Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Singleton Health Care Center during CMS and state inspections, most recent first.
The facility did not timely update resident trust account records, causing multiple accounts to show negative balances that staff acknowledged did not reflect actual resident funds. Fourteen residents with various chronic conditions, including dementia, schizophrenia, depression, COPD, and DM, were affected, with negative balances ranging from small amounts to over one thousand dollars. Staff interviews revealed that the Business Office Manager relied on the Executive Director to provide information on cashed checks and cost-of-care payments, and both the Administrator and Executive Director admitted they were behind on bookkeeping and documentation. Facility policies allowed residents or their representatives to request account balances and detailed fund activity, but the delayed updates meant the financial records were not accurate at the time of review.
A resident with severe cognitive impairment and multiple chronic conditions, including vascular dementia, COPD, and CKD, had incomplete and inaccurate medical records. Over a 12‑month period, there were no psychiatric evaluations or notes documented, and there was no record that the VA psychiatric physician was consulted about pharmacy recommendations or medications ordered by the facility physician, including psychotropics. The DON confirmed that although several telehealth meetings occurred between the resident, the spouse, facility staff, and the VA physician, there was no documentation of these encounters or any recommendations made.
A resident with severe cognitive impairment was not treated with respect and dignity by a medical secretary at the facility. The resident, who has Alzheimer's, dementia, schizophrenia, and schizoaffective disorder, was addressed in a rude and blunt manner when she knocked on a locked door. The medical secretary admitted to the interaction, and the resident confirmed that she sometimes experienced disrespectful treatment. This incident violated the facility's policy on resident rights and dignity.
A facility failed to complete a baseline care plan for a resident with diabetes and pancreatic cancer within 48 hours of admission. The care plan was initiated by an LPN but was not completed or entered into the electronic system, leaving it unavailable for nursing staff. This was contrary to the facility's policy, which requires completion within 48 hours.
The facility failed to document fall prevention measures and conduct post-fall assessments for a resident with epilepsy and dementia, and did not complete a baseline care plan for another resident requiring a Hoyer lift, leading to a fall during care. The DON confirmed documentation errors and policy non-compliance, resulting in unsafe conditions.
A facility failed to follow pharmacy recommendations for a resident's medication management. The resident, with diagnoses including schizophrenia, was on Haldol, an antipsychotic medication. The pharmacist suggested an end date for the medication, but the medical director did not address this recommendation. The DON confirmed the oversight, which was against the facility's policy requiring gradual dose reductions for psychotropic medications.
A facility failed to accurately document fall risk assessments for a resident at risk of falls. The resident, with multiple diagnoses including epilepsy and dementia, was receiving antihypertensives, antiseizure, and diuretic medications. However, the assessments did not reflect these medications or the presence of seizures, leading to incorrect documentation. An LPN confirmed the errors in the assessments, which were identical despite being conducted months apart.
Untimely Resident Trust Account Updates Result in Inaccurate Negative Balances
Penalty
Summary
The facility failed to properly hold, secure, and manage residents' personal funds by not keeping resident trust account financial records timely updated, resulting in multiple accounts showing negative balances. Fourteen residents' financial records were reviewed, and each showed a negative balance as of 02/27/26, despite facility leadership stating that most of these residents did not actually have negative balances. The residents involved had a range of medical diagnoses, including hypertension, dementia, schizophrenia, major depressive disorder, COPD, diabetes, and other chronic conditions, and several had documented cognitive impairments ranging from mild to severe, while others were cognitively intact. Specific review of each resident's trust account information dated 02/27/26 revealed negative balances varying in amount. One resident had a negative balance of -$970.99, another had -$31.45, and others had negative balances such as -$59.09, -$77.14, -$110.97, -$31.57, -$56.96, -$44.47, -$4.73, -$18.97, -$64.57, -$39.72, and -$36.71. One resident's account showed a significantly larger negative balance of -$1,819.10. These negative balances were documented for residents with differing cognitive statuses, including residents whose MDS assessments showed severe cognitive impairment, mild cognitive impairment, intact cognition, and some whose cognitive status had not yet been evaluated. Interviews with facility staff confirmed that the negative balances were largely due to delays and backlogs in bookkeeping and updating of financial records, rather than actual overspending by residents. The Business Office Manager stated that many resident financial records were not up to date and that she depended on the Executive Director to provide information about cashed checks and cost-of-care payments before she could update the accounts. The Administrator acknowledged that the facility was behind in paperwork and bookkeeping, resulting in resident financial records reflecting negative balances that did not correspond to the residents' true financial status. The Executive Director confirmed he could fall behind on documenting resident financial expenses and revenues and that most residents with negative balances did not truly have negative balances because the records had not yet been updated. Facility policies stated that residents are permitted to manage their personal funds or, if managed by the facility, to receive quarterly statements and to obtain their account balances and written breakdowns of fund activity upon request, underscoring the requirement for accurate and timely financial recordkeeping that was not being met.
