Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clepper Manor during CMS and state inspections, most recent first.
The facility did not comply with building rehabilitation standards, as several projects were completed without submitting plans or obtaining occupancy approval. An outside generator was installed, a fire alarm panel was replaced, and the fire detection system and sprinkler head were removed from the elevator pit without proper documentation. The maintenance director confirmed the lack of required plans during the survey.
The facility was found non-compliant with building construction type requirements. A fire door failed to latch between components, and documentation proving the flame retardancy of a discharge exit canopy was missing. The maintenance director confirmed these issues during the survey.
The facility failed to maintain sprinkler system requirements as the hydraulic elevator pit lacked a sidewall sprinkler installed within two feet of the floor. This deficiency was confirmed by the maintenance director.
The facility did not meet alcohol-based hand rub dispenser requirements in a smoke compartment. An observation revealed that the basement electric control room had over 10 gallons of hand rub stored outside a cabinet and near an ignition source, with about 40 containers of 40 ounces each. The maintenance director confirmed this deficiency.
The facility was found to have deficiencies in portable fire extinguisher compliance. A fire extinguisher in the basement washing room was blocked by a janitor cart, and another in the basement elevator control room was outdated, with a last inspection date of November 2023. These issues were confirmed by the maintenance director.
The facility failed to maintain electrical system requirements as a desk was found blocking access to electric panels in the basement control room. This deficiency was confirmed by the maintenance director, indicating non-compliance with NFPA 70-110.26(a).
The facility did not meet emergency preparedness guidelines, as the last review of their emergency preparedness plan was in 2019. An interview with the maintenance director confirmed the absence of documentation for an updated review, indicating non-compliance with the required annual updates.
The facility did not meet emergency preparedness guidelines due to the absence of a documented risk assessment utilizing an all-hazards approach. This deficiency was confirmed during a document review and an interview with the maintenance director, highlighting non-compliance with the requirement to maintain an updated emergency preparedness plan.
The facility was found deficient for not providing accurate, portable floor plans during a survey. The maintenance director confirmed the inaccuracy, and observations revealed missing doors and smoke detection in certain areas. The facility also lacked accurate rating information for dining room doors. The Life Safety Code Floor Plan must include specific safety features, which were absent.
The facility did not meet fire alarm system maintenance requirements due to a communication error on the fire alarm panel. An observation revealed a trouble signal, and the maintenance director confirmed the issue.
The facility did not comply with sprinkler system maintenance standards when a minion figure was found taped to a sprinkler line in the basement electric control room. This was confirmed by the maintenance director during a survey.
A resident with a urinary catheter was observed with the drainage bag and tubing lying uncovered on the floor, contrary to infection control protocols. The LPN and Nursing Home Administrator confirmed that the catheter should not be in contact with the floor and should be covered.
Clepper Manor failed to provide written notice of the bed-hold policy to residents or their representatives when transferred to a hospital. Four residents were transferred for various medical conditions, but their records lacked evidence of the required notice. This was confirmed by an Administrative Nurse.
The facility did not ensure the Medical Director completed the required annual CME hours. There was no evidence available to confirm the completion of at least four hours of CME pertinent to medical direction or post-acute and LTC medicine. The Nursing Home Administrator could not provide documentation to verify this requirement was met.
A facility failed to document a clinical rationale for extending the use of a PRN anti-anxiety medication beyond 14 days for a resident with multiple diagnoses, including anxiety. The facility's policy requires such documentation, but the resident's record lacked evidence of the physician's rationale for the extended use of Trazadone. The DON confirmed the absence of an ordered duration for the extended PRN use.
