Clara Manor Nursing Home

FHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0727 · Deficient, Provider has date of correction (Nov 30, 2025)

FProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Nov 30, 2025)

EEnsure that residents are fully informed and understand their health status, care and treatments.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0552 · Deficient, Provider has date of correction (Nov 30, 2025)

EHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Deficient, Provider has date of correction (Nov 30, 2025)

EEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (Nov 30, 2025)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Nov 30, 2025)

DThe resident has the right to receive notices in a format and a language he or she understands.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0574 · Deficient, Provider has date of correction (Nov 30, 2025)

DAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0577 · Deficient, Provider has date of correction (Nov 30, 2025)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Nov 30, 2025)

DProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0623 · Complaint inspection · Deficient, Provider has date of correction (Mar 26, 2025)

DNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0622 · Complaint inspection · Deficient, Provider has date of correction (Feb 22, 2025)

DProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0623 · Complaint inspection · Deficient, Provider has date of correction (Mar 26, 2025)

DEnsure each resident must receive and the facility must provide necessary behavioral health care and services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0740 · Complaint inspection · Deficient, Provider has date of correction (Feb 22, 2025)

FEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0801 · Deficient, Provider has date of correction (Jan 5, 2025)

FEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0803 · Deficient, Provider has date of correction (Jan 5, 2025)

FDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0882 · Deficient, Provider has date of correction (Jan 5, 2025)

FMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0925 · Deficient, Provider has date of correction (Jan 5, 2025)

FEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0947 · Deficient, Provider has date of correction (Jan 5, 2025)

EAssure the security of all personal funds of residents deposited with the facility.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0570 · Deficient, Provider has date of correction (Feb 22, 2025)

EHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Deficient, Provider has date of correction (Jan 5, 2025)

EEnsure services provided by the nursing facility meet professional standards of quality.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0658 · Deficient, Provider has date of correction (Feb 22, 2025)

EProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0678 · Deficient, Provider has date of correction (Jan 5, 2025)

EProvide enough food/fluids to maintain a resident's health.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0692 · Deficient, Provider has date of correction (Jan 5, 2025)

EProvide safe and appropriate respiratory care for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Deficient, Provider has date of correction (Feb 22, 2025)

EPost nurse staffing information every day.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0732 · Deficient, Provider has date of correction (Jan 5, 2025)

EEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (Feb 22, 2025)

EProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Jan 5, 2025)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Jan 5, 2025)

EDevelop and implement policies and procedures for flu and pneumonia vaccinations.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0883 · Deficient, Provider has date of correction (Jan 5, 2025)

EEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0887 · Deficient, Provider has date of correction (Jan 5, 2025)

EMake sure that a working call system is available in each resident's bathroom and bathing area.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0919 · Deficient, Provider has date of correction (Jan 5, 2025)

EMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0921 · Deficient, Provider has date of correction (Jan 5, 2025)

DHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Deficient, Provider has date of correction (Jan 5, 2025)

DDevelop and implement policies and procedures to prevent abuse, neglect, and theft.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0607 · Deficient, Provider has date of correction (Jan 5, 2025)

DNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0622 · Complaint inspection · Deficient, Provider has date of correction (Feb 22, 2025)

DProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0623 · Complaint inspection · Deficient, Provider has date of correction (Mar 26, 2025)

DPermit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0626 · Complaint inspection · Deficient, Provider has date of correction (Mar 26, 2025)

DEnsure each resident receives an accurate assessment.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0641 · Deficient, Provider has date of correction (Jan 5, 2025)

DDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Deficient, Provider has date of correction (Jan 5, 2025)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Jan 5, 2025)

DProvide safe, appropriate dialysis care/services for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (Jan 5, 2025)

DTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0700 · Deficient, Provider has date of correction (Jan 5, 2025)

DHave a policy regarding use and storage of foods brought to residents by family and other visitors.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0813 · Deficient, Provider has date of correction (Jan 5, 2025)

