Cleveland Community Care Center

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to ensure a resident who was admitted with multiple pressure ulcers and other wounds received necessary treatment and services to promote healing and prevent worsening by failing to obtain wound treatment orders and initiate wound care upon admission for one (1) of three (3) residents reviewed for pressure ulcers. Resident #1.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident's right to dignity, choice, and self-determination by failing to assist one (1) of the twenty-seven sampled residents to attend the facility's beauty shop as requested. Resident #37Findings Include: Review of the facility policy titled, Resident Rights with revision date of December 2016, revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . On 1/5/26 at 11:45 AM, an observation and interview revealed Resident #37 seated in her wheelchair with visibly overgrown hair, measuring approximately four inches of gray overgrowth with red coloring remaining on the bottom half of her hair. [...]

Inspectors wroteBased on resident and staff interview, record review and facility policy review the facility failed to ensure residents' grievances regarding missing personal clothing were investigated, resolved, and communicated to the resident for two (2) of 27 sampled residents. Resident #29, and Resident #37. Findings Include:Record review of the facility policy titled Resident Care Grievance Policy with an effective date of 6/26/2023 revealed, Grievance decisions should include the following: [...]

Inspectors wroteBased on observations, resident and staff interviews, record review, and a review of facility policy, the facility failed to honor residents' rights by secluding two (2) of twenty (20) residents in a locked Memory Care unit without proper assessment. This practice violated the residents' right to be free from involuntary seclusion. Resident #23 and Resident #83Findings Include: Review of the facility policy titled, Abuse Component Plan, with an effective date of 10/24/22, revealed under policy, Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion. Resident #23 An observation and interview on 01/05/2026 at 11:50 AM with Resident #23 revealed him sitting up in chair watching television in his room. [...]

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to ensure a resident's Minimum Data Set (MDS) was accurately coded for one (1) of twenty-seven (27) MDS assessments reviewed (Resident #105).

Inspectors wroteBased on observation, staff and resident interview, record review, and facility policy review, the facility failed to develop a communication care plan for (Resident #46), failed to implement a Behavioral care plan for (Resident #22), failed to implement an activities of daily living (ADL) care plan for (Resident #29, #64, and #105), and failed to implement a range of motion (ROM) care plan for (Resident # 105) for six (6) of 27 care plans reviewed.

Inspectors wroteBased on observations, resident and staff interview, record review, and facility policy review, the facility failed to provide activities of daily living (ADL) care for three (3) of 113 residents residing in the facility. Resident # 29, #64, and # 105 Findings Include: Review of the facility policy titled, ADLs Supporting undated, revealed .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Review of the facility policy titled, Fingernail Care, Foot Care, and Podiatry Referral, effective date 4/18/2017, revealed the stated purpose was to provide guidelines for the delivery of safe, evidence-based nail and foot care which promote good personal hygiene, prevent hand, foot, and nail infections, soft tissue injury, and foot ulcers . [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide Range of Motion (ROM) services for (2) two of 60 residents who have limited ROM. (Resident #24 and #105)

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to provide adequate supervision to prevent accidents for one (1) of twenty-seven (27) residents on the sample (Resident #22).

Inspectors wroteBased on observation, staff interview, Payroll Based Journal data, record review and facility policy review the facility failed to provide adequate staffing to provide nursing and related services to meet the residents' needs safely and in a timely manner for one (1) of 28 sampled residents during survey and five (5) of 5 weekends in July 2023. Findings Include. The Administrator (ADM) provided on facility letterhead that the facility does not have a policy on staffing, the facility follows the State Department of Health Licensure regulations. A record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 4 2023 (July1-September 30), revealed Excessively Low Weekend Staffing - Triggered. Triggered = Submitted Weekend Staffing data is excessively low. [...]

Inspectors wroteBased on observations, staff, and resident interviews the facility failed to correct maintenance issues in a resident bathroom for two (2) of 28 residents sampled. Residents #39 & #46 Findings Include: Review of the written statement on facility letterhead dated 2/14/24 and signed by the Administrator revealed the facility does not have a policy regarding maintenance repairs. An interview and observation on 02/12/24 at 11:06 AM, with Resident's #39 and #46 revealed the residents share a bathroom and the water in the bathroom will not turn on and there is a puddle of water in the floor approximately 2 feet wide by 2 feet wide between the toilet and the sink. Resident #39 & #46 revealed the sink has not worked in a long time and they both walk independently. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed timely for one (1) of 28 resident's MDS reviewed.

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to implement a care plan for a resident requiring two person assistance utilizing a total lift with transfers for one (1) of 28 resident care plans reviewed. Resident #55 Findings Include: Record review of the facility policy titled Comprehensive Person-Centered Care Plan with a revision date of 3/18 revealed Policy .Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care . [...]

