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 Eastbrook Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain safe and sanitary conditions in multiple resident rooms and shared bathrooms, including a shared toilet that remained plugged and unusable for days with visible urine and feces, while residents were told to use a communal bathroom that lacked toilet paper. Surveyors observed sticky floors, heavy dust on vents and fans, stained privacy curtains and fall mats, and walls with stains and splatters that appeared to be blood or feces. Several rooms contained scattered food, trash, dirty urinals, gloves, and incontinence briefs, and a resident reported repeatedly asking staff to clean and help arrange items within reach. Common shower rooms and bathrooms had dirty floors, tissue and toilet paper on the ground, dried urine and feces-like stains on toilets, used razors and hair in sinks, dirty faucet seals, dust-laden vents, and apparent mold and build-up in shower areas, along with cracked and raised flooring at one room entry. These conditions were confirmed by the DON, Administrator, housekeeping staff, CNA, and an LPN.
Two residents experienced failures in accurate clinical documentation. A resident with morbid obesity, diabetes, CKD, and COPD had a weekly Mounjaro order for diabetes and weight management, but the MAR showed missed or blank entries on multiple occasions with no nursing notes indicating that the PCP was notified, despite a physician note to continue the medication and the resident reporting he sometimes did not receive it. Another resident with paraplegia and an indwelling catheter had care plan and Kardex directions for catheter care, but there were no physician orders specifying catheter care, no TAR or task documentation that catheter care was completed over an extended period, and the resident was dependent on staff for toileting hygiene, while the DON stated she believed care was done but not documented.
Failure to provide restorative services for residents with declining function. The facility did not have a restorative care program or policy and relied on therapy referrals after decline was identified rather than ongoing ROM or restorative interventions. A resident with multiple chronic conditions, wheelchair use, and limited assistance needs had no restorative services in the care plan, another resident with stroke-related deficits and a contracted hand was unsure about exercises to maintain function, and a third resident with hemiplegia and a contracted hand had no ROM interventions despite a clenched hand and prior palm wound.
A facility failed to make the most recent survey results readily accessible to residents and family members. The public survey binder was observed on the bottom shelf of a table near the entrance with no signage, and the newest survey in the binder was dated 01/27/22. The Administrator confirmed the most recent survey results were not included in the binder.
The facility failed to maintain therapy equipment, affecting a resident and potentially impacting all 91 residents. A resident with moderate cognitive impairment reported inadequate therapy equipment, leading to unsafe practices like using a sink for support. Observations confirmed that essential equipment was not maintained, and balance bars were inaccessible and unsafe. Therapy staff indicated the need for the equipment, but the facility had not serviced it since July 2024, despite being responsible for its maintenance.
A resident with multiple health issues fell during peri care due to being assisted by only one staff member instead of the required two. The care plan and Kardex indicated the need for two-person assistance, which was not followed, leading to the fall. The incident was confirmed by various staff members, and the facility's fall prevention policy was not adhered to.
The facility exceeded the acceptable medication error rate, with two errors identified during observations. One resident received the wrong form of Aspirin, while another received an incorrect dosage of Senna. Both errors were confirmed by the LPNs involved, indicating a failure to adhere to the facility's medication administration policy.
The facility failed to serve food at palatable temperatures, affecting several residents. Observations showed that meals were delivered without warming containers, resulting in food being served below the facility's temperature standards. Residents expressed dissatisfaction with the cold meals, highlighting a failure to comply with safe food handling practices.
The facility failed to ensure food items were appropriately labeled, dated, and contained, affecting 85 residents. Observations revealed unlabeled desserts, uncovered bacon and chicken, and improperly stored lettuce and cheese. A sanitizer pail was also found in the dry storage room. Cook #116 confirmed these findings, which were against the facility's food storage policy. Three residents were NPO at the time.
The facility failed to provide monthly spend-down letters for two residents approaching or over the resource limit, contrary to facility policy. The Business Office Manager only provided quarterly notifications, affecting residents with significant medical conditions.
The facility failed to accurately code comprehensive assessments for two residents, leading to deficiencies in their medical records. One resident's opioid use and discharge status were incorrectly documented, while another resident's fall was not recorded in the annual MDS assessment.
The facility failed to maintain a medication error rate below five percent, resulting in a 19.35% error rate. Errors included incorrect administration of nystatin and insulin for a resident, failure to flush a PEG tube before and after medication administration for another resident, and omission of several medications for a third resident.
