Deficiency Records for Clepper Manor
Updated as of January 01, 2022
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? |
|---|---|---|---|---|
| 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 |
| 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 | 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 |
| 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 |
| 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 |