Failure to Maintain Complete and Accurate Psychiatric and Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple chronic conditions, including type II diabetes, hydrocephalus, vascular dementia, COPD, chronic kidney disease, and a severe cognitive impairment documented on an MDS assessment. Review of this resident’s medical record showed no psychiatric evaluations or notes regarding psychiatric meetings for the previous 12 months, despite the resident receiving psychiatric care through the VA. There was no documentation that the VA psychiatric physician was consulted or informed of pharmacy recommendations related to the resident’s ordered medications, including psychotropic medications, nor any documentation that the VA psychiatric physician was consulted about medications ordered by the facility physician. During an interview, the DON confirmed there was no documentation in the resident’s record to support psychiatric appointments or meetings with the VA physician. She acknowledged that telehealth meetings involving the resident, his wife, facility staff, and the VA physician had occurred on three separate dates, but the facility had no documentation of these encounters, including what was discussed or any recommendations made regarding the resident’s health. This lack of documentation resulted in incomplete and inaccurate medical records for the resident.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as required by their policy. The resident, who had severe cognitive impairment due to Alzheimer's disease, dementia, schizophrenia, and schizoaffective disorder, was observed interacting with a medical secretary in a manner that lacked respect. The resident approached a locked door and knocked, prompting the medical secretary to open the door forcefully and address the resident in a rude and blunt tone, questioning the resident's actions. This interaction caused the resident to step back and walk away after receiving an unclear response to her question. Further interviews revealed that the medical secretary admitted to not always speaking to residents in such a manner but justified her behavior by stating that the resident was knocking hard on the door. The resident later confirmed that she was sometimes treated with respect and dignity but noted that the medical secretary could be mean and rude. The facility's policy on resident rights and dignity, which mandates that residents be treated with courtesy and respect, was not adhered to in this instance.
Failure to Complete Baseline Care Plan Timely
Penalty
Summary
The facility failed to complete a baseline care plan for Resident #200 within the required 48-hour timeframe following admission. Resident #200, who had diagnoses including diabetes mellitus and malignant neoplasm of the pancreas, was admitted to the facility and later discharged to the hospital without returning. Upon review, the baseline care plan in the electronic health record was found to be blank and incomplete. An LPN involved in the process confirmed that she had started the care plan by hand but did not complete it or enter it into the computer system, which should have been done within 48 hours of admission as per facility policy. This oversight meant that the nursing staff did not have access to the necessary care plan for Resident #200 during their stay.
Deficiencies in Fall Prevention and Documentation
Penalty
Summary
The facility failed to ensure proper fall prevention measures and accurate documentation for Resident #34, who was admitted with multiple diagnoses including epilepsy and dementia. Despite being on medications that could increase fall risk, the facility did not document fall prevention interventions on the Kardex, nor did they conduct post-fall assessments for 72 hours as per their policy. The fall risk assessment was inaccurately completed, failing to account for the resident's medications and predisposing diseases, which contributed to the oversight in fall prevention. For Resident #200, the facility did not complete a baseline care plan within the required 48 hours of admission, leaving staff without guidance on necessary interventions to prevent falls. This resident, who required a mechanical Hoyer lift and was dependent on staff for personal hygiene, fell out of bed during care when a CNA rolled him onto his side. The CNA did not ensure the bed was positioned safely against the wall and did not have assistance from another staff member, which was necessary due to the resident's condition. The Director of Nursing confirmed the deficiencies in documentation and care, acknowledging that the baseline care plan for Resident #200 was not completed timely, and the fall risk assessment for Resident #34 was incorrect. These lapses in documentation and adherence to policy resulted in unsafe conditions for both residents, highlighting the facility's failure to provide adequate supervision and accident prevention measures.
Failure to Follow Pharmacy Recommendations for Medication Management
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were followed for a resident, leading to a deficiency in medication management. The resident, who was admitted with diagnoses including arthritis, schizophrenia, and insomnia, was cognitively intact and required varying levels of assistance for daily activities. A review of the Medication Administration Record for July 2024 showed an order for Haldol, an antipsychotic medication, to be administered intramuscularly every six hours as needed. The pharmacist recommended adding an end date to this medication order, but there was no evidence that the medical director addressed this recommendation. The Director of Nursing confirmed that the recommendation was not addressed, which was contrary to the facility's policy on medication monitoring that required gradual dose reductions for psychotropic medications unless clinically contraindicated.
Inaccurate Fall Risk Assessment Documentation
Penalty
Summary
The facility failed to accurately document fall risk assessments for a resident identified as being at risk of falls. This deficiency was discovered during a review of the medical records and interviews with staff. The resident in question was admitted with multiple diagnoses, including epilepsy, hypertension, bradycardia, and dementia, among others. Despite these conditions, the fall risk assessments conducted on two separate occasions inaccurately reflected the resident's medication regimen and predisposing diseases. Specifically, the assessments failed to account for the resident's use of antihypertensives, antiseizure, and diuretic medications, as well as the presence of seizures, which are relevant to fall risk. An interview with the MDS LPN confirmed the inaccuracies in the fall risk assessments. The assessments, dated several months apart, contained identical errors, indicating a failure to update or accurately document the resident's current medical status and medication use. This oversight in documentation could potentially impact the resident's care plan and safety measures related to fall prevention.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Crawford Manor Healthcare Center | 0.1 mi | ★★★★★ | 2 | 0 |
| The Gardens Of Fairfax Health Care Center | 0.7 mi | ★★★★★ | 14 | 0 |
| Cityview Healthcare And Rehabilitation | 0.8 mi | ★★★★★ | 9 | 1 |
| Judson Park | 1.5 mi | ★★★★★ | 0 | 0 |
| University Manor Health & Reha | 1.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.