Facility Non-Compliance with Building Rehabilitation Standards
Penalty
Summary
The facility failed to comply with building rehabilitation requirements as evidenced by several projects completed without submitting plans to the State Plan Review or obtaining a granted occupancy from the Division of Safety Inspection. On April 8, 2025, during an observation between 8:45 a.m. and 11:00 a.m., it was noted that an outside generator was installed in November 2023 without the necessary plans or an H number. Additionally, the fire alarm panel was replaced, and the automatic fire detection system and sprinkler head were removed from the elevator pit. An interview with the maintenance director on the same day confirmed that the facility was unable to provide the required plans documentation at the time of the survey. These actions indicate a failure to adhere to the NFPA 101 Building Rehabilitation standards, specifically regarding repair, renovation, modification, or reconstruction requirements, as well as the necessary compliance for changes in use or occupancy and additions.
Plan Of Correction
Maintenance director and administrator will obtain the appropriate plans and H number for the outside generator installation from the contractor and submit to the state by 5/13/2025. Maintenance director and administrator will obtain plans for the fire alarm panel that was replaced from the contractor and submit to the state by 5/13/2025. Maintenance director and administrator will obtain the appropriate plans and H number for the outside generator installation from the contractor and submit to the state by 5/13/2025. Maintenance director and administrator will obtain plans for the fire alarm panel that was replaced from the contractor and submit to the state by 5/13/2025.
Non-Compliance with Building Construction Type Requirements
Penalty
Summary
The facility was found to be non-compliant with building construction type requirements during a survey conducted on April 8, 2025. The first deficiency was observed when the fire door separating component 01 from component 02, located next to the resident entertainment room, failed to positively close or latch when released. This issue was confirmed during an interview with the maintenance director, who acknowledged the door's failure to latch at the time of inspection. Additionally, a document review revealed that the facility lacked documentation proving that the discharge exit canopy near room 112 was flame retardant. The canopy, which extends over four feet from the building and is attached to it, does not have sprinkler coverage, necessitating it to be inherently flame retardant. The maintenance director confirmed the absence of flame retardant documentation during the survey.
Plan Of Correction
Maintenance Director has replaced the latch on the fire door separating component 01 from component 02, located next to the resident entertainment room on 4/12/2025. The door now properly latches when released. The Maintenance Director will audit twice a week, Monday through Friday - ongoing. The results of the audit will be reviewed in the quality assurance committee monthly to determine if a quality assurance plan is required.
Sprinkler System Deficiency in Elevator Pit
Penalty
Summary
The facility failed to maintain sprinkler system requirements as evidenced by the absence of a sidewall sprinkler in the hydraulic elevator pit. During an observation conducted on April 8, 2025, at 12:00 p.m., it was noted that the elevator pit did not have a sidewall sprinkler installed within two feet of the floor, which is a requirement for proper sprinkler system installation. This deficiency was confirmed through an interview with the maintenance director at the same time, who acknowledged the lack of a sidewall sprinkler in the elevator pit.
Plan Of Correction
Maintenance Director to contact Mike at the department of labor elevator division and Tony from Schindler Elevator to determine/obtain documentation of the requirement needed for the elevator sprinkler.
Non-compliance with ABHR Storage Requirements
Penalty
Summary
The facility failed to comply with alcohol-based hand rub dispenser requirements in one of its smoke compartments. During an observation on April 8, 2025, it was found that the basement electric control room contained over 10 gallons of alcohol-based hand rub stored outside of a storage cabinet. This storage was located within feet of an ignition source, which is against the stipulated guidelines. The observation revealed approximately 40 containers, each holding 40 ounces of the hand rub. The maintenance director confirmed the presence of this deficiency during an interview conducted at the same time.
Plan Of Correction
Regional Maintenance Director educated administrator on the regulation pertaining to storage of alcohol based hand rub. Administrator will educate housekeeping director and housekeeping staff of the regulation. Education will be completed by 4/30/2025. Excess hand rub was removed from electric control room on 4/8/2025. There now is less than 10 gallons stored in the control room in storage cabinet.
