Clepper Manor

In the surveyor’s words

From the most serious findings on record at Clepper Manor, in the surveyor’s own words.

• Immediate jeopardy, patternF600Dec 13, 2023

  Based on review of clinical records, facility policy, and facility documentation, and staff interviews, it was determined that the facility failed to protect the residents' right to be free from neglect by not providing all necessary emergency services for one resident requiring cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest). This failure placed 14 residents in an Immediate Jeopardy situation. […]

• Immediate jeopardy, patternF836Dec 13, 2023

  Based on review of clinical records, facility policy, and facility documentation, and staff interviews, it was determined that the facility failed to comply with professional standards of care in accordance with Pennsylvania Code Title 49 Professional and Vocational Standards as required for one of one residents reviewed who had requested that cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) be administered in the event that they became unresponsive with no pulse and failed to provide all necessary emergency services for one resident requiring CPR. This failure placed 14 residents in an Immediate Jeopardy situation. […]

• No harm, potential for more than minimal, patternF839Aug 26, 2026

  Based on review of facility documentation and staff interviews, it was determined that the facility did not ensure one member of the nursing staff was appropriately licensed while providing care to residents on six of six days reviewed (6/22/26, 6/23/26, 6/24/26, 6/25/26, 6/26/26 and 6/29/26). Findings include: Review of facility documentation revealed that Licensed Practical Nurse (LPN), Employee E1, had worked on the following dates and hours as an LPN: 6/22/26- 8 hour shift 6/23/26 - 8 hour shift 6/24/26 -12 hour shift 6/25/26- 16 hour shift 6/26/26 -16 hour shift 6/29/26- 12 hour shift Further review revealed that the nursing license for LPN Employee E1 had been suspended on 6/17/26. During an interview on 8/21/26, at 1:00 p.m. […]

• No harm, potential for more than minimal, patternF655Feb 27, 2026

  Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to initiate a baseline care plan and/or provide a written summary of the baseline care plan and order summary to the resident and/or representative for three of 15 residents reviewed (Residents R3, R4, and R41).Findings include: A facility policy dated 1/21/26, entitled Baseline Care Plan revealed The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. […]

• No harm, potential for more than minimal, patternF657Feb 27, 2026

  Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan and failed to review and/or revise resident care plans for three of 15 residents reviewed (Residents R7, R32, and R33). Findings include: Review of a facility policy entitled, Comprehensive Care Plans with a policy review date of 1/21/26, indicated that the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set - federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment. […]