St Agatha Comfort Care, LLC
Henderson, Nevada · CCN 291634
11145 S Eastern Ave, Suite 140
12 federal deficiencies across 2 surveys, January 20, 2023 to January 29, 2026.
Excludes the inspector’s preamble, which is not a finding
Federal surveys with at least one deficiency
Findings against a Condition of Participation — a compliance grade, not a measure of harm
What level the findings sit at
- Standard-level12100.0%
- A requirement within a Condition of Participation. The Condition itself was not cited.
These are compliance grades, not harm grades: how deep in the regulation a finding sits, not whether anyone was harmed.
Who conducted the surveys
CHAP, TJC.
Federal surveys are carried out by the state agency or a CMS-approved accrediting organisation.
Most-cited requirements
- L0795Criminal Background Checks2
- E0039EP Testing Requirements1
- L0523Timeframe for Completion of Assessment1
- L0545Content of Plan of Care1
- L0547Content of Plan of Care1
Survey record
| Survey | Type | Deficiencies | Condition-level |
|---|---|---|---|
| Jan 29, 2026 | Initial with CCN | 3 | — |
| Jan 20, 2023 | Initial | 9 | — |
In the inspector’s words
The complete written findings for this hospice, in the inspector’s own words.
Hospice findings published by CMS on QCOR, covering surveys from January 20, 2023 to January 29, 2026. The inspectors’ written findings come from a single CMS survey-report extract.
Federal survey findings only. State licensure findings for hospices are not shown.
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