CLEVELAND, OK- CLEVELAND CARE & REHABILITATION CENTER

The Department of Health & Human Services conducted an inspection of the facility. The following  highlighted decencies listed below were found in a public survey.

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Based on record review and interview, the facility failed to implement their abuse policy for one of five new employees reviewed for background checks.

The Abuse Prevention policy, dated 10/21/2022 read in parts, . The facility will pre-screen all potential new employees and residents for a history of abusive behavior.

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

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.

Ensure medication error rates are not 5 percent or greater.

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%.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

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

Provide and implement an infection prevention and control program.

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.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Based on record review and interview, the facility failed to ensure influenza vaccinations were offered for one (#41) of five residents reviewed for immunizations.

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member’s vaccination status.

Based on record review and interview, the facility failed to ensure COVID-19 vaccinations were offered for one (#41) of five residents reviewed for immunizations.