Cleveland Pines

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Resident #15 was dependent on staff for all ADL care. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was severely cognitively impaired and had been assessed as requiring total care assistance from staff with all ADL care. Resident #15 was also coded as having no refusals with care. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Resident #3 was readmitted to the facility on [DATE] with diagnoses which included bilateral above knee amputation, cerebrovascular accident (stroke), tonic-clonic seizure disorder, chronic anticoagulation, and altered mental status. Resident #3's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired, unable to make her needs known and staff had to anticipate her needs daily. The assessment also revealed she required extensive assistance of 2 staff members for bed mobility, and she was on a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to complete a thorough investigation of an allegation of resident-to-resident abuse for 1 of 3 residents reviewed for abuse (Residents #9). Findings included: The facility's Prohibit and Prevent Violations of Resident Abuse, Neglect, Misappropriation of Resident Property and Exploitation policy indicated in part, all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/ or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. All resident to resident altercations must be reported in accordance with the regulations to include any willful action that results in physical injury, mental anguish, or pain. Should an incident or suspected incident of resident abuse, neglect, exploitation, mistreatment of residents, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II review was completed for residents with new mental health diagnoses for 2 of 4 residents (Resident #9 and Resident #43) reviewed for PASRR.The findings included: 1. Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE] with a readmission on [DATE]. PASRR level I was completed on 9/07/17 prior to admission with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. The electronic medical record revealed Resident #9 was diagnosed with anxiety disorder on 9/09/17, mood affective disorder on 8/01/23, and schizophrenia on 10/24/24. No PASRR level II was completed. During an interview on 9/26/25 at 5:35 PM with the Administrator, she communicated her understanding that PASRR level II should be completed in a timely manner…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and staff interviews, the facility failed to follow their infection control standards and procedures when Nurse #6 failed to sanitize her hands and change her gloves between replacing the new tracheostomy (a surgically created opening in the windpipe through the neck to provide an airway for breathing) ties and neck collar and before cleaning the stoma and outer cannula and applying new disposable inner cannula and when Nurse #7 failed to sanitize her hands and change her gloves after inserting the new inner cannula and before cleaning around the stoma and outer cannula and placing the stoma dressing and new neck collar and ties. The deficient practice occurred for 2 of 2 residents reviewed for respiratory care (Resident #15 and Resident #39).The findings included:1. Resident #15 was admitted to the facility on [DATE] with diagnoses which included respiratory failure and tracheostomy status.Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews with staff, the facility failed to have effective systems in place for accurate reconciliation of controlled medications and maintaining accurate records of a resident's controlled medication declining count sheet for 1 of 6 residents reviewed for pharmacy services (Resident #46).The findings included:Review of the facility's Controlled Substances Distribution and Control Policy read in part:PROCEDURESD. A separate record will be maintained on each controlled substance in the form of a declining inventory record (Controlled Substance Sign-Out Sheet). Such record will be accurately maintained and will include: 6) The quantity of the controlled substance currently on hand.10) Such records will be reconciled to a physical count of the remaining doses at each shift change by two licensed nurses including the nurse taking charge of these controlled substances 11) Such record will be retained by the facility for a period of not less than three (3) years.Resident #46 was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The findings included: A review of the activity calendars for January 2024 through July 2024 revealed activities for inside of the facility or grounds during the week and some activities on the weekends. There were no activities scheduled for outside of the facility and grounds. Review of the Resident Council Meeting minutes for April 2023 through June 2024 revealed the residents requested in July 2023 and August 2023…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews, the facility failed to clarify and update the medical records to reflect the desired advance directive for 1 of 1 resident (Resident #64) reviewed for code status. The findings included: Resident #64 was admitted to the facility on [DATE]. A review of Resident #64's paper chart at the nurses' station revealed a paper copy of Resident #64's Medical Orders for Scope of Treatment (MOST) form dated 1/30/24 which indicated to attempt resuscitation with full scope of treatment. The MOST form was signed by Resident #64 and the Nurse Practitioner on 1/30/24. A review of Resident #64's electronic medical record indicated a physician's order dated 3/27/24 for Do Not Attempt Resuscitation (DNAR)/limited scope of treatment. A progress note in Resident #64's medical record dated 3/27/24 by the Medical Director (MD) indicated Resident #64's family wanted to keep her at facility for now and not to send to hospital. (The family) noted that they were aware of decline. (The MD)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident, staff, and Nurse Practitioner interview the facility failed to follow physician's order to provide and apply a left resting hand splint to prevent further contracture for 1 of 3 resident reviewed for limited range of motion. (Resident #30) The findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis of left side and muscle weakness. A quarterly Minimum Data Set for Resident #30 dated 6/25/24 revealed the resident was cognitively intact with no refusals or rejection of care and no orthotic use documented. The care plan for Resident #30 updated on 6/25/24 revealed, Resident #30 had an Activities of Daily Living deficit related to physical functioning with weakness status post hemiplegia following a stroke. A review of the nurse practitioner order dated 4/29/24 revealed occupational therapy to evaluate and treat Resident #30 for left hand contracture, current left-hand splint provided would not fit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record reviews, and staff interviews, the facility failed to implement their infection control policy for hand hygiene/handwashing, when the Treatment Nurse did not perform hand hygiene according to the facility's policy and procedure when she doffed her gloves after preparing her dressing for the wound and did not sanitize her hands before donning clean gloves to remove the old dressing from the wound for a resident (Resident #4). This occurred for 1 of 1 resident observed for wound care. The findings included: The facility's policy entitled Hand Hygiene last revised on 08/21/23 read in part: The hands are the conduits for almost every transfer of potential pathogens from one patient to another, from contaminated object to a patient, and from a staff member to a patient. Because of this, hand hygiene is the single most important procedure to prevent infection. Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids, when exposure to potential spore-forming pathogens is strongly suspected or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. The cook was interviewed on 3/22/23 at 1:13 PM and stated the cooks were responsible to wash, clean and sanitize the knives after use. He said the knives were checked for cleanliness before placing them into the storage rack for use. The cook said he believed the 2 knives were overlooked when they were cleaned. The Administrator stated on 3/23/23 at 2:14…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place following the facility's 6/10/21 recertification survey. The failure related to two deficiencies that were originally cited during the 6/10/21 recertification survey and was cited on the current recertification and complaint survey of 3/20/23. The recited deficiencies were in the areas of infection prevention and control and food safety requirements and store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The continued failure of the facility during two surveys of record in the same area showed a pattern of the facility's inability to sustain an effective Quality Assurance program. The Findings included: This tag is cross referenced to: F-880 Based on observations, record review and staff interviews the facility failed to implement their policy for Infection Prevention when 1 of 1 staff (Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and staff interviews, the facility failed to implement their policy for Infection Prevention when 1 of 1 staff (Nurse Aide #1) failed to put on gloves and a gown before entering a resident's room for 1 of 2 residents on contact precautions (Resident #6). The findings included: The facility's policy entitled, Infection Prevention .Contact, Contact Enteric . read in part, Isolation precautions will be used .when standard precautions alone are not adequate to eliminate or minimize occupational exposure to communicable disease .contact precautions are indicated for patients who are known or suspected to be infected with microorganisms that can be transmitted by direct contact with the patient or indirect contact with environmental surfaces .personal protective equipment (PPE) including gloves and gown are worn to enter a patient's room. Perform hand hygiene with soap and water when leaving room. Resident #6 was admitted to the facility on [DATE] with current diagnoses of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.