Cleveland Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF656Aug 28, 2023

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 11 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan included supervision and fall prevention interventions to prevent Resident #1 from falling from her Geri-chair (chairs useful for those with mobility issues and can also be used for bedridden patients who have difficulty sitting upright in a conventional wheelchair) and sustaining fractures to her hip and pelvis on 7/20/23. An Immediate Jeopardy (IJ) situation was identified on 08/09/23 at 11:40 am. The IJ template was provided to the facility on [DATE] at 11:40 a.m. […]

• Immediate jeopardy, isolatedF689Aug 28, 2023

  Based on interview and record review, the facility failed to ensure each resident received adequate assistance and supervision to prevent accidents for 1 of 11 residents (Resident #1) reviewed for accidents. The facility failed to ensure adequate supervision to prevent falls. On 7/20/23, Resident #1 fell out of her Geri-chair (chairs useful for those with mobility issues and can also be used for bedridden patients who have difficulty sitting upright in a conventional wheelchair) and sustained a fractured left hip and fractured pelvis that required surgical intervention. An Immediate Jeopardy (IJ) situation was identified on 08/09/23 at 11:40 am. The IJ template was provided to the facility on [DATE] at 11:40 a.m. […]

• Immediate jeopardy, isolatedF600May 27, 2021

  Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 7 residents reviewed for abuse. (Resident #2) Facility staff observed Resident #1 with his left hand on Resident #2's exposed left breast after staff hearing loud, distressed shouting. The facility failed to address Resident #1's inappropriate behaviors/touching toward female residents On [DATE] at 2:35 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the potential of actual harm which is not Immediate Jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for abuse. […]

• Actual harm, isolatedF690Aug 29, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF641Jun 17, 2026

  Based 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. Findings include: 1. […]