Deficiency Records for Clovernook Health Care and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Clovernook Health Care and Rehabilitation 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-05 | 2024-01-09 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-12-13 | 2023-12-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-13 | 2023-12-13 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-12-13 | 2023-12-13 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-11-02 | 2023-11-17 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-11-02 | 2023-11-17 | Y |
| 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 | 2023-09-19 | 2023-09-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-19 | 2023-09-19 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-16 | 2023-09-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-18 | 2023-07-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-09 | 2023-06-23 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-09 | 2023-06-23 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-09-26 | 2022-11-02 | 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 | 2022-09-26 | 2022-11-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-26 | 2022-11-02 | 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 | 2022-09-26 | 2022-11-02 | 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 | 2022-09-26 | 2022-11-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-26 | 2022-11-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-26 | 2022-11-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-26 | 2022-11-02 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-26 | 2022-11-02 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-05 | 2022-11-02 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-09-22 | 2022-11-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-22 | 2022-11-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-22 | 2022-11-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-09-22 | 2022-11-02 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-08-02 | 2022-08-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-02 | 2022-08-19 | 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 | 2022-08-02 | 2022-08-19 | Y |
| 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 | 2022-08-02 | 2022-08-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-14 | 2022-04-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-21 | 2022-04-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-21 | 2022-04-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-21 | 2022-04-29 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-21 | 2022-04-29 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-21 | 2022-04-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-02 | 2022-04-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-10 | 2022-02-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-10 | 2022-02-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-10 | 2022-02-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-10 | 2022-02-04 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-10 | 2022-02-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-10 | 2022-02-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-10 | 2022-02-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-22 | 2022-02-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-19 | 2021-12-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-19 | 2021-12-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-19 | 2021-12-09 | Y |
| 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 | 2021-11-19 | 2021-12-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-19 | 2021-12-09 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-10 | 2021-12-09 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-11-10 | 2021-12-09 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-11-10 | 2021-12-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-28 | 2021-12-09 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-28 | 2021-12-09 | Y |
| 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 | 2021-09-14 | 2021-09-29 | 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 | 2021-09-14 | 2021-09-29 | Y |
| 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 | 2021-07-15 | 2021-08-03 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-15 | 2021-08-03 | Y |
| 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 | 2021-07-15 | 2021-08-03 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-06-22 | 2021-07-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-26 | 2019-10-31 | 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 | 2019-09-26 | 2019-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-26 | 2019-10-31 | N |
| Use approved construction type or materials. | Fire Safety | 2019-09-23 | 2019-10-31 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-09-23 | 2019-10-31 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2019-09-23 | 2019-10-31 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-09-23 | 2019-10-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-23 | 2019-10-31 | 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 | 2018-08-16 | 2018-10-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-16 | 2018-10-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-08-16 | 2018-10-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-14 | 2018-10-02 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-08-14 | 2018-10-02 | N |
