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 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-06 | 2021-04-29 | 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 |
