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Deficiency Records for Northwest Manor Health Care Center
A list of the most recent deficiencies for Northwest Manor Health Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Northwest Manor Health Care Center. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-08 | 2024-10-01 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-05-08 | 2024-07-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-08 | 2024-06-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-05-08 | 2024-05-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-05-08 | 2024-05-27 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2024-05-08 | 2024-05-27 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-05-08 | 2024-05-27 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-05-08 | 2024-05-27 | N |
| Meet other general requirements. | Fire Safety | 2024-05-08 | 2024-05-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-05-08 | 2024-05-27 | 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 | 2024-05-08 | 2024-05-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-08 | 2024-05-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-08 | 2024-05-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-05-08 | 2024-05-27 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2024-05-08 | 2024-05-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-08 | 2024-05-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-08 | 2024-05-27 | 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 | 2024-04-04 | 2024-05-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-04 | 2024-05-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-04-04 | 2024-05-06 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-02-07 | 2023-02-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-07 | 2023-02-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-07 | 2023-02-26 | 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 | 2023-02-07 | 2023-02-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-07 | 2023-02-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-02-07 | 2023-02-24 | 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 | 2023-01-20 | 2023-02-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-20 | 2023-02-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-20 | 2023-02-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-01-20 | 2023-02-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-20 | 2023-02-20 | 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 | 2023-01-20 | 2023-02-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-20 | 2023-02-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-20 | 2023-02-20 | 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 | 2023-01-20 | 2023-02-20 | 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 | 2023-01-20 | 2023-02-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-03-26 | 2019-04-25 | 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 | 2019-03-26 | 2019-04-25 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-03-26 | 2019-04-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-03-26 | 2019-04-25 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2019-03-26 | 2019-04-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-26 | 2019-04-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-26 | 2019-04-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-26 | 2019-04-25 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-02-22 | 2019-03-06 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-02-22 | 2019-03-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-22 | 2019-03-06 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-02-22 | 2019-03-06 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-02-22 | 2019-03-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-22 | 2019-03-06 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2019-02-22 | 2019-03-06 | N |
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