A list of the most recent deficiencies for Cloverleaf of Knightsville. 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? |
|---|---|---|---|---|
| Have exits that are accessible at all times. | Fire Safety | 2023-11-27 | 2023-12-27 | N |
| Have an externally vented heating system. | Fire Safety | 2023-11-27 | 2023-12-27 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-11-27 | 2023-12-14 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-11-27 | 2023-12-14 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-11-27 | 2023-12-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-27 | 2023-12-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-27 | 2023-12-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-27 | 2023-12-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-27 | 2023-12-14 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-11-27 | 2023-12-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-27 | 2023-12-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-03 | 2023-12-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-03 | 2023-12-08 | 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 | 2023-11-03 | 2023-12-08 | 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 | 2023-11-03 | 2023-12-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-03 | 2023-12-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-03 | 2023-12-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-11-03 | 2023-12-08 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-11-03 | 2023-12-08 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-08-30 | 2022-09-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-08-30 | 2022-09-30 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-08-30 | 2022-09-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-30 | 2022-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-30 | 2022-09-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-30 | 2022-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-30 | 2022-09-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-30 | 2022-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-30 | 2022-09-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-30 | 2022-09-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-04 | 2022-09-04 | 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 | 2022-08-04 | 2022-09-04 | 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 | 2022-08-04 | 2022-09-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-04 | 2022-09-04 | 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 | 2022-08-04 | 2022-09-04 | 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 | 2022-08-04 | 2022-09-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-04 | 2022-09-04 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-08-04 | 2022-09-04 | N |
| Meet other general requirements. | Fire Safety | 2021-08-26 | 2021-10-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-26 | 2021-10-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-26 | 2021-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-26 | 2021-10-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-08-26 | 2021-10-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-26 | 2021-10-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-13 | 2021-09-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-08-13 | 2021-09-12 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-08-13 | 2021-09-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-13 | 2021-09-12 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-08-13 | 2021-09-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-13 | 2021-09-12 | 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 | 2021-08-13 | 2021-09-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-13 | 2021-09-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-08-13 | 2021-09-12 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-08-13 | 2021-09-12 | 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 | 2021-08-13 | 2021-09-12 | 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 | 2021-08-13 | 2021-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-13 | 2021-09-12 | N |