DDispose of garbage and refuse properly.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0814 · Deficient, Provider has date of correction (Jan 5, 2025)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Deficient, Provider has date of correction (Jan 5, 2025)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (Sep 26, 2024)

DRespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Complaint inspection · Deficient, Provider has date of correction (Sep 26, 2024)

DProvide 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.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0742 · Complaint inspection · Deficient, Provider has date of correction (Sep 26, 2024)

DProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0623 · Complaint inspection · Deficient, Provider has date of correction (Mar 29, 2024)

DPrepare residents for a safe transfer or discharge from the nursing home.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0624 · Complaint inspection · Deficient, Provider has date of correction (Mar 29, 2024)

FPost nurse staffing information every day.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0732 · Deficient, Provider has date of correction (Jul 12, 2023)

FEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0801 · Deficient, Provider has date of correction (Jun 11, 2023)

FEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0803 · Deficient, Provider has date of correction (Jun 11, 2023)

FProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Jun 11, 2023)

FSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Deficient, Provider has date of correction (Jun 11, 2023)

FElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Potential for more than minimal harm · Administration Deficiencies · Tag F0851 · Deficient, Provider has date of correction (Jun 11, 2023)

FEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0947 · Deficient, Provider has date of correction (Jun 11, 2023)

EAllow residents to self-administer drugs if determined clinically appropriate.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0554 · Deficient, Provider has date of correction (Jun 11, 2023)

EHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Deficient, Provider has date of correction (Jun 11, 2023)

ERespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Deficient, Provider has date of correction (Jun 11, 2023)

ENotify 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0625 · Deficient, Provider has date of correction (Jun 11, 2023)

EDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Deficient, Provider has date of correction (Jun 11, 2023)

EEnsure services provided by the nursing facility meet professional standards of quality.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0658 · Deficient, Provider has date of correction (Jun 11, 2023)

EProvide safe and appropriate respiratory care for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Deficient, Provider has date of correction (Jun 11, 2023)

EEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0804 · Deficient, Provider has date of correction (Jun 11, 2023)

EAdminister the facility in a manner that enables it to use its resources effectively and efficiently.

Potential for more than minimal harm · Administration Deficiencies · Tag F0835 · Deficient, Provider has date of correction (Jun 11, 2023)

EEnsure 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.

Potential for more than minimal harm · Administration Deficiencies · Tag F0836 · Deficient, Provider has date of correction (Jun 11, 2023)

EEnsure staff are vaccinated for COVID-19

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0888 · Deficient, Provider has date of correction (Jun 11, 2023)

DProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Deficient, Provider has date of correction (Jun 11, 2023)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Deficient, Provider has date of correction (Jun 11, 2023)

DCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0644 · Deficient, Provider has date of correction (Jun 11, 2023)

DDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Deficient, Provider has date of correction (Jun 11, 2023)

DPlan the resident's discharge to meet the resident's goals and needs.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0660 · Deficient, Provider has date of correction (Jun 11, 2023)

DProvide care and assistance to perform activities of daily living for any resident who is unable.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Deficient, Provider has date of correction (Jun 11, 2023)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Deficient, Provider has date of correction (Jul 12, 2023)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Deficient, Provider has date of correction (Jun 11, 2023)

DEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (Jun 11, 2023)

DProvide or obtain dental services for each resident.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0791 · Deficient, Provider has date of correction (Jun 11, 2023)

DHave a policy regarding use and storage of foods brought to residents by family and other visitors.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0813 · Deficient, Provider has date of correction (Jun 11, 2023)

DDispose of garbage and refuse properly.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0814 · Deficient, Provider has date of correction (Jun 11, 2023)

DProvide or get specialized rehabilitative services as required for a resident.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0825 · Deficient, Provider has date of correction (Jul 12, 2023)

DDevelop and implement policies and procedures for flu and pneumonia vaccinations.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0883 · Deficient, Provider has date of correction (Jun 11, 2023)