Deficiency Records for North Star Manor
Updated as of June 01, 2021
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 |
| 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 necessary and PRN use is limited. | Health | 2018-01-05 | 2018-02-14 | N |
