Deficiency Records for North Star Manor
Updated as of July 01, 2022
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? |
---|---|---|---|---|
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 |
Meet requirements for sections of health care facilities separated by fire resistive construction. | 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 |
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 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-29 | 2019-05-06 | N |
Respond appropriately to all alleged violations. | Health | 2019-03-29 | 2019-05-06 | 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 |
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 |