North Starr Postacute Care

In the surveyor’s words

From the most serious findings on record at North Starr Postacute Care, in the surveyor’s own words.

• Actual harm, isolatedF686Aug 20, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF761Sep 13, 2024

  Based 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. Findings: During a concurrent observation and interview, on 9/10/24, at 11:52 a.m., with the Director of Nursing (DON), inside the medication room, the DON was observed reviewing the temperature log of the medication room and the medication refrigerator. […]

• No harm, potential for more than minimal, widespreadF943Sep 13, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812May 13, 2021

  Based on observation, interview, and record review, the facility failed to ensure sanitary conditions and safe food handling were maintain in the kitchen for 22 of 22 sampled residents when: 1. 12 food bowls and three cups were placed on top of one another and were stored moist; 2. One food bowl contained a white substance was stored with clean food bowls; 3. Five loaves of expired bread was stored in the kitchen; 4. A fan in the food preparation area had black substance present on the fan blades. These failures placed 22 residents at risk for foodborne illness (illness caused by contaminated food or water). Findings: 1. […]

• No harm, potential for more than minimal, widespreadF867May 13, 2021

  Based on interview and record review, the facility failed to take actions aimed at performance improvement when an ice machine (water?) filter, oxygen concentrators (a medical device that provides oxygen to patients) and call light system were not maintained (maintenanced per manufactures guidelines? ). [Refer F908, F919] These failures had the potential to result in physical harm to residents from foodborne illnesses, supplying inadequate oxygen levels, and having needs unmet by staff. Findings: During an interview on 5/13/21, at 1:46 p.m., with the Administrator (ADM), the ADM stated the facility was not aware of the water filter (is the ice machine filter the same as the water filter?) not being serviced for over a year. […]