Cleveland Health Care Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 21 residents (Resident #16, Resident #58, and Resident #62) who were reviewed for accuracy of assessments. 1. The facility failed to accurately complete the MDS assessment to indicate Resident #16 did not have a bedrail restraint. 2. The facility failed to accurately complete the MDS assessment to indicate Resident #58 did not have a bedrail restraint. 3. The facility failed to accurately complete the MDS assessment to indicate Resident #62's PASRR status was positive. These failures could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store, prepare, distribute, and serve food in accordance with the professional standards for food service safety 1 of 3 dining rooms (the main dining room) reviewed for food and nutrition services. The facility failed to ensure the staff wore a hair net when plating the soup in the main dining room on 06/15/2026 at the lunch meal. This failure could place residents, who received food and beverages from the kitchen, at risk for health complications, foodborne illnesses, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to make sure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 31 residents (Resident #16 and Resident #58) reviewed for care plans. 1. The facility failed to ensure Resident #16's comprehensive care plan was reviewed and revised when her bedrails were removed from her bed.2. The facility failed to ensure Resident #58's comprehensive care plan was reviewed and revised when her bedrails were removed from her bed. This failure could place residents at risk of not receiving the care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications were properly secured and stored in locked compartments for 1 of 7 medication carts (Nurse Hall 100) reviewed for pharmacy services. The facility failed to keep unattended medications secured by leaving it on top of a medication cart. This failure could place residents at risk of misappropriation of medications, adverse reactions by ingesting medication that did not belong to them, and not receiving therapeutic effects of medication.

Inspectors wroteBased on interview and record review, the facility failed to permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare for 1 of 3 residents (Resident #1) reviewed for discharge requirements. The facility failed to ensure Resident #1 remained in the facility and not transferred when not ordered. This failure could place discharged residents and residents residing in the facility at risk of being inappropriately discharged and causing a disruption in their care and/or services.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental, and psychosocial needs for 1 of 18 residents reviewed for care plans. (Resident #57) The facility did not have a care plan to address Resident #57's use of polymyxin b-trimethoprim ophthalmic solution (antibiotic eye drops to treat eye infections). This failure could place residents at risk of not having their individual needs met and not receiving needed services.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for catheter care. The facility failed to change a suprapubic catheter monthly for Resident #1 as ordered by the physician. Resident #1 developed a UTI in June 2024 and his SPT was obstructed and calcified due to lack of adequate care per urology appointment on 8/1/2024. This failure could place residents at risk for urinary tract infections, pain, confusion and sepsis (infections that spread to the blood) and urinary calcifications.

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain laboratory services ordered by a physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with state law, including scope of practice laws and promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fell outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician orders for 1 of 4 residents (Resident #1) reviewed for laboratory services. The facility failed to report laboratory results received on 11/02/2023 and 11/18/2023 for Resident #1 in a timely manner to the urologist. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure preadmission screening for individuals identified with MI, DD, or ID were evaluated for services for 1 of 18 residents reviewed for resident assessment (Resident #68). The facility did not have an accurate PASRR level 1 screening (PL1) for Resident #68 upon admission date of 05/12/23. This failure could place residents who have a diagnosis of mental disorder, developmental disability, or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on interview and record review, the facility failed to provide services as outlined by the comprehensive care plan, to meet professional standards of quality for consultation with the resident's physician when there was a significant change in the resident's condition or a need to alter treatment significantly for one (Resident #9) of 18 residents reviewed for following physician's orders. The facility failed to implement Resident #9's care plan when her blood pressure and/or heart rate was below prescribed parameters and did not notify her physician in March 2024. (03/01/24, 03/02/24,03/03/24, 03/04/24, 03/05/24, 03/06/24, 03/08/24, 03/09/24, 03/10/24, 03/11/24, 03/12/24 and 03/13/24). The failure placed residents, who required blood pressure and heart rate monitoring, at risk for complications due to delayed physician intervention.

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 18 residents reviewed for medication administration. (Resident #9) The facility did not document blood pressure or heart rate for Resident #9 on the MAR, before administering medications with orders that included instructions to hold for prescribed parameters. This deficient practice failure could place residents with prescribed medication parameters at risk of not receiving the desired therapeutic effects of their medications.