Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
CLEPPER MANOR
SHARON, PA · 54 certified beds · Last Life Safety survey April 4, 2025
CMS Certification Number 396071 · first certified May 2000
Ownership
Operated by EMBASSY HEALTHCARE · For profit - Corporation
- Ownership changed May 1, 2020 (change of ownership)from NUBRIDGE ASSOCIATES LP
Position within PA
24 citations — more than 89% of the 656 certified nursing homes in PA. Compared within PA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 7 citations; the earlier surveys in the window averaged 8.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (February 2026 to April 2026), and past the point by which nine in ten PA facilities have been surveyed. This facility’s last Life Safety survey was April 2025. Facilities in PA are typically surveyed 10–12 months after the last one (median 11), measured over 1,113 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
Get an email about CLEPPER MANOR
One email when it happens. No account; stop it any time with one click.
2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
5 of the 24 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 24 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 24 |
| Median facility in PA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 2, 2023 | 5 |
| May 17, 2024 | 12 |
| April 4, 2025 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2025-04-04 |
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | 2 | 2025-04-04 |
| K-0100 | Meet other general requirements. | 2 | 2025-04-04 |
| E-0036 | Establish emergency prep training and testing. | 2 | 2024-05-17 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-05-17 |
| K-0912 | Have power receptacles that are properly grounded. | 1 | 2024-05-17 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2024-05-17 |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | 1 | 2023-06-02 |
What the citations cover
- Smoke Deficiencies 8
- Construction Deficiencies 5
- Emergency Preparedness Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Construction Deficiencies | 5 |
| Emergency Preparedness Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 4, 2025 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (May 15, 2025) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (May 15, 2025) |
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (June 25, 2025) |
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Deficient, Provider has date of correction (June 25, 2025) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (May 15, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 15, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (June 25, 2025) |
May 17, 2024 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 28, 2024) |
June 2, 2023 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (July 1, 2023) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (July 1, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 1, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 1, 2023) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Waiver has been granted (July 1, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.