Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cleveland Community Care Center during CMS and state inspections, most recent first.
Multiple residents experienced failures in the development and implementation of their care plans. A resident with psychiatric diagnoses did not receive required 1:1 behavioral supervision when the assigned staff member was found asleep. A cognitively intact resident with CVA, cancer, and Crohn’s disease did not receive scheduled showers or grooming, resulting in wearing the same clothes for days and uncombed hair. A Spanish-speaking resident with intact cognition had no care plan addressing his communication barrier despite relying on a phone translator. Another resident, PEG-fed and dependent for oral hygiene, had visibly dirty teeth and reported that staff did not brush them despite a care plan requiring daily oral care. A further resident with diabetes and severe hand contractures had very long fingernails and no ROM performed to the contracted hands, despite a care plan specifying nail care and ROM with AM and PM care.
Surveyors found that the facility failed to provide required ADL care to three dependent residents. One cognitively intact resident reported missing scheduled showers, wearing the same soiled clothing for several days, and not having her hair combed for an extended period, with observations confirming disheveled appearance and staff acknowledging she did not refuse care. A PEG-fed resident with dysphagia and moderate cognitive impairment was repeatedly observed with visible yellowish-tan buildup along the gum line and between teeth; the resident stated staff did not brush his teeth, and both an LPN and CNA confirmed that oral care expected every shift was not provided. Another resident with diabetes and a contracted hand was observed multiple times with fingernails about one inch long, some digging into the palm; staff confirmed the nails were excessively long, required trimming, and that nurses were responsible for this care.
Failure to Assist Resident With Requested Hair Care Services: A resident with polyneuropathy, MDD, anxiety disorder, and moderate cognitive impairment was not assisted to attend the beauty shop despite repeated requests since admission. Staff observed her with visibly overgrown hair, and interviews showed the beautician had stopped coming, CNAs were told to handle hair care during showers, and the ADM and DON were unaware the resident’s request had not been honored.
Unresolved grievances about missing resident clothing: Two residents reported repeated loss of personal clothing after another resident entered rooms and took belongings. One resident was cognitively intact with a BIMS of 15, and the other had moderate cognitive impairment with a BIMS of 10. Staff, including CNA, RN, social worker, and the administrator, confirmed the clothing theft was an ongoing issue, that clothing was being found hidden in a wheelchair, and that complaints remained unresolved with no grievance process completed.
Two residents were kept behind locked doors in a memory care area and were not allowed to leave freely. Staff said the unit was used for residents with dementia as well as residents with behaviors, and one resident was moved there because he was disruptive and asking for snacks and money. The ADON confirmed he had not had a psych eval or other services before the move, and a second resident said she had to stay behind the doors and ask staff to get items for her.
A resident's Quarterly MDS was inaccurately coded in Section GG as having no upper extremity impairment even though observation showed bilateral hand contractures and the DON confirmed the resident had contracted hands and was supposed to have hand splints. The resident had diagnoses including type 2 diabetes and right-hand contracture, and a BIMS score of 9 indicating moderate cognitive impairment. Facility policy required staff completing the assessment to certify the accuracy of their portion of the MDS.
Two residents with limited ROM and hand contractures did not receive ordered or recommended ROM-related care. One resident had a left hand splint and staff training documented, but staff did not consistently apply the splint or ensure it was worn as directed, and there was no order in the chart. Another resident was observed with bilateral hand contractures and no splints in place, while staff reported splints were in the dresser and had not been applied for about two days; the DON could not locate documentation of ROM services or splint application. OT records showed both residents had been trained for splint wear and passive ROM to maintain ROM and prevent further contracture.
A resident with paranoid schizophrenia and bipolar disorder was on 1:1 precautions for aggressive behaviors, but the assigned transporter fell asleep while sitting with him. The resident stated the sitter was supposed to be watching him but was sleeping, and CNA staff had to wake the transporter after he did not respond to repeated calls. An LPN and the DON confirmed the resident was not being supervised as directed while staff slept.
