North Star Manor

In the surveyor’s words

From the most serious findings on record at North Star Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF805Aug 18, 2026

  Based on observation, interview and document review the facility failed to ensure fluids were provided in a consistency/thickness to meet the needs for 1 of 1 resident (R1) reviewed for liquid consistency. This resulted in an immediate jeopardy for R1 who was served thin liquids, not in accordance with recommendations by the speech language pathologist (SLP).The IJ began on 8/1/26, when facility staff provided R1 with thin liquids despite an order for nectar thickened liquids. The IJ was identified on 8/18/26, the administrator was notified of the immediate jeopardy at 3:00 p.m. on 8/18/26. The immediate jeopardy was removed on 8/2/26, the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. […]

• Actual harm, isolatedF656Jul 30, 2026

  Based on observation, interview and document review the facility failed to ensure care planned interventions were implemented for toileting, resulting in a fall for 1 of 3 residents (R1). This resulted in actual harm to R1 when he fell and sustained a pelvic fracture. The facility had implemented actions to prevent recurrence prior to the survey; therefore, the citation was issued at past non-compliance. Findings include:R1's admission Record indicated R1 admitted to the facility 6/26/26. R1's diagnosis included stroke, spinal stenosis, weakness, blindness in one eye and fracture of left pubis (a break in the pubic bone at the front of the pelvis).R1's admission Minimum data Set (MDS) dated [DATE], identified moderate cognitive impairment and indicated R1 did not display behaviors. […]

• Actual harm, isolatedF689Jun 26, 2026

  Based on interview and record review the facility failed to provide care and supervision consistent with resident's needs, orders, and care plan to eliminate the risk of an accident during cares for 1 of 3 residents (R1) reviewed for falls. R1 needed increased monitoring for safety due to four previous falls at the facility, strict posterior hip precautions, and was unable to ambulate with nursing staff due to non-weight bearing status of right leg. This resulted in actual harm to R1 when RN-A was aware of the ambulation status, assisted R1 to the bathroom with walker and heard a popping sound during ambulation. This resulted in swelling of R1's right leg and complaints of increased pain. […]

• No harm, potential for more than minimal, widespreadF851Jun 27, 2024

  Based on interview and document review, the facility failed to ensure registered nurse hours were submitted accurately on the payroll-based journal. This had the potential to affect all 30 residents residing in the facility. Findings include: The PBJ (payroll-based journal) Staffing Report CASPER Report 1705D FY [fiscal year] Quarter 2 2024 (January 1 - March 31) identified a a trigger for no registered nurse (RN) hours on the following days: 2/24, 3/9, 3/10, 3/17, 3/24 and 3/31. The facility payroll and working scheduled were reviewed for 2/24, 3/9, 3/10, 3/17, 3/24 and 3/31 and there was a RN working for 8 hours consecutively on all 6 days identified on the PBJ report. During interview on 6/27/24, at 9:55 a.m. […]

• No harm, potential for more than minimal, widespreadF880Jun 27, 2024

  Based on observation, interview and document review, the facility failed to ensure soiled and potentially contaminated laundry was sorted in a manner to reduce the risk of cross contamination and spread of infection. This had the potential to affect all 38 residents who utilized laundry services. Findings include: On 6/25/24, a laundry tour was completed with housekeeper (HSK)-A. HSK-A stated dirty laundry from the nursing floor came down to the laundry room in barrels. The resident laundry went into one cart, the facility laundry (such as sheets or soaker pads); and kitchen laundry in another cart. The facility did not send out any of their laundry and all laundry was washed at the facility. […]