A list of the most recent deficiencies for Northern Lights Hcc. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-09 | 2023-06-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-09 | 2023-06-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-09 | 2023-06-19 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-05-09 | 2023-06-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-09 | 2023-06-19 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-05-09 | 2023-06-19 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-05-10 | 2023-06-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-10 | 2023-06-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-10 | 2023-06-09 | 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 | 2023-05-10 | 2023-06-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-10 | 2023-06-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-10 | 2023-06-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-10 | 2023-06-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-10 | 2023-06-09 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-05 | 2023-03-28 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-04-06 | 2022-05-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-04-06 | 2022-05-19 | 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 | 2022-04-06 | 2022-05-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-06 | 2022-05-19 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-04-06 | 2022-05-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-06 | 2022-05-19 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-04-05 | 2022-05-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-05 | 2022-05-19 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-04-05 | 2022-05-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-05 | 2022-05-19 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-04-05 | 2022-05-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-05 | 2022-05-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-07 | 2021-06-07 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-04-06 | 2021-05-31 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-04-06 | 2021-05-31 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-04-06 | 2021-05-31 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-04-06 | 2021-05-31 | 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 | 2021-04-06 | 2021-05-31 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-04-06 | 2021-05-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-06 | 2021-05-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-06 | 2021-05-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-06 | 2021-05-31 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-04-06 | 2021-05-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-07 | 2021-05-05 | N |
| Respond appropriately to all alleged violations. | Health | 2021-04-07 | 2021-05-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-07 | 2021-05-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-07 | 2021-05-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-04-07 | 2021-05-05 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-04-07 | 2021-05-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-07 | 2021-05-05 | N |