Failure to Develop and Implement Comprehensive Care Plans for Behavior, ADLs, Communication, Oral Care, and ROM
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for multiple residents. One resident with paranoid schizophrenia and bipolar disorder had a behavior management care plan that included one-on-one precautions, but during an observation the staff member assigned to provide continuous supervision was found asleep in a chair and did not respond when his name was called three times. The resident, who was cognitively intact, stated that the person in the chair was supposed to be watching him, indicating that the one-on-one supervision intervention was not being carried out as planned. Another cognitively intact resident with a history of CVA with left-sided weakness/hemiplegia, right hand contracture, incontinence, liver and colon cancer, and Crohn’s disease had a care plan requiring assistance with ADLs, including showers every other day and as needed. The resident reported not receiving a scheduled shower, wearing the same clothes for four days, and not having her hair combed since two days before Thanksgiving. Observations confirmed that her hair was disheveled and unkempt and that her gown had dried liquid stains, demonstrating that the ADL care plan, including grooming and hair care associated with showering, was not implemented as written. The facility also failed to develop and implement appropriate care plans for communication, oral care, and ROM. A cognitively intact resident whose preferred language was Spanish and who did not speak English had no care plan addressing his language or communication barrier, despite using a phone translator to communicate with staff. Another resident, dependent on staff for oral hygiene and receiving nutrition via PEG tube due to dysphagia, was observed with a yellowish-tan substance along the gum line and between the teeth and reported that staff did not brush his teeth, contrary to his care plan specifying daily and PRN oral care. A further resident with type 2 diabetes and hand contractures had a care plan calling for nail care by a nurse and ROM to upper and lower extremities with AM and PM care, yet was observed with contracted hands, no positioning devices, and fingernails approximately one inch long; a CNA confirmed that no ROM was being performed on the hands and that nails had not been trimmed, indicating the ROM and nail care interventions were not implemented.
Failure to Provide ADL, Oral Hygiene, and Nail Care for Three Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate activities of daily living (ADL) care, including hygiene and grooming, to three residents in accordance with its own policies. For one resident with Crohn’s disease, hemiplegia/hemiparesis, and colon cancer who was cognitively intact, surveyors observed on consecutive days that she remained in bed with disheveled, uncombed hair and wearing the same soiled gown with dried liquid stains. The resident reported she was scheduled to receive showers on specific days of the week and stated she had missed a scheduled shower, had not been offered one, and had worn the same clothes for four days. She also stated her hair had not been combed since two days before Thanksgiving, and staff interviews confirmed she did not refuse care and was supposed to receive showers on the days she identified. A second resident, who was PEG-tube fed, had dysphagia, hemiplegia, hemiparesis, and moderate cognitive impairment, was observed lying in bed with a yellowish-tan substance along the lower gum line and between the teeth on two separate occasions. The resident stated he could not take anything by mouth and that staff did not brush his teeth or keep his mouth clean, adding that staff did not have time but needed to take time to provide this care. An LPN and the DON both confirmed the visible soiling of the resident’s teeth and acknowledged that mouth care was expected every shift. A CNA who had provided care the previous day confirmed that she did not brush the resident’s teeth, despite knowing that oral care was expected every shift, and described difficulty providing mouth care due to the resident’s PEG feeding and need to remain upright. The third resident, with type 2 diabetes, a right-hand contracture, and moderate cognitive impairment, was repeatedly observed with fingernails on both hands approximately one inch in length. On further observation, fingernails on the right hand were seen digging into the resident’s palm, and both a CNA and an LPN confirmed that the nails were very long, bent inward toward the palm, and needed trimming. Staff interviews indicated that nurses were responsible for trimming this resident’s fingernails due to his diabetes. The DON acknowledged observing the contracted hands and fingernails digging into the palm and stated that failure to provide nail care services could result in worsening skin breakdown and accidents. These observations and interviews demonstrated that the facility did not provide necessary ADL care, including bathing, grooming, oral hygiene, and nail care, as required by its policies.