Deficiencies in Portable Fire Extinguisher Compliance
Penalty
Summary
The facility failed to comply with the requirements for portable fire extinguishers as outlined in NFPA 10. During an observation on April 8, 2025, two deficiencies were identified. Firstly, a portable fire extinguisher in the basement washing room was obstructed by a janitor cart, preventing easy access in case of an emergency. Secondly, the portable fire extinguisher located in the basement elevator control room was found to be outdated, with a last inspection date of November 2023. These deficiencies were confirmed during an interview with the maintenance director at the time of the survey.
Plan Of Correction
Housekeeping Director immediately removed the janitor cart away from the portable fire extinguisher in the basement washing room. Regional director of maintenance educated administrator on the portable fire extinguishers on 4/14/2025. Administrator will educate housekeeping director and all housekeeping staff of the regulation pertaining to the portable fire extinguishers. Education will be completed by 5/13/2025. Administrator/designee will audit weekly for four weeks to ensure that fire extinguisher regulation is followed.
Obstructed Access to Electric Panels in Basement Control Room
Penalty
Summary
The facility failed to maintain electrical system requirements in one of over three smoke compartments. During an observation on April 8, 2025, at 10:55 a.m., it was noted that the basement electric control room had a desk obstructing access to the electric panels. This deficiency was confirmed through an interview with the maintenance director at the same time, indicating non-compliance with NFPA 70-110.26(a).
Plan Of Correction
Housekeeping director immediately moved the desk that was blocking the electric panel when surveyor observed. Regional director of maintenance educated the administrator and maintenance director on the electrical system requirements on 4/14/2025. Administrator will educate housekeeping director and all housekeeping staff. Education will be completed by 5/14/2025. Administrator/designee will audit for compliance weekly for 4 weeks to ensure compliance.
Failure to Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to comply with emergency preparedness guidelines as required by federal regulations. During a document review on April 8, 2025, it was discovered that the last annual review of the facility's emergency preparedness plan was conducted on January 17, 2019. This indicates that the facility did not perform the required annual review and update of the emergency preparedness plan for several years, which is a clear violation of the regulatory requirements. An interview with the maintenance director on the same day confirmed that the facility was unable to provide documentation of an updated annual review date at the time of the survey. This lack of documentation further substantiates the facility's failure to maintain compliance with the emergency preparedness guidelines, as they could not demonstrate that the plan had been reviewed and updated as mandated.
Plan Of Correction
1. Administrator and Maintenance Director conducting review and updates for emergency preparedness plan. 2. Emergency preparedness plan will be updated by 5/12/2025. 3. Administrator and Maintenance Director will provide all staff education on emergency preparedness plan. 4. All staff education will be completed by 5/14/2025.
Failure to Document All-Hazards Risk Assessment
Penalty
Summary
The facility failed to meet emergency preparedness guidelines as required by regulations. During a document review on April 8, 2025, it was found that the facility did not have a documented risk assessment that utilized an all-hazards approach. This is a critical component of the emergency preparedness plan that should be reviewed and updated at least annually for long-term care facilities. An interview with the maintenance director on the same day confirmed the absence of the necessary documentation. The lack of a documented risk assessment indicates that the facility did not comply with the requirement to develop and maintain an emergency preparedness plan based on a facility-based and community-based risk assessment, which is essential for addressing potential emergency events.
Plan Of Correction
Risk assessment was completed for the facility in our company's electronic system. The facility printed the assessment and has placed it in our life safety binder. The maintenance director and administrator will ensure that when the risk assessment is completed, it is printed and placed in the life safety binder at the time of completion.
Inaccurate Life Safety Code Floor Plans and Missing Safety Features
Penalty
Summary
The facility was found to be deficient in providing an accurate and portable set of floor plans during a document review conducted on April 8, 2025. The Division of Safety Inspection mandates that all facilities under its jurisdiction maintain such floor plans on-site for use during Life Safety Code Surveys. The review revealed that the facility's floor plans were not accurate, as confirmed by the maintenance director. This deficiency was noted during an interview with the maintenance director, who acknowledged the inaccuracy of the Life Safety Code Floor Plan at the time of the survey. Additionally, an observation conducted on the same day revealed multiple areas within the facility that lacked doors and smoke detection systems leading to the corridor. Furthermore, the facility was unable to provide accurate rating information for the dining room doors leading to the entertainment area. The Life Safety Code Floor Plan is required to include specific details such as smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, shaft walls, and a door schedule. The absence of these elements in the facility's floor plan contributed to the deficiency noted in the survey.