Failure to Maintain Safe and Sanitary Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident rooms and shared bathrooms in a safe and sanitary condition for multiple residents. One shared bathroom serving two rooms had a toilet that had been plugged and unusable for two days, with old urine and feces visible in the bowl. Residents using that bathroom reported being given urinals but having no place to empty them due to the broken toilet, and one resident reported that the communal bathroom they were told to use lacked toilet paper. The DON stated she was unaware of the problem and confirmed that no work order had been placed as previously reported to the resident. Additional observations showed multiple resident rooms with unclean and cluttered conditions. Several rooms had sticky floors, visible dust build-up on vents, fans, and mini refrigerators, and stained privacy curtains and fall mats. In some rooms, there were food crumbs, candy, banana pieces, foam cups, plastic food containers, dirty urinals, gloves, incontinence briefs, and other trash scattered on or under beds and on the floor. Walls near sinks, bathrooms, and beds had numerous stains and splatters that appeared to be blood or feces. Some residents reported having asked staff multiple times to clean their rooms and help arrange items so they could reach them. Common shower rooms and bathrooms on both floors were also found in unsanitary condition. Surveyors observed dirty floors with tissue paper, footprints, toilet paper rolls on the floor, dried urine splatter on toilet seats, stains that appeared to be feces on toilets, brown debris and stains around toilets, used disposable razors and hair clippings left in sinks, dirty faucet seals, and visible dust on floor and ceiling vents. One shower area had what appeared to be mold in the corner, orange build-up along tile grout, and soap build-up on the dispenser. In addition, damaged flooring was observed at the entryway of one room, where cracked and raised vinyl with a hole was present. These findings were confirmed at the time of observation by the DON, Administrator, Housekeeping Director, housekeepers, CNA, and LPN. The facility’s own policy required a safe, clean, comfortable, and orderly environment.
Failure to Accurately Document Medication Administration and Catheter Care
Penalty
Summary
The deficiency involves failures to maintain accurate and complete medical records and documentation for two residents. For a resident with morbid obesity, diabetes with neuropathy, chronic kidney disease, and COPD, the care plan identified risks related to hypoglycemia/hyperglycemia and nutritional problems, with interventions including glucose monitoring, insulin administration, medication monitoring, and weight and diet management. The resident had a standing order for weekly Mounjaro injections for diabetes and obesity management. Review of the MAR showed that on one date the dose was marked as not given because it was being reordered, and on two later dates the MAR was left blank, with no indication the medication was administered. Further review of nursing notes for the same periods revealed no documentation that the PCP was notified when the resident did not receive the ordered Mounjaro doses. The quarterly MDS showed the resident was cognitively intact, and a physician progress note confirmed ongoing diagnoses of morbid obesity, diabetes, and COPD, and recommended continuation of Mounjaro. In interviews, the resident reported he was supposed to receive Mounjaro weekly, mainly for weight loss, and stated that at times he did not receive the medication, though he could not recall specific dates. The DON confirmed the MAR entries showing the missed or undocumented doses and acknowledged there was no nursing documentation of physician notification, stating she believed the medication may have been given but not documented. For a second resident with paraplegia, hypertension, and neuromuscular bladder dysfunction, the care plan and Kardex indicated the need for catheter care per policy, keeping the catheter bag below bladder level and covered, and providing catheter care per policy and after each bowel incontinence episode, though no frequency was specified. The quarterly MDS documented that this resident had intact cognition, an indwelling catheter, and was dependent on staff for toileting hygiene. Review of the TAR for two consecutive months and the task bar over a one‑month period showed no documentation that catheter care was completed, and the physician orders listed only an indwelling catheter to continuous drainage with no catheter care order. In interview, the resident was unsure how often catheter care was provided, and the DON verified there was no physician order specifying catheter care and no documentation of its completion, stating she believed it was done every shift but not documented. The facility’s catheter care policy described the purpose of preventing catheter-associated UTIs but did not address documentation or frequency of catheter care.
Failure to Provide Restorative Services for Residents With Declining Function
Penalty
Summary
The facility failed to provide restorative services to maintain or improve residents’ range of motion and functional abilities, and instead relied on therapy referrals when residents declined. The report states the facility did not have a restorative care policy or a restorative therapy system in place, and staff confirmed that residents were not routinely provided restorative therapy services. The Director of Nursing stated the facility only completed quarterly restorative assessments and referred residents to therapy when a decline in function was identified. Resident #14 had multiple diagnoses including diabetes, emphysema, pulmonary fibrosis, dementia with agitation, dysphagia, depression, pain, muscle weakness, abnormal gait and mobility, and long-term drug therapy. The resident used a wheelchair, needed limited assistance with transfers, walking, dressing, toileting, personal hygiene, and bathing, and was noted on restorative assessment to be unsteady with standing, walking, turning, toileting, and transfers. The care plan did not include restorative services to prevent decline in balance or transitions, and the resident stated he was not receiving therapy services to increase strength for independent ADLs. Resident #10 had diagnoses including dementia, kidney failure, anemia, malnutrition, stroke, dysphagia, hemiplegia and hemiparesis, and impaired mobility. The care plan goal was to maintain current ADL ability, but there were no interventions to address that goal beyond assistance levels and therapy referral as needed. The resident had a contracted right hand and was unsure whether he was receiving exercises to maintain function. Resident #54 had diagnoses including nontraumatic cerebral hemorrhage, hemiplegia and hemiparesis, dysphagia, facial weakness, dysarthria, PTSD, agitation, and a contracted left hand. The care plan lacked interventions for the hand contracture, ROM, or exercises, and the resident was observed with the left hand clenched tightly in the palm. Therapy staff stated the resident had developed a wound on the left palm from the fingernails digging into the palm, and the DON confirmed the facility did not have restorative exercises in place for the contracture.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to post the most recent survey results in a manner readily accessible to residents and family members. During observation, the public survey binder was found on the bottom shelf of a table by the facility entrance door, and there was no signage identifying the binder or indicating how to access it. The last survey included in the binder was dated 01/27/22, and there were no more recent surveys contained in the binder. During interview, the Administrator verified that the most recent survey results were not included in the survey binder for resident and family access.
