CLEVELAND MANOR NURSING & REHAB

LOCATED: 900 NORTH DIVISION, CLEVELAND, OK 74020

CLEVELAND MANOR NURSING & REHAB was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.

FACILITY FAILED TO PROTECT EACH RESIDENT FROM ALL ABUSE, PHYSICAL PUNISHMENT, AND BEING SEPARATED FROM OTHERS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, it was determined the facility failed to protect a resident from abuse for one (#3) of three sampled residents who were reviewed for allegations of abuse. Resident #3 was found to have an estimated 12 wipes pushed up into his rectum. The facility identified 52 residents who resided at the facility.

With the confession of abuse from (name deleted CNA #1) and failure to report and protect by (name deleted CNA #2), both are substantiated and terminated from this facility. (Name deleted CNA #1) is in jail at this time . The report was signed by the administrator and the director of nursing. This report was faxed to OSDH on 09/13/17 at 1:37 p.m.

After a tour of the facility and interviewing some residents the surveyor reviewed the facility’s investigation of the above allegation of abuse. The facility’s investigation included two pictures. One picture showed what appeared to be a resident’s anal area with something whitish in color sticking out of a resident’s anus. The object sticking out of the resident’s anus was covered with what looked to be bowel movement (BM) except for a few small areas where the whitish color could be seen. The area around the resident’s anus looked engorged. The resident’s buttocks had BM on them. The other picture was of a resident’s buttocks area that was red in various places.

On 09/15/17 at 3:48 p.m., the chief of police was asked what were the findings of their investigation of the abuse allegation of resident #3 and CNA #1. The police chief stated the CNA had confessed. He stated the wipes were 8 inches by 12 inches in size and they estimated 12 wipes were used. He stated he had the CNA show him, how he had put the wipes into the resident’s rectum. The chief showed the surveyor how he had made his hand with his first finger and thumb into a circle. He stated the CNA roughly pushed into the open area of chief’s hand.

On 09/15/17 at 7:13 p.m., CNA #4 was asked to tell the surveyor about the incident related to resident #3. She stated she and CNA #3 had put the resident to bed after dinner. She stated they went to pull down his brief. She stated he was all dirty. She stated she could see one white spot then the resident looked like he started to have a BM and it (the wipes) started to come out. She stated CNA #3 started to carefully slowly pull it out. She stated she went to go get the nurse. She stated she was in shock. She stated, that was in his rectum. When asked she stated she was not in the resident’s room when the nurse came into the resident’s room. When asked she stated she did not know what the nurse did because she got busy. She stated she did see the DON and then the police came to the facility. She stated she had filled out a statement for the DON and the police. CNA #4 was asked what the resident did while the wipes were coming out. She stated he called out oh nurse and cinched his buttocks. The CNA was asked what the resident did while he was getting cleaned up. She stated he called out, oh nurse.

On 09/15/17 at 7:59 p.m., LPN #1 was asked to tell the surveyor about the incident with resident #3. She stated it was rolled up like a tampon. She stated CNA #3 had to pull them out of his rectum. She stated she immediately left the room and called the DON. She stated the DON called the administrator and the administrator called the police. She stated the police came to the facility. She stated she and the DON started getting paperwork together and called the physician. She stated the police asked if the resident was getting an abdominal xray. She stated the resident was sent to the hospital.

On 09/19/17 at 4:17 p.m., a phone interview was conducted with CNA #3. The CNA was asked when she took a picture of the resident’s buttocks and anal area. She stated before she touched it or anything, she took a picture. CNA #3 was asked why she took the pictures. She stated, Evidence.

Personal Note from NHA–Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.