Plan Of Correction
Maintenance Director and Administrator will update the floor plan with clear description of: a. smoke barrier walls (outside wall to outside wall) b. fire barrier walls (1-2 hour walls) c. horizontal exits d. rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) e. exits noted f. shaft walls g. door schedule This will be completed by 5/13/2025. Maintenance Director and Administrator will update the portable floor plan to keep in life safety manual to include: a. smoke barrier walls (outside wall to outside wall) b. fire barrier walls (1-2 hour walls) c. horizontal exits d. rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) and they will be clearly designated e. required exits clearly noted f. shaft walls g. door schedule This will be completed by 5/14/2025.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to meet the fire alarm system maintenance and testing requirements as evidenced by a communication error on the fire alarm panel. During an observation on April 8, 2025, at 10:45 a.m., a trouble signal was noted on the fire alarm panel indicating a communication error. This issue was confirmed through an interview with the maintenance director at the same time, who acknowledged the presence of the communication error.
Plan Of Correction
Maintenance director contacted Summit Fire regarding the trouble signal listed for communication error. Summit came out on 4/29/2025, reset the panel, and the issue was temporarily corrected. Summit ordered the part needed to repair completely, and it is scheduled to be in and repaired at the latest 5/12/2025. Maintenance director contacted Summit Fire to come out and correct the fire panel communication error. Summit came out and ordered a new part to fix the issue on April 31, 2025. Once the part arrives, Summit will be out to replace the part.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to meet the sprinkler system maintenance and testing requirements as evidenced by an observation in the basement electric control room. During the survey conducted on April 8, 2025, at 10:30 a.m., it was observed that a fictional character figure, specifically a minion, was taped to the sprinkler line. This deficiency was confirmed through an interview with the maintenance director at the same time, indicating a lapse in adhering to the standards set by NFPA 25 for the inspection, testing, and maintenance of water-based fire protection systems.
Plan Of Correction
Fictional character was removed immediately when noted by life safety surveyor. Regional maintenance director educated administrator on regulation on sprinkler system maintenance and testing requirements on 4/15/2025. Administrator will educate housekeeping director and all housekeeping staff on sprinkler system maintenance and testing requirements by 5/14/2025. Maintenance director/designee will round weekly for the next four weeks to ensure compliance. Results of audit will be reviewed with administrator weekly.
Infection Control Lapse with Urinary Catheter
Penalty
Summary
The facility failed to adhere to acceptable infection control practices concerning the care and treatment of a resident with a urinary drainage catheter. During an observation, it was noted that the catheter drainage bag and tubing of a resident were lying on the floor without any covering. This was confirmed by a Licensed Practical Nurse (LPN) who acknowledged that the drainage bag and tubing should not be in contact with the floor or any unclean surface. The resident involved had an admission date of March 17, 2025, and was diagnosed with osteolysis, chronic obstructive pulmonary disease (COPD), and a urinary tract infection. The Nursing Home Administrator also confirmed that catheter bags should not be placed on the floor and should be covered, indicating a lapse in following the facility's infection control protocols.
