Deficiency Records for North Star Manor
Updated as of May 01, 2024
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Deficiency Records for North Star Manor
A list of the most recent deficiencies for North Star Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for North Star Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
---|---|---|---|---|
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-13 | 2023-11-07 | N |
Provide and implement an infection prevention and control program. | Health | 2023-09-14 | 2023-10-10 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-13 | 2023-09-21 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-13 | 2023-09-13 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-09 | 2023-08-24 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-06 | 2023-02-01 | Y |
Respond appropriately to all alleged violations. | Health | 2023-01-06 | 2023-02-01 | Y |
Ensure that residents are free from significant medication errors. | Health | 2023-01-06 | 2023-02-01 | Y |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-06-16 | 2022-07-15 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-25 | 2022-07-08 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-25 | 2022-07-08 | N |
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-05-24 | 2022-06-24 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-05 | 2021-12-21 | Y |
Respond appropriately to all alleged violations. | Health | 2021-11-05 | 2021-12-21 | Y |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-02-19 | 2020-04-15 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-19 | 2020-04-15 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-19 | 2020-04-15 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-02-19 | 2020-04-15 | N |
Ensure that residents are free from significant medication errors. | Health | 2020-02-19 | 2020-04-15 | N |
Provide and implement an infection prevention and control program. | Health | 2020-02-19 | 2020-04-15 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-02-19 | 2020-04-15 | N |
Include a process for Emergency Preparedness collaboration. | Fire Safety | 2020-02-19 | 2020-04-15 | N |
Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-02-19 | 2020-04-15 | N |
Establish policies and procedures for sheltering. | Fire Safety | 2020-02-19 | 2020-04-15 | N |
Establish policies and procedures for medical documentation. | Fire Safety | 2020-02-19 | 2020-04-15 | N |
Establish policies and procedures for volunteers. | Fire Safety | 2020-02-19 | 2020-04-15 | N |
Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-02-19 | 2020-04-15 | N |
Provide primary/alternate means for communication. | Fire Safety | 2020-02-19 | 2020-04-15 | N |
Establish methods for sharing information. | Fire Safety | 2020-02-19 | 2020-04-15 | N |
Provide a means of sharing information on occupancy/needs. | Fire Safety | 2020-02-19 | 2020-04-15 | N |
Provide family notifications of emergency plan. | Fire Safety | 2020-02-19 | 2020-04-15 | N |
Establish staff and initial training requirements. | Fire Safety | 2020-02-19 | 2020-04-15 | N |
Conduct testing and exercise requirements. | Fire Safety | 2020-02-19 | 2020-04-15 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-19 | 2020-04-15 | N |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-02-19 | 2020-02-20 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-19 | 2020-02-20 | N |
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