Failure to Maintain Therapy Equipment
Penalty
Summary
The facility failed to maintain therapy equipment in proper working order, affecting one resident and potentially impacting all 91 residents. Resident #51, who has moderate cognitive impairment and requires assistance for mobility, reported that the therapy gym lacked necessary equipment, forcing him to use a sink for support while standing. Observations confirmed that essential therapy equipment, such as an ultrasound and TENS unit, were not maintained and thus unusable. Additionally, balance bars were inaccessible due to being surrounded by other equipment and were not secured, making them unsafe for use. Interviews with therapy staff, including a Certified Occupational Therapy Assistant and the Rehabilitation Director, revealed that the facility had not serviced the equipment since at least July 2024, despite being responsible for its maintenance according to the contract with therapy services. The Administrator acknowledged the overdue maintenance but argued that the equipment was not needed since there were no current orders for its use. However, therapy staff indicated they would utilize the equipment if it were operational. The facility's contract explicitly states that it is responsible for maintaining therapy equipment, yet this obligation was not fulfilled, leading to the deficiency.
Failure to Ensure Safe Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, resulting in a fall. Resident #73, who had a history of systolic congestive heart failure, acute respiratory failure, acute kidney failure, and required assistance with personal care, was involved in the incident. The resident's care plan specified the need for two-person assistance for toileting and transfers. However, during peri care, the resident was assisted by only one staff member, STNA #305, who was new and did not check the Kardex for the required assistance level. This oversight led to the resident falling out of bed. The incident was reported by STNA #305 to LPN #223, who assessed the resident and, along with STNA #305, manually lifted the resident back to bed without using a mechanical lift. Interviews with various staff members, including the Nurse Practitioner, LPNs, and the Director of Nursing, confirmed that the resident required two-person assistance as per the care plan and Kardex. The facility's policy on managing falls and fall risks, revised in March 2018, emphasized implementing a resident-centered fall prevention plan, which was not adhered to in this case. The deficiency was investigated under Complaint Number OH00156029.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 6.9% error rate during the observation period. Two errors were identified out of 29 medication administration opportunities. The first error involved Resident #36, who was diagnosed with hemiplegia and hemiparesis following a cerebral infarction. The resident was prescribed Aspirin 81 mg chewable to be taken orally in the morning. However, during the medication administration, the LPN administered Aspirin 81 mg enteric coated instead of the chewable form. The LPN confirmed the error during an interview, acknowledging that she did not verify the specific type of Aspirin before administration. The second error involved Resident #73, who had diagnoses including systolic congestive heart failure, acute respiratory failure, and acute kidney failure. The resident was prescribed Senna 8.6 mg, 50 mg PO, one tablet, twice a day for constipation. During the medication administration, the LPN administered only Senna 8.6 mg, one tablet PO, failing to provide the correct dosage. The LPN confirmed the error during an interview, admitting that the medication given did not match the physician's order. The facility's policy on medication administration, which requires verification of the right resident, medication, dosage, time, and method, was not adhered to in these instances.
Failure to Ensure Palatable Food Temperature
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, affecting four out of five residents observed for food palatability. Observations revealed that pre-prepared plates were sent from the kitchen to the second-floor dining room without warming containers, covered only in plastic wrap, and left on an open-air cart. This resulted in food being served at temperatures below the facility's policy standards for palatability, with hot dogs and French fries served at temperatures as low as 91 degrees Fahrenheit. Interviews with residents confirmed dissatisfaction with the temperature of their meals. One resident reported that their hot dog was not warm, another resident's food was cold upon returning from dialysis, and a third resident expressed a desire for warmer food. The facility's policy states that hot food should be served at temperatures between 100 and 120 degrees Fahrenheit or greater, indicating a failure to comply with safe food handling practices. This deficiency was investigated under Master Complaint Number OH00155188.
