Inspection Reports for
North Star Assisted & Senior Living

.250.10.d. Heating, Ventilation, and Air-Conditioning (HVAC): facility could not provide documentation for inspection/testing of Fire Dampers within the last 4 years.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: facility could not provide documentation for the 5-year smoke detector sensitivity testing and emergency light testing monthly and annually (previously cited 9/25/2020).

.405.01.a. Electrical Installations and Equipment: multi plug adapters prohibited; rooms 144 and 149 were using multi plug adapters (previously cited 9/25/2020).

.405.04. Fuel-Fired Heating: facility could not provide documentation for annual fuel-fired heating systems inspection and service (previously cited 9/25/2020).

.330.15.a.ii. Fire and Life Safety Records: facility failed to ensure fire and life safety records were maintained; missing 5-year smoke detector sensitivity testing results led to a repeated deficiency.

.130.09. Correction of Non-Core Issues: facility failed to resolve previously cited deficiencies since last survey date of 9/25/2020; no documentation or communication was obtained regarding delay of resolution, leading to 3 repeat deficiencies on survey conducted on 2/8/2024.

.009.06.c Use of previous criminal history and background check: two of seven employees who required a state police background check did not have one completed; ISP background checks were not completed (previously cited 9/14/2016).

.450 Requirements for food and nutritional care services: the facility did not have any staff with Certified Food Protection Manager certification at the time of survey.

.335.02 Standard Precautions: the facility did not follow public health district or CDC recommendations to prevent transmission of infectious disease; staff, management, and visitors were observed wearing masks improperly or not at all.

.155.01 Relocation agreements: the facility had only one relocation agreement instead of the required two, and the existing agreement was dated "Infinite".

.410 Requirements for emergency actions and fire drills: fire drills were missing for first shift on first and second quarter 2020, and documentation for second shift, fourth quarter 2019 was incomplete with no time annotated.

.405.01.a Electrical installations and equipment: two extension cords and two multi-plug adapters were in use in the kitchen, including one for the microwave and other appliances.

.405.04 Fuel-fired heating: the facility could not provide documentation for the annual inspection of the gas fireplace in the living area.

.404 Fire and life safety standards for existing buildings: the facility lacked documentation for multiple required tests and inspections including smoke detector sensitivity, emergency lighting, sprinkler inspections, and had multiple penetrations and non-operational self-closing doors; kitchen cooler and freezer lacked sprinklers, some sprinkler heads were painted, and kitchen hood filters had gaps allowing grease vapors to enter (previously cited 12/17/2021).

.250.10.b Heating, ventilation, and air-conditioning (HVAC): gas fireplace in common living area did not have a safety barrier.

.220.03.d. Services, Supports, and Rates: the facility used a point system to determine service package charges but failed to adjust points down when outside services were paid for, potentially causing residents to pay higher rates for services not received.

.350.04. Written Response to Complaint Within Thirty Days: the administrator did not provide written responses to all complainants, responding verbally instead.

.550.23.b. Fee Changes: the facility did not provide written notice five days prior to fee changes; for example, rates were increased on the date notice was given when level of care increased.

.009.06.c Use of Previous Criminal History and Background Check: two of seven employees did not have evidence a state only background check was completed.

.300.01 Licensed Professional Nurse (RN): there was no documented evidence the facility nurse had delegated to four of four medication technicians.

.305.03 Resident Health Status: the facility RN did not document she had assessed residents when they had changes of condition, including wounds, weight loss, post-op wound, edema, swollen knee and urinary tract infection (previously cited 9/12/2013).

.153.01 Response of staff to abuse, neglect or exploitation of residents: the facility's abuse policy did not include a procedure to ensure Adult Protection and law enforcement were notified according to state statutes.

.215.07 Notification of Adult Protection and law enforcement: the administrator did not ensure that Adult Protection was notified immediately and law enforcement was notified within 4 hours when narcotic medications were diverted.

.711.04 Refusal of care consequences: the facility did not document a resident had been informed of the consequences of refusing cares and there was no documentation the resident's physician was informed of the refusals.

.405.01.a Electrical installations and equipment: three 6-2 multiple plug adapters were in use at the Nurse's office, Reception area abutting Lobby, and Med Room.

.405.05.a Structure, maintenance, equipment to assure safety: two fire doors in the 2-hour fire separation would not close and latch.