A list of the most recent deficiencies for The Clayberg. 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 | 2023-03-02 | 2023-03-20 | 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 | 2023-03-02 | 2023-03-15 | 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 | 2023-03-02 | 2023-03-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-02 | 2023-03-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-03-02 | 2023-03-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-02 | 2023-03-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-02 | 2023-03-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-02 | 2023-03-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-10 | 2023-01-23 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-01-13 | 2022-01-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-13 | 2022-01-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-13 | 2022-01-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-22 | 2021-10-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-27 | 2021-09-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-27 | 2021-09-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-05 | 2021-08-19 | 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 | 2020-10-08 | 2020-11-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-08 | 2020-11-05 | 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 | 2020-10-08 | 2020-11-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-10-09 | 2020-11-05 | N |
| Develop a communication plan. | Fire Safety | 2020-10-09 | 2020-11-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-10-09 | 2020-11-05 | 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 | 2020-10-09 | 2020-11-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-10-09 | 2020-11-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-09 | 2020-11-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-10-09 | 2020-11-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-10-09 | 2020-11-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-10-09 | 2020-11-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Establish methods for sharing information. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-10-09 | 2020-10-30 | N |
