A list of the most recent deficiencies for Clay Healthcare 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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-31 | 2023-12-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-10-31 | 2023-12-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-31 | 2023-12-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-01 | 2023-12-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-11-01 | 2023-12-01 | N |
| 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 | 2023-11-01 | 2023-12-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-01 | 2023-12-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-01 | 2023-12-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-01 | 2023-12-01 | 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 | 2023-11-01 | 2023-12-01 | N |
| Provide activities to meet all resident's needs. | Health | 2023-11-01 | 2023-12-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-01 | 2023-12-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-11-01 | 2023-12-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-01 | 2023-12-01 | 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 | 2023-11-01 | 2023-12-01 | N |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2023-11-01 | 2023-12-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-01 | 2023-12-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-11-01 | 2023-12-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-29 | 2022-08-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-29 | 2022-08-08 | 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 | 2022-06-29 | 2022-08-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-29 | 2022-08-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-29 | 2022-08-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-29 | 2022-08-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-06-29 | 2022-08-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-06-29 | 2022-08-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-29 | 2022-08-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-06-29 | 2022-08-08 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-29 | 2022-07-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-29 | 2022-07-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-07 | 2021-04-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-07 | 2021-04-09 | N |