Plan Of Correction
No residents were negatively impacted. When notified by the surveyor, the Director of Nursing provided a privacy bag to the resident with a Foley catheter and ensured it was off the floor. The Director of Nursing observed all other residents with Foley catheters to ensure they had privacy in place and that it was not touching the floor. The Regional Director of Clinical Operations educated the Administrator and Director of Nursing on the Catheter Care Policy and infection control policy on 4.15.25. The Director of Nursing/designee will educate all direct care staff on the Catheter Care policy and infection control policy beginning on 4.15.25. All education will be completed by 5.1.25. The Director of Nursing/designee will audit all residents with Foley catheters three times per week for four weeks to ensure that proper policy and infection control measures are being followed. Audits will begin on 5.1.25. Results of the audit will be reviewed by the QA committee to determine further need.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
Clepper Manor was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the notice of bed-hold policy before and upon transfer of residents. The facility failed to provide written notice of the bed-hold policy to residents or their representatives when residents were transferred to a hospital. This deficiency was identified through a review of clinical records and staff interviews, which revealed that four residents, identified as R5, R8, R15, and R40, did not receive the required written notice of the bed-hold policy upon their transfer to a hospital. The clinical records of these residents showed that they were transferred to an acute care hospital for various medical conditions, including a urinary tract infection, a cardiac event, acute respiratory failure, and a fractured left leg. Despite these transfers, there was no evidence in the clinical records that the residents or their representatives were provided with the necessary written information about the duration and cost of the bed-hold policy. This was confirmed during an interview with the Administrative Nurse, who acknowledged that the bed-hold policy was not provided as required.
Plan Of Correction
No residents negatively impacted. Director of Nursing and Social Service designee did identify residents during the time of survey that were sent out to the hospital that did not receive bed hold notices. Social Service designee was able to correct by providing the notices to those residents. Regional Director of Clinical Operations educated Administrator, Social Service Designee, and Director of Nursing on bedhold letter, policy, and process on 4.15.25. Administrator / designee will educate all nurses on bedhold letter, policy, and process beginning 4.15.25. All education will be completed by 5.1.25. Administrator / designee will audit all resident transfers for 4 weeks to ensure notices are sent with resident (POA if applicable), at the time of transfer or within 24 hours, per regulation and the policy was followed. Audits will begin 4.15.25. Results of audit will be reviewed by QA committee to determine further need.
Medical Director CME Requirement Not Met
Penalty
Summary
The facility failed to ensure that the Medical Director completed the required annual continuing medical education (CME) hours. According to the regulation, the Medical Director must complete at least four hours annually of CME pertinent to the field of medical direction or post-acute and long-term care medicine. However, upon review of facility documentation and through staff interviews, it was determined that there was no available evidence to confirm the completion of these CME hours. During an interview, the Nursing Home Administrator was unable to provide documented evidence that the Medical Director had fulfilled this requirement.
Plan Of Correction
Medical Director was out of the country at the time of survey. Administrator to follow up with Medical Director upon return and obtain certificate of completion. Medical Director returned from vacation week of 4/14/2025. Facility did reach out and obtained documentation of completed continuing education, which was forwarded to the field office. Administrator/designee will review in quarterly quality assurance committee meeting to ensure we have up-to-date documentation on hand.
Failure to Document Clinical Rationale for Extended PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a PRN anti-anxiety psychotropic medication had a clinical rationale identified for use beyond the 14-day limitation for a resident. The facility's policy on the use of psychotropic medication requires that PRN orders for such drugs be used only when necessary to treat a diagnosed specific condition documented in the clinical record and for a limited duration of 14 days. If an extension is needed, the attending physician must document the rationale and indicate the duration in the resident's medical record. In this case, a resident with diagnoses including palliative care, severe protein-calorie malnutrition, chronic obstructive pulmonary disease, and anxiety was prescribed Trazadone 100 mg by mouth at hour of sleep PRN. However, the clinical record lacked evidence of a clinical rationale for the use of Trazadone beyond 14 days. During an interview, the Director of Nursing confirmed that there was no duration ordered by the physician for the extended use of the PRN Trazadone beyond the 14-day period.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sharon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hermitage Nursing And Rehabilitation | 1.3 mi | — | 5 | 0 |
| O'brien Memorial Health Care C | 1.8 mi | — | 0 | 0 |
| Addison Healthcare Center | 2.6 mi | — | 0 | 0 |
| Saint John Xxiii Home | 2.7 mi | — | 1 | 0 |
| Meadowbrook Manor | 6.5 mi | — | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.