Cleveland Care and Rehab Center

Inspectors wroteBased on record review and interview, the facility failed to ensure medication was administered as ordered by the physician for 1 (#44) of 1 resident sampled reviewed for medication administration. The regional director identified 58 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to evaluate a resident for vaping/e-cigarette use safely for 1 (#44) of 2 sampled residents reviewed for safe smoking. The regional director identified 58 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the head of bed was elevated for 1 (#5) of 1 resident reviewed for continuous tube feeding. The ADON identified two residents received tube feeding.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's nebulizer and oxygen mask were bagged when not in use to prevent cross contamination for 1 (#4) of 16 sampled residents reviewed for infection control practices. The regional director identified 58 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with an allergy to latex did not receive an indwelling latex urinary catheter for 1 (#1) of 1 sampled resident reviewed for a latex allergy. The administrator identified 54 residents resided in the facility. The DON identified one resident with a latex allergy.

Inspectors wroteOn 04/03/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide a safe and orderly discharge for Resident #7. Resident #7 was discharged to a prepaid motel room located away from their community, leaving the resident without identification, financial means, or caregiver support. The facility did not provide the resident with a 30-day notice of intent to discharge, nor notify the Office of the Ombudsman or the State agency (OSDH) of the resident's anticipated discharge as required. Resident #7 was a direct admitted from the Department of Corrections to the facility on [DATE] with Medicaid pending for their pay source status and without state issued identification, birth certificate, or social security card. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a resident with a bed wide enough to allow the resident to reposition themselves and side rails/trapeze bar for the resident to use in positioning for 1 (#2) of 3 residents sampled for accommodation of needs. The alphabetical resident roster identified 56 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident and/or resident's representative the right to participate in the development and implementation of their person-centered plan of care for 1 (#5) of 1 sampled resident reviewed for care plan meetings. The DON identified 52 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents on antipsychotic medications were assessed for tardive dyskinesia for three (#6, 18, and #19) of five residents who were reviewed for unnecessary medications. The DON identified eight residents who were ordered antipsychotic medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 30 opportunities were observed with two errors. The total medication error rate was 6.67%. The DON identified 47 residents received medications in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were dated when opened for three (300/400 hall medication cart, 200 hall treatment cart, and 400 hall treatment cart) of three medication/treatment carts observed. The DON identified five medication/treatment carts in the facility.

Inspectors wroteBased on record review and interview, the facility failed to implement a program designed to help prevent the development of Legionellosis. The administrator reported the census was 47.

Inspectors wroteBased on record review and interview, the facility failed to implement their abuse policy for one of five new employees reviewed for background checks. The Abuse Prevention policy, dated 10/21/2022 read in parts, . The facility will pre-screen all potential new employees and residents for a history of abusive behavior. A review of five new employees revealed one CNA #1 with no documented background check completed or in progress. On 04/03/24 at 03:47 p.m. the administrator stated they could not find a clearance letter for CNA#1. That apparently they never went to be fingerprinted. The CNA has been suspended and will not be allowed to work until final clearance has been received.

Inspectors wroteBased on record review and interview, the facility failed to ensure influenza vaccinations were offered for one (#41) of five residents reviewed for immunizations. The administrator reported the census was 47.

Inspectors wroteBased on record review and interview, the facility failed to ensure COVID-19 vaccinations were offered for one (#41) of five residents reviewed for immunizations. The administrator reported the census was 47.

Inspectors wroteBased on observation and interview, the facility failed to employ a registered nurse as the full-time Director of Nursing. The DON identified 52 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to maintain personal funds in an interest-bearing account for all residents on the trust fund. The administrator stated there are 18 residents on the trust fund in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide quarterly financial statements to residents on the trust fund. The administrator stated there are 18 residents on the trust fund in the facility.

Inspectors wroteBased on record review and interview, the facility failed to obtain a surety bond to assure the security of all personal funds of residents. The administrator stated there are 18 residents on the trust fund in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure MDS assessments were completed within the required time of the ARD for 13 (#5, 7, 11, 21, 34, 41, 98, 99, 100, 101, 102, 103, and #105) of 55 residents whose MDS dates were reviewed. The Resident Census and Conditions of Residents form documented 55 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure MDS assessments were submitted and accepted by CMS no later than 14 calendar days after completion. The Resident Census and Conditions of Residents form documented 55 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure accuracy of MDS assessments for two (#15 and #22) of three residents reviewed for MDS discrepancies. The Resident Census and Conditions of Residents form documented 55 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure behavior and side effect monitoring for psychotropic medications was completed each shift for two (#30 and #35) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 42 residents received psychotropic medications.

Inspectors wroteBased on record review and interview, the facility failed to guarantee the person designated to serve as the DM met the state requirement for DM. The Resident Census and Conditions of Residents form documented 55 residents resided in the facility. No residents were identified as receiving nutrition and hydration solely through tube feeding.

Inspectors wroteBased on record review, observation, and interview, the facility failed to perform hand hygiene prior to and after finger stick blood sugar monitoring and insulin administration. The Resident Census and Conditions of Residents report documented 12 residents received injections in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's code status was listed in the EHR for one (#21) of two residents sampled for advance directives. The Resident Census and Conditions of Residents form documented 55 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide the ABN form CMS-10055 and NOMNC form CMS 10123 to residents who received skilled services and afterwards stayed in the facility for two (#17 and #24) of three residents sampled for beneficiary protection notification review. The DON identified six residents who had discharged from skilled services in the last six months.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a baseline care plan for one (#21) of 14 residents whose care plans were reviewed. The administrator identified one resident who admitted in the last 30 days.

Inspectors wroteBased on record review, observation, and interview, the facility failed to administer medication as ordered for one (#20) of six residents sampled for medication administration. The Resident Census and Conditions of Resident report documented 55 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a physician rationale was documented related to a declination of a GDR for one (#30) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 55 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored and prepared in accordance with professional standards. The Resident Census and Conditions of Residents form documented 55 residents resided in the facility.