Failure to Assist Resident With Requested Hair Care Services
Penalty
Summary
The facility failed to honor a resident’s right to dignity, choice, and self-determination by not assisting Resident #37 to attend the beauty shop as she requested. The resident was observed seated in her wheelchair with visibly overgrown hair, described as approximately four inches of gray overgrowth with red coloring remaining on the bottom half of her hair. She stated that she had been requesting help to go to the beauty shop since her admission in June 2025 and said, “It’s like it falls on deaf ears. No one ever takes me.” She also stated, “I have never had my hair look so terrible.” A follow-up observation the next day showed no change in her appearance. During interviews, CNA #1 confirmed the resident had previously requested to go to the beauty shop and stated the beautician had only been coming a few times a month and staff did not know when she would be there, so they would miss her. CNA #1 later said she did not think there was a beautician now and acknowledged the resident’s hair was visibly overgrown. The SW stated the facility learned in late December that the beautician would not be returning and that CNAs were told they would be responsible for residents’ hair care during showers. The Administrator stated he was unaware the resident had requested beauty shop services and agreed that if she was requesting it and was not assisted, her rights were violated. The DON also stated she was unaware of the request and confirmed the facility failed to ensure the resident’s rights were honored. Resident #37’s record showed diagnoses including polyneuropathy, major depressive disorder, and anxiety disorder, and her MDS indicated a BIMS score of 10, consistent with moderate cognitive impairment.
Unresolved grievances about missing resident clothing
Penalty
Summary
The facility failed to ensure resident grievances about missing personal clothing were investigated, resolved, and communicated to the residents for two sampled residents. The facility policy titled Resident Care Grievance Policy required grievance decisions to include the date received, a summary of the grievance, steps taken to investigate, pertinent findings or conclusions, whether the grievance was confirmed, corrective action taken or to be taken, and the date the decision was issued. Resident #29, who was admitted with Crohn's Disease, hemiplegia and hemiparesis, and malignant neoplasm of the colon and had a BIMS score of 15, reported that another resident repeatedly entered her room and removed clothing from her closet. She stated she had reported the issue for a long time, but it remained unresolved, and she kept her privacy curtain open so she could watch her closet and yell if the other resident entered. Resident #37, admitted with polyneuropathy, major depressive disorder, and anxiety disorder and with a BIMS score of 10, reported that clothing brought in on admission was no longer in her closet and that she had repeatedly notified staff without resolution. She stated she was unable to leave her room because she lacked clothing, and observation of her closet showed no clothing and six empty hangers. Staff interviews confirmed that missing clothing was an ongoing problem on the unit, that a cognitively impaired resident was taking clothing from other residents' rooms and hiding it in her wheelchair, and that staff routinely retrieved clothing and redirected her without effective resolution. The social worker confirmed awareness of the issue and stated no steps had been taken to resolve it, while the administrator stated he was not aware of specific resident complaints and acknowledged that no grievances had been filed for Residents #29 or #37.
Residents Kept Behind Locked Doors Without Proper Assessment
Penalty
Summary
The facility failed to protect residents from involuntary seclusion by placing two residents in a locked Memory Care unit without a proper assessment. The facility policy stated that residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and involuntary seclusion. Surveyors found that the locked unit was used for residents with dementia as well as residents with behaviors or psychiatric issues, and staff described the area as a place where residents were kept behind locked double doors and could only leave if staff entered a code to unlock them. One resident, who had diagnoses including unspecified impulse disorder, restlessness, and agitation, was observed sitting in his room behind locked double doors and stated that he had been moved there because he was "acting a fool" on the other hall and that staff put him back there so they would not have to deal with him anymore. He said he could not get out without asking someone. Staff confirmed he had been moved from the South Hall to the locked unit because he was constantly taking snacks, asking for money, and following staff around. The RN and ADON stated that residents with behaviors and those needing close monitoring were placed behind the locked doors, and the ADON acknowledged that the resident had not had a psychiatric evaluation or other services before being moved. A second resident, who had diagnoses including type 2 diabetes mellitus, schizoaffective disorder, and peripheral vascular disease, was observed sitting near the locked double doors in the women's unit and stated she was not allowed outside the doors and had to ask staff to get items for her. She said she stayed behind the doors as she was supposed to, but would like to go outside them. A CNA confirmed that residents did not come out of the locked unit and staff retrieved items for them. The corporate nurse stated the residents had been placed in an involuntary seclusion area without proper assessment, and the facility administrator acknowledged that the locked unit was used for residents with behaviors as well as those with Alzheimer's disease.
