Cleveland Pines

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF687Nov 18, 2025

  Based on observations, record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to ensure resident's toenails were trimmed and podiatry services were arranged for 3 of 7 residents reviewed for foot care (Resident #15, Resident #90, and Resident #24). The findings included: 1. Resident #15 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included traumatic brain injury and contractures to bilateral upper and lower extremities. Review of revised care plan dated 6/15/25 revealed Resident #15 was care planned for activities of daily living (ADL) self-care performance deficits related to her disease process. […]

• No harm, potential for more than minimal, patternF700Nov 18, 2025

  Based on observations, record reviews, and Nurse Practitioner and staff interviews, the facility failed to review risks and benefit of side rails use with the resident or resident representative prior to installation, failed to obtain informed consent, and failed to accurately assess 5 of 8 severely cognitively impaired residents for the use of bilateral half side rails on their beds (Resident #3, Resident #9, and Resident #15, Resident #39, Resident #35). Findings included: 1. […]

• No harm, potential for more than minimal, patternF679Jul 18, 2024

  Based on record reviews, facility activity calendars, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 6 of 8 residents reviewed for activities. (Residents #58, #8, #53, #20, #63, and #16). The residents expressed not being able to leave the facility for almost 2 years made them feel more dependent, sad, depressed, and they missed getting out with the group to shop and socialize with other people. […]

• No harm, potential for more than minimal, patternF812Mar 23, 2023

  Based on observations and staff interviews the facility failed to ensure food preparation knives ready for use were clean. This practice had the potential to affect food served to residents. Findings included: On 3/22/23 at 11:55 AM an observation of the kitchen revealed two food preparation knives ready for use in the knife storage rack contained visible dried debris on the sides of the blades. The cook was present when the observation was made. On 3/22/23 at 12:54 PM the Dietary Manager (DM) stated the knives were assigned to be cleaned by the cook after use and were placed in the knife rack by the cook. The DM said the knives should have been cleaned and stored without dried debris on them and were overlooked before storing them. […]

• No harm, potential for more than minimal, patternF641Jun 10, 2021

  Based on observations, resident and staff interviews and record review the facility failed to ensure the Minimum Data Set (MDS) was accurate for 2 of 3 residents reviewed for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 1.Resident #6 was admitted to the facility on [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #6 required limited assistance with activities of daily living (ADL) and was not coded for active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 03/08/21 revealed Resident #6 had stated to a staff member that he felt like killing himself at times. […]