A list of the most recent deficiencies for Clara Manor Nursing Home. 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? |
|---|---|---|---|---|
| Post nurse staffing information every day. | Health | 2023-04-28 | 2023-07-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-28 | 2023-07-12 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-04-28 | 2023-07-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-28 | 2023-07-12 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2023-04-28 | 2023-06-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-04-28 | 2023-06-11 | 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 | 2023-04-28 | 2023-06-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-28 | 2023-06-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-28 | 2023-06-11 | 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 | 2023-04-28 | 2023-06-11 | 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 | 2023-04-28 | 2023-06-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-28 | 2023-06-11 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-04-28 | 2023-06-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-28 | 2023-06-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-28 | 2023-06-11 | 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 | 2023-04-28 | 2023-06-11 | N |
| Provide or obtain dental services for each resident. | Health | 2023-04-28 | 2023-06-11 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-04-28 | 2023-06-11 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-04-28 | 2023-06-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-28 | 2023-06-11 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-04-28 | 2023-06-11 | N |
| Dispose of garbage and refuse properly. | Health | 2023-04-28 | 2023-06-11 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-04-28 | 2023-06-11 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-04-28 | 2023-06-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-28 | 2023-06-11 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-04-28 | 2023-06-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-28 | 2023-06-11 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-04-28 | 2023-06-11 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-04-28 | 2023-06-11 | N |
| Respond appropriately to all alleged violations. | Health | 2023-04-28 | 2023-06-11 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-04-28 | 2023-06-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-28 | 2023-06-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-28 | 2023-06-11 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-28 | 2023-06-11 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-04-28 | 2023-06-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-04-28 | 2023-06-11 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-04-28 | 2023-06-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-04-28 | 2023-06-11 | 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 | 2023-04-28 | 2023-06-11 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-04-28 | 2023-06-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-28 | 2023-06-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-28 | 2023-06-11 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-04-28 | 2023-06-11 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-04-28 | 2023-06-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-28 | 2023-06-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-28 | 2023-06-11 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-04-28 | 2023-06-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-28 | 2023-06-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-28 | 2023-06-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-16 | 2023-01-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-16 | 2023-01-29 | Y |
| 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 | 2022-12-16 | 2023-01-29 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-12-16 | 2023-01-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-26 | 2021-11-08 | 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 | 2021-07-26 | 2021-11-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-26 | 2021-11-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-26 | 2021-11-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-26 | 2021-11-08 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-07-26 | 2021-11-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-26 | 2021-11-08 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-07-26 | 2021-09-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-26 | 2021-09-08 | N |
| Respond appropriately to all alleged violations. | Health | 2021-07-26 | 2021-09-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-26 | 2021-09-08 | 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 | 2021-07-26 | 2021-09-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-26 | 2021-09-08 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-07-26 | 2021-09-08 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-07-26 | 2021-09-08 | 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 | 2021-07-26 | 2021-09-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-26 | 2021-09-08 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-07-26 | 2021-09-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-26 | 2021-09-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-26 | 2021-09-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-26 | 2021-09-08 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Use approved construction type or materials. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-26 | 2021-09-08 | 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 | 2021-07-26 | 2021-09-08 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-07-26 | 2021-09-08 | 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 | 2021-07-26 | 2021-09-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-26 | 2021-09-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-09 | 2019-10-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-09 | 2019-10-23 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-09-09 | 2019-10-23 | 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 | 2019-09-09 | 2019-10-23 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-09-09 | 2019-10-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-09 | 2019-10-23 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-09-09 | 2019-10-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-09 | 2019-10-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-09 | 2019-10-23 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2019-09-09 | 2019-10-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-09 | 2019-10-23 | 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 | 2019-09-09 | 2019-10-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-09 | 2019-10-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-09 | 2019-10-23 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2019-09-09 | 2019-10-23 | 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 | 2019-09-09 | 2019-10-23 | N |
| Provide or obtain dental services for each resident. | Health | 2019-09-09 | 2019-10-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-09 | 2019-10-23 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-09-09 | 2019-10-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-09 | 2019-10-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-09 | 2019-10-23 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-09-09 | 2019-10-23 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-09 | 2019-10-23 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-09-09 | 2019-10-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-09-09 | 2019-10-23 | 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 | 2019-09-09 | 2019-10-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-09 | 2019-10-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-09 | 2019-10-23 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-09-09 | 2019-10-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-09 | 2019-10-23 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-09-09 | 2019-10-23 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2019-09-09 | 2019-10-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-09 | 2019-10-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-09 | 2019-10-23 | N |