Inspectors wroteBased on observations, staff and resident interviews, record review and facility policy review, the facility failed to ensure an environment free of accident hazards as evidenced by one staff member using a two-person total body lift to transfer Resident #55 and standing water in a bathroom (Resident's #39 & 46) for three (3) of 28 residents reviewed on sample. Findings Include Review of the typed statement on facility letterhead dated 2/14/24 and signed by the Administrator revealed the facility does not have a policy regarding accident and hazard prevention. Review of the facility policy titled, Invacare Total Lift with a revision date of 8/16 revealed under the Policy .The Invacare Total Lift is used for total lifts and/or to obtain a resident's weight from bed to chair, chair to bed, or from the floor . [...]

Inspectors wroteBased on record review, policy/procedure review, and interviews, the facility neglected to identify a crisis of suicidal ideation of Resident #1 and neglected to provide the psychiatric services that were necessary to prevent death for one (1) of seven (7) residents sampled as evidenced by Resident #1 committed suicide by hanging on [DATE] using the remote-control cord from his bed and using an exposed pipe on the ceiling in his room. On [DATE], during the admission process Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on [DATE], a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On [DATE], Resident #1 elected to be admitted to hospice services. [...]

Inspectors wroteBased on record review, policy/procedure review and interviews, the facility failed to report an injury of unknown origin resulting in a serious bodily injury to law enforcement agencies after the death of one (1) of seven (7) residents sampled, Resident #1 as evidenced by Resident #1's suicide on [DATE]. Resident #1 told the admitting nurse during the admission process on [DATE] that he wanted to call a friend to pick him up and take him to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on [DATE], a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On [DATE], Resident #1 wanted to be admitted to hospice services. Another MD order was written on [DATE] to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained on one-on-one observation through to [DATE] when he went to every hour observations. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to coordinate a resident review with the Preadmission Screening and Resident Review (PASARR) program under Medicaid by not referring a resident that expressed suicidal ideations on admission for a significant change in status assessment for review by the State Designated Authority for one (1) of seven (7) residents sampled. Resident #1. During the admission process on 8/8/23, Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on 8/9/23, a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On 8/9/23, Resident #1 wanted to be admitted to hospice services. Another MD order was written on 8/9/23 to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. [...]

Inspectors wroteBased on policy and procedure review, record review, and staff interviews, the facility failed to provide behavioral health services to address a resident's needs as evidenced by failure to act upon Resident #1's verbalized suicidal ideations which resulted in Resident #1's suicide in the facility for one (1) of seven (7) residents sampled. During the admission process on [DATE], Resident #1 expressed suicidal thoughts when he told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. On [DATE], the facility obtained an physician order for a psychiatric evaluation. On the same day [DATE], the facility obtained a physician order for hospice services and obtained a second physician order to discontinue the psychiatric evaluation. [...]

Inspectors wroteBased on record review, policy/procedure review and interviews, the facility failed to be administered effectively and efficiently to provide the mental health care for one (1) of seven (7) residents, Resident #1, as evidenced by Resident #1 committed suicide by hanging on [DATE] using the remote control cord from his bed and using an exposed pipe on the ceiling in his room. During the admission process on [DATE], Resident #1 told the admitting nurse that he wanted to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on 8/ On [DATE], a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On [DATE], Resident #1 wanted to be admitted to hospice services. Another MD order was written on [DATE] to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. [...]

Inspectors wroteBased on record review, policy/procedure review and interviews, the Medical Director failed to coordinate, implement and evaluate the facility's care of one (1) of seven (7) residents, Resident #1, as evidence by Resident #1 committed suicide by hanging himself with the remote control cord of his bed on an exposed pipe in the ceiling of his room [ROOM NUMBER] days after the Medical Director discontinued the Physician Order for a Psychiatric (psych) Evaluation (eval) for suicidal ideations. During the admission process on 8/9/23, Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. On 8/9/23, a Medical Doctor's (MD) order was written for a psychiatric evaluation. On 8/9/23, Resident #1 wanted to be admitted to hospice services. [...]

Inspectors wroteBased on record review, policy/procedure review and interviews, the facility failed to ensure an effective communication process, including how the communication would be documented between the Long-Term Care (LTC) facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours a day for one (1) of seven (7) residents sampled. Resident #1. During the admission process on 8/8/23, Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. On 8/9/23, a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On 8/9/23, Resident #1 wanted to be admitted to hospice services. Another MD order was written on 8/9/23 to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. [...]

Inspectors wroteBased on observations, staff interviews, facility policy review, and in-service record review the facility failed to prevent the potential for the spread of infection as evidenced by all staff not wearing or improperly wearing a face mask for one (1) of four (4) days of survey.