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Deficiency Records for The Clayberg
A list of the most recent deficiencies for The Clayberg. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for The Clayberg. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-31 | 2024-06-10 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-15 | 2024-06-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-15 | 2024-06-05 | 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 | 2024-05-15 | 2024-06-05 | 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 | 2024-05-15 | 2024-06-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-15 | 2024-06-05 | 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 | 2024-05-15 | 2024-05-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-15 | 2024-05-31 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2024-05-15 | 2024-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-02 | 2023-03-20 | 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 | 2023-03-02 | 2023-03-15 | 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 | 2023-03-02 | 2023-03-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-02 | 2023-03-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-03-02 | 2023-03-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-02 | 2023-03-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-02 | 2023-03-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-02 | 2023-03-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-10 | 2023-01-23 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-01-13 | 2022-01-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-13 | 2022-01-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-13 | 2022-01-26 | N |
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