A list of the most recent deficiencies for Clepper Manor. 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? |
|---|---|---|---|---|
| Provide family notifications of emergency plan. | Fire Safety | 2023-06-06 | 2023-07-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-06-06 | 2023-07-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-06 | 2023-07-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-06 | 2023-07-01 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-06-06 | 2023-07-01 | N |
| Respond appropriately to all alleged violations. | Health | 2023-06-02 | 2023-06-30 | 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 | 2023-06-02 | 2023-06-30 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-06-02 | 2023-06-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-02 | 2023-06-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-06-02 | 2023-06-30 | 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 | 2023-06-02 | 2023-06-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-02 | 2023-02-24 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-02-02 | 2023-02-24 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-18 | 2022-10-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-18 | 2022-09-16 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-07-15 | 2022-08-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-15 | 2022-08-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-15 | 2022-08-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-15 | 2022-08-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-03 | 2022-03-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-09 | 2021-10-01 | 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 | 2021-08-09 | 2021-10-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-09 | 2021-10-01 | 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 | 2021-08-09 | 2021-10-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-09 | 2021-10-01 | 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 | 2021-08-09 | 2021-10-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-09 | 2021-10-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-09 | 2021-10-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-08-09 | 2021-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-09 | 2021-10-01 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-08-09 | 2021-10-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-09 | 2021-10-01 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-08-12 | 2021-10-01 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-08-12 | 2021-10-01 | N |
| Use approved construction type or materials. | Fire Safety | 2021-08-12 | 2021-10-01 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-08-12 | 2021-10-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-08-12 | 2021-10-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-12 | 2021-10-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-12 | 2021-10-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-12 | 2021-10-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-12 | 2021-10-01 | 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 | 2021-06-25 | 2021-07-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-25 | 2021-07-21 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-06-25 | 2021-07-21 | Y |
| Report COVID19 data to residents and families. | Health | 2021-06-25 | 2021-07-21 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-05-21 | 2021-06-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-22 | 2021-05-06 | Y |
| 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 | 2021-04-22 | 2021-04-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-13 | Not Fixed | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-12-13 | Not Fixed | Y |
| 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 | 2023-12-13 | Not Fixed | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-19 | Not Fixed | Y |
