02-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-07
F · Potential for more than minimal harm
2024-02-20
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-04-07
E · Potential for more than minimal harm
2024-02-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-04-07
E · Potential for more than minimal harm
2024-02-20
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F578 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F700 · Quality of Life and Care Deficiencies
Health
Try 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.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F887 · Infection Control Deficiencies
Health
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.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2024-04-07
D · Potential for more than minimal harm
2024-02-20
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-04-07
C · Minimal harm
2024-02-20
F584 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2024-04-07
D · Potential for more than minimal harm
2023-10-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-29
D · Potential for more than minimal harm
2023-09-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-13
E · Potential for more than minimal harm
2023-05-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-07
E · Potential for more than minimal harm
2023-05-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-03-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-25
F · Potential for more than minimal harm
2022-12-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-12-01
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F887 · Infection Control Deficiencies
Health
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.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-01-23
Penalties and ownership
What sits behind the stars
$70,296
2024-02-20
Fine
Fine · fine $70,296
Fine
Ownership
Covenant Care California, LLC
5% Or Greater Direct Ownership Interest · Organization
Ashley, Dava
Operational/Managerial Control · Individual
Ashley, Dava
Corporate Officer · Individual
Carney, Kevin
Corporate Officer · Individual
Centre Capital Investors V, LP
5% Or Greater Indirect Ownership Interest · Organization
Centre Covenant Purchaser (B), LLC
5% Or Greater Indirect Ownership Interest · Organization
Centre Covenant Purchaser (Q), LLC
5% Or Greater Indirect Ownership Interest · Organization
Centre Covenant Purchaser (S), LLC
5% Or Greater Indirect Ownership Interest · Organization
Centre V Secondary Fund, L.p.
5% Or Greater Indirect Ownership Interest · Organization
Covenant Care, LLC
5% Or Greater Indirect Ownership Interest · Organization
Covenant Holdco, LLC
5% Or Greater Indirect Ownership Interest · Organization
Covenant Subco, LLC
5% Or Greater Indirect Ownership Interest · Organization
Evans, Mary
5% Or Greater Indirect Ownership Interest · Individual
Evans, Mary
Corporate Officer · Individual
Levin, Robert
5% Or Greater Indirect Ownership Interest · Individual
Levin, Robert
Corporate Officer · Individual
Midcap Funding Iv Trust
5% Or Greater Security Interest · Organization
Sims, Christine
5% Or Greater Indirect Ownership Interest · Individual
Sims, Christine
Corporate Officer · Individual
Sparks, Carol
W-2 Managing Employee · Individual
State Treasurer Of Mich Custodian Of Public School Empl Rtmnt Systems
5% Or Greater Indirect Ownership Interest · Organization
Stockwell Fund Ii LP
5% Or Greater Indirect Ownership Interest · Organization
Torok, Andrew
5% Or Greater Indirect Ownership Interest · Individual
Torok, Andrew
Corporate Officer · Individual
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