Inaccurate MDS Coding for Upper Extremity ROM
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident when Section GG0115, Functional Limitation in Range of Motion, on the Quarterly MDS was coded as having no impairment to the upper extremities despite the resident having bilateral hand contractures. During observation, the resident's bilateral hands appeared contracted in appearance, and the DON later stated she had observed the contracted hands and that the resident was supposed to have splints applied to his hands. Review of the resident's record showed diagnoses including type 2 diabetes and contracture of the right hand, and the BIMS dated 11/20/25 showed a score of 9, indicating moderate cognitive impairment. The facility policy titled, Certifying Accuracy of the Resident Assessment, required personnel completing any portion of the resident assessment to sign and certify the accuracy of that portion of the assessment.
Failure to Provide ROM and Splinting for Two Residents with Contractures
Penalty
Summary
The facility failed to provide ROM services for two residents with limited ROM and contractures. The deficiency was identified through observation, resident and staff interviews, record review, and facility policy review. The facility policy stated that residents with limited ROM would receive treatment and services to increase and/or prevent further decrease in ROM. Resident #24 was observed sitting in his wheelchair with contractures of the second through fifth digits of his left hand, with the fingers stiff, bent inward, and the fingernails touching the palm. He stated he had a hand brace in his dresser drawer, but he sometimes had difficulty applying it because of his limited hand use and needed staff help. He also stated that nurses and aides did not offer to put the splint on and that he had to ask for assistance. RN #1 stated the resident knew to ask for help but staff did not make sure the brace was applied, and the DON confirmed there was no order for the hand splint even though therapy had trained staff on how to apply it. The OT discharge summary documented a left resting hand splint and instructed staff to apply it three times a week for two to four hours, along with passive ROM exercises, to maintain ROM and decrease further risk for contracture. Resident #105 was observed with bilateral hand contractures, with no positioning devices in place, and later the right hand was observed with the first and second fingernails digging into the palm. CNA #2 stated splints were in the dresser drawer but had not been applied for approximately two days, and that ROM was not performed because of the severity of the contractures. LPN #1 also observed the contracted hands and no splints in place. The DON stated the resident was supposed to have splints applied, that failure to provide ROM and splinting could worsen contractures, and that the facility could not locate documentation of ROM services or splint application. The OT discharge summary for this resident documented a right wrist-hand-finger orthosis and training of facility staff on the restorative program, including splint wear, hand hygiene, and passive ROM.
Failure to Maintain One-on-One Supervision for a Resident with Behavioral Precautions
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for one resident who was on one-on-one precautions for aggressive behaviors. The resident had diagnoses including paranoid schizophrenia and bipolar disorder, and a BIMS score of 15 indicating he was cognitively intact. A facility policy stated that resident safety and supervision to prevent accidents were facility-wide priorities, and the resident had an order dated 12/31/25 for one-on-one precautions related to aggressive behaviors for seven days. During observation, the resident stated he wanted to go back to where he came from and said the man asleep in the room was supposed to be watching him but was sleeping. The sleeping individual was identified by CNA #3 as the transporter assigned to sit with the resident for one-on-one supervision. The transporter did not awaken when CNA #3 called his name three times and remained asleep until another staff member woke him. The transporter stated he had dozed off and knew he was not supposed to sleep while on duty. An LPN and the DON confirmed the resident was supposed to be under one-on-one supervision due to threats to kill staff and other residents, and that while staff were asleep the resident was not being supervised as directed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cleveland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bolivar Medical Center Ltc | 0.6 mi | ★★★★★ | 0 | 0 |
| Delta Rehabilitation And Healthcare Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Walter B Crook Nursing Facility | 8.8 mi | ★★★★★ | 7 | 0 |
| Ruleville Community Care Center | 8.9 mi | ★★★★★ | 13 | 0 |
| Diversicare Of Shelby | 14.3 mi | ★★★★★ | 0 | 0 |
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