Deficiency Records for Clepper Manor
Updated as of August 01, 2019
This is not the most recent data for Clepper Manor. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-23 | 2019-06-07 | N |
| 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 | 2019-04-19 | 2019-06-03 | 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 | 2019-04-19 | 2019-06-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-19 | 2019-06-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-19 | 2019-06-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-19 | 2019-06-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-19 | 2019-06-03 | N |
| 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 | 2019-04-19 | 2019-06-03 | 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 ne | Health | 2019-04-19 | 2019-06-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-04-19 | 2019-06-03 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-06-16 | 2018-09-05 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-02-06 | 2018-04-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-02-06 | 2018-04-06 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-02-06 | 2018-04-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-06 | 2018-04-06 | 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 | 2018-02-06 | 2018-04-06 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-02-06 | 2018-04-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-02-06 | 2018-04-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-02-06 | 2018-04-06 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-02-06 | 2018-04-06 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2018-02-13 | 2018-04-04 | 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 | 2018-02-13 | 2018-04-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-02-13 | 2018-04-04 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2017-09-12 | 2017-10-20 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2017-09-12 | 2017-10-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-09-12 | 2017-10-20 | Y |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-09-12 | 2017-10-20 | Y |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-09-12 | 2017-10-20 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-09-12 | 2017-10-20 | Y |
| Provide clean bed and bath linens that are in good condition. | Health | 2017-08-30 | 2017-09-30 | Y |
| Provide food in a way that meets a resident's needs. | Health | 2017-08-30 | 2017-09-30 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-30 | 2017-09-30 | Y |
| Have a correctly designed non-healthcare occupancy area in a health care facility. | Fire Safety | 2017-03-21 | 2017-05-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-03-21 | 2017-05-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-03-21 | 2017-05-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-03-21 | 2017-05-20 | N |
| Provide housekeeping and maintenance services. | Health | 2017-03-16 | 2017-05-15 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-03-16 | 2017-05-15 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-03-16 | 2017-05-15 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-16 | 2017-05-15 | N |
