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Deficiency Records for Clepper Manor
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.
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? |
|---|---|---|---|---|
| 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 | 2024-05-17 | 2024-07-02 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-05-09 | 2024-06-28 | N |
| Meet other general requirements. | Fire Safety | 2024-05-09 | 2024-06-28 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2024-05-09 | 2024-06-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-05-09 | 2024-06-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-09 | 2024-06-28 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-05-09 | 2024-06-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-09 | 2024-06-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-09 | 2024-06-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-05-09 | 2024-06-28 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-05-09 | 2024-06-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-05-09 | 2024-06-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-09 | 2024-06-28 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-06-06 | 2023-07-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-06-06 | 2023-07-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-06 | 2023-07-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-06 | 2023-07-01 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-06-06 | 2023-07-01 | N |
| Respond appropriately to all alleged violations. | Health | 2023-06-02 | 2023-06-30 | 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 | 2023-06-02 | 2023-06-30 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-06-02 | 2023-06-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-02 | 2023-06-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-06-02 | 2023-06-30 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-06-02 | 2023-06-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-02 | 2023-02-24 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-02-02 | 2023-02-24 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-18 | 2022-10-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-18 | 2022-09-16 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-07-15 | 2022-08-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-15 | 2022-08-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-15 | 2022-08-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-15 | 2022-08-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-03 | 2022-03-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-13 | Not Fixed | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-12-13 | Not Fixed | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-12-13 | Not Fixed | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-19 | Not Fixed | Y |
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