Cleveland Care and Rehab Center

In the surveyor’s words

From the most serious findings on record at Cleveland Care and Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF624Apr 4, 2025

  On 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. […]

• No harm, potential for more than minimal, patternF758Apr 5, 2024

  Based 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. Findings: The Monitoring of Anti-Psychotics policy, dated 2024, read in parts, .Upon initiation of antipsychotic medication therapy [or upon admission for new residents receiving anti-psychotics] and every three months thereafter, the Abnormal Involuntary Movement Scale [AIMS] or similar test is administered to the resident. The results, and actions taken in response to the results, are recorded in the residents medical record . 1. […]

• No harm, potential for more than minimal, patternF759Apr 5, 2024

  Based 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. Findings: 1. Resident #14 had diagnoses which included rib fractures. The Physician's Orders, dated 02/02/24, documented Calcium 600mg by mouth daily for rib fracture. 2. Resident #32 had diagnoses which included cough and seasonal allergies. The Physician's Orders, dated 04/02/24, documented Geri-Tussin DM 10-100mg/5ml - give 10ml orally every four hours as needed for cough. […]

• No harm, potential for more than minimal, patternF761Apr 5, 2024

  Based 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. Findings: 1. On 04/04/24 at 9:10 a.m., the 300/400 medication cart was observed with CMA #1. CMA #1 stated they were to date medications when they were opened. The following medications were observed to be open but not dated: a. Ketorolac eye drops for Resident #12. b. Imodium liquid 1mg/7.5ml house stock. c. Chloraseptic throat lozenges for Resident #22. On 04/04/24 at 9:11 a.m., the 200 hall treatment cart was observed with the ADON. […]

• No harm, potential for more than minimal, patternF880Apr 5, 2024

  Based 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. Findings: An undated facility policy titled Legionella Water Management Program, read in part, .Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella . The water management program includes the following elements . A detailed description and diagram of the water system . On 04/03/24 at 10:30 a.m., the maintenance director stated they did not have a detailed description and diagram of the water system.