Deficiency Records for Clepper Manor
Updated as of June 01, 2021
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? |
---|---|---|---|---|
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-02 | 2020-04-27 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-02 | 2020-04-27 | 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 | 2020-02-28 | 2020-04-14 | N |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-10-22 | 2019-12-18 | 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 | 2019-10-22 | 2019-12-18 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-31 | 2019-08-21 | Y |
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 necessary and PRN use is limited. | 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 |
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 | 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 |
Honor each resident's preferences, choices, values and beliefs. | 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 |
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 an enclosure around a vertical opening shaft. | 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 |