Failure to Properly Label, Date, and Contain Food Items
Penalty
Summary
The facility failed to ensure food items were appropriately labeled, dated, and contained, which had the potential to affect 85 residents receiving meals from the kitchen. During an observation of the kitchen, it was found that four desserts in styrofoam bowls lacked labels or dates, a case of bacon slices and a pan of fried chicken were uncovered in the walk-in cooler, and a bag of lettuce, a pack of sliced cheese, and a bag of shredded cheese were not labeled or dated. Additionally, a sanitizer pail was found in the dry storage room, and a bin of sugar was open to air. Cook #116 confirmed these findings and acknowledged that food items should be covered, labeled, and dated before being placed in the coolers. The facility's undated policy on food storage also required that all products be dated upon receipt, when opened, and when prepared. Three residents were noted to be NPO at the time of the observation.
Failure to Provide Monthly Spend-Down Letters
Penalty
Summary
The facility failed to provide spend-down letters for each month residents were approaching or over the resource limit, affecting two residents. Resident #11, diagnosed with paranoid schizophrenia, violent behavior, unspecified psychosis, impulse disorder, anxiety, and hypertension, had an ending balance of $1832.49 on 01/31/24, $1872.59 on 02/29/24, and $1912.69 on 03/31/24. The Business Office Manager (BOM) informed Resident #11's guardian on 03/27/24 that the resident was in jeopardy of losing Medicaid due to an abundance of funds. However, no spend-down letters were available for January and February 2024. Similarly, Resident #16, diagnosed with bipolar disorder, anxiety disorder, hypertension, dementia without behavioral disturbance, and chronic hepatitis C, had an ending balance of $1808.61 on 01/31/24, $1838.70 on 02/29/24, and $1868.79 on 03/31/24. A spend-down letter was provided on 03/29/24, but none were available for January and February 2024. The BOM confirmed that spend-down letters were only provided quarterly when residents had a balance of $1800.00 or more, contrary to the facility policy that required notification when the balance reached $200.00 less than the SSI resource limit.
Inaccurate Coding of Comprehensive Assessments
Penalty
Summary
The facility failed to accurately code comprehensive assessments for two residents, leading to deficiencies in their medical records. Resident #88, who had multiple diagnoses including surgical aftercare, diabetes, stroke, and end-stage renal disease, was admitted with an order for oxycodone for pain management. Despite receiving oxycodone for severe pain during a dressing change, the admission MDS assessment incorrectly indicated that the resident did not receive any opioids. Additionally, the discharge assessment for Resident #88 was inaccurately coded as a transfer to the hospital, whereas the resident was discharged against medical advice and arranged for a ride home. Resident #54, diagnosed with vascular dementia, adult failure to thrive, hyperlipidemia, chronic kidney disease, and hypertension, had an annual MDS assessment that failed to document a fall that occurred on 09/19/23. The assessment incorrectly indicated that no falls had occurred since the prior assessment. The MDS RN confirmed the error, acknowledging that the resident did have a fall, which was not reflected in the assessment. These inaccuracies in coding comprehensive assessments highlight deficiencies in the facility's record-keeping and assessment processes.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, resulting in a 19.35% error rate during the observation period. This affected three residents. For Resident #241, the LPN administered nystatin incorrectly by instructing the resident to spit instead of swallow, and administered insulin without priming the needle as required. The LPN confirmed these practices were her typical methods, which were not in accordance with the physician's orders or the facility's medication administration policy. For Resident #41, the LPN administered acetaminophen through a PEG tube without flushing the tube before or after the medication administration, resulting in a significant amount of medication being left in the cup and not administered to the resident. The LPN confirmed the omission of the flush and the leftover medication in the cup. This was not in accordance with the facility's policy for administering medications through an enteral tube. For Resident #58, the LPN failed to administer several medications, including a Breo Ellipta inhaler, Flonase nasal spray, and magnesium, and did not sign off on these medications in the Medication Administration Record. The LPN admitted to the omissions and the unavailability of magnesium. These actions were not in accordance with the physician's orders and the facility's medication administration policy.
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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) |
|---|---|---|---|---|
| Hillside Plaza | 0.5 mi | ★★★★★ | 1 | 0 |
| Willows Health And Rehab Ctr | 0.9 mi | ★★★★★ | 0 | 0 |
| Gardens Of Mcgregor And Amasa Stone | 1.4 mi | ★★★★★ | 20 | 0 |
| Mount Saint Joseph Rehab Center | 2 mi | ★★★★★ | 0 | 0 |
| Candlewood Healthcare And Rehabilitation | 2.1 mi | ★★★★★ | 0 | 0 |
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