Deficiency Records for North Star Manor
Updated as of November 01, 2019
This is not the most recent data for North Star Manor. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Have a correctly designed non-healthcare occupancy area in a health care facility. | Fire Safety | 2019-03-28 | 2019-05-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-03-28 | 2019-05-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-28 | 2019-05-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-28 | 2019-05-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-03-28 | 2019-05-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-03-29 | 2019-05-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-03-29 | 2019-05-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-29 | 2019-05-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-03-29 | 2019-05-06 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-03-29 | 2019-04-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-03-29 | 2019-04-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-03-28 | 2019-04-17 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-03-28 | 2019-04-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-03-28 | 2019-04-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-28 | 2019-04-17 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-03-28 | 2019-04-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-03-28 | 2019-04-05 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-01-05 | 2018-02-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-01-05 | 2018-02-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-01-05 | 2018-02-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-01-05 | 2018-02-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-01-05 | 2018-02-14 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-01-05 | 2018-02-14 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-01-05 | 2018-02-14 | 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 ne | Health | 2018-01-05 | 2018-02-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-07-06 | 2017-07-28 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2017-07-06 | 2017-07-28 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2017-07-06 | 2017-07-28 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-07-06 | 2017-07-28 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-07-06 | 2017-07-28 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-07-06 | 2017-07-24 | N |
