Deficiency Records for Northern Lights Hcc
Updated as of May 01, 2022
This is not the most recent data for Northern Lights Hcc. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Have a correctly designed non-healthcare occupancy area in a health care facility. | 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 other general requirements that are deficient. | Fire Safety | 2021-04-06 | 2021-05-31 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2021-04-07 | 2021-05-05 | 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 |
| Honor the resident's right to choose his or her attending physician. | Health | 2021-01-07 | 2021-02-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-10-28 | 2020-11-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-10-28 | 2020-11-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-18 | 2020-03-16 | 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 | 2020-02-18 | 2020-03-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-02-18 | 2020-03-16 | Y |
| Assess the resident when there is a significant change in condition | Health | 2019-08-07 | 2019-09-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-08-07 | 2019-09-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-07 | 2019-09-07 | 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 | 2019-08-07 | 2019-09-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-08-07 | 2019-09-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-08-07 | 2019-09-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-07 | 2019-09-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-07 | 2019-09-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-07 | 2019-09-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-07-19 | 2018-08-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-19 | 2018-08-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-19 | 2018-08-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-07-19 | 2018-08-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-07-19 | 2018-08-19 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-07-11 | 2018-07-11 | 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 | 2018-07-11 | 2018-07-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-07-11 | 2018-07-11 | N |
