Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Care And Rehab Center during CMS and state inspections, most recent first.
A resident with documented candidiasis of the skin and nails and intact cognition had a physician order for Nystatin powder to be applied to skin folds, abdomen, and neck every shift. Review of the medication administration record for a given month showed that the Nystatin powder was not documented as given on multiple night shifts. During interview, the ADON confirmed that if the medication administration record checkbox was not marked, they assumed the treatment had not been completed, indicating the ordered topical antifungal was not administered as prescribed.
A resident who was bedbound, on continuous O2, and receiving hospice care was repeatedly observed in bed with multiple vape/e-cigarette devices on the bedside table, while using an oxygen concentrator via nasal cannula. The resident reported vaping in the room and stated staff were aware but did not intervene because the resident could not go outside. A CNA confirmed the resident’s in-room vaping and possession of e-cigarettes, and the ADON acknowledged the resident hid under a blanket to vape despite being on continuous O2. The facility’s smoking policy and smoking safety assessments did not address vaping/e-cigarettes, and leadership confirmed that vaping was not included in smoking evaluations, even though residents were not permitted to use vapes/e-cigarettes inside the facility.
A resident receiving continuous tube feeding was repeatedly observed with the head of the bed flat and not elevated, despite having severe protein calorie malnutrition, GERD, and moderate cognitive impairment. Over several observations, staff, including an LPN, reported not seeing the bed elevated, while the resident stated they preferred the bed flat to sleep. The ADON acknowledged the bed should be elevated to 45 degrees to prevent aspiration and that the resident would lower the bed, and also confirmed the resident had not been educated on the possible complications of refusing head-of-bed elevation.
Surveyors found that a resident with CHF, anemia, moderately impaired cognition, and orders for continuous O2 and routine nebulizer treatments had a nasal cannula left loose on a recliner and a nebulizer mask with tubing left on a cart, both unbagged despite orders to store tubing and mask in a dry protective cover when not in use. An LPN confirmed the resident’s respiratory orders and acknowledged the cannula should not have been left on the chair, and the ADON confirmed that both the cannula and nebulizer mask were not bagged and stated they should have been bagged for infection control.
A resident with a known latex allergy received a latex urinary catheter instead of the ordered silicone type, resulting in skin irritation. The allergy was documented in the medical record and care plan, but staff did not verify allergies prior to catheter insertion, leading to the use of the incorrect catheter material.
A resident with paraplegia and multiple Stage 4 pressure ulcers was not provided with a bed wide enough for safe repositioning or with requested adaptive devices such as side rails and a trapeze bar. The resident reported being unable to reposition independently and feeling unsafe, while the facility cited policy restrictions and delays in providing the necessary equipment.
A facility failed to involve a resident with chronic obstructive pulmonary disease and kidney failure in the development of their person-centered care plan. Despite the resident's intact cognition and desire to participate, there was no documentation of their involvement. The DON relied on the MDS coordinator for scheduling, but meetings were not conducted due to staff being too busy, contrary to the policy requiring quarterly meetings.
Failure to Administer Ordered Topical Antifungal Medication Every Shift
Penalty
Summary
The deficiency involves the facility’s failure to administer a prescribed topical antifungal medication as ordered by the physician for one resident. A physician order dated 07/09/24 directed that Nystatin powder be applied to the resident’s skin folds, abdomen, and neck every shift. A significant change assessment dated 11/17/25 documented that the resident had candidiasis of the skin and nails and a BIMS score of 15, indicating the resident was cognitively intact for daily decision making. Review of the November 2025 medication administration record for the night shift showed that the resident did not receive the ordered Nystatin powder on multiple specified dates throughout the month. During interview, the ADON stated that if the checkbox on the medication administration record was not marked to indicate completion, they assumed the task had not been done. These findings show that, despite an active physician order and documented skin candidiasis, the ordered Nystatin powder was not administered on numerous night shifts as required, and the facility relied on unchecked MAR boxes as an indication that the treatment had not been provided.
Failure to Assess and Control Vaping/E-Cigarette Use for Oxygen-Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to evaluate and manage a resident’s vaping/e-cigarette use as part of its smoking safety program. On multiple observations, the resident was seen in bed using continuous supplemental oxygen via nasal cannula from an oxygen concentrator, with three pink vape/e-cigarette devices on the bedside table. The facility’s Smoking Protocol policy, dated 10/25/22, did not address vaping or e-cigarettes, and the resident’s Smoking Safety Evaluation, dated 11/05/25, documented that the resident did not smoke. The comprehensive assessment dated 11/17/25 showed the resident had COPD, hypoventilation syndrome, intact cognition with a BIMS score of 15, required substantial to maximum assistance with bed mobility, was dependent for bed transfers, used supplemental oxygen, and was documented as not a tobacco user. During interviews, the resident stated they were bedbound, used continuous supplemental oxygen, and vaped e-cigarettes in their room, adding that staff “turned their heads” because the resident could not go outside. The resident also reported being told by the ADON not to smoke in the room but believed this was related to their inability to get out of bed. A CNA confirmed the resident used e-cigarettes/vapes, kept them on the bedside table, did not like to get out of bed except for showers, and had confided that they vaped in the room despite nurses’ requests not to. The ADON acknowledged the resident was bedbound, on continuous oxygen, on hospice, required three to four staff for transfers, used e-cigarettes/vapes in their possession, and hid under a blanket to vape in the room, and further stated that vaping/e-cigarettes were not included on smoking assessments. The administrator also confirmed that vaping/e-cigarettes were not included in the smoking assessment or smoking policy, and stated that residents were not allowed to use vapes/e-cigarettes inside the facility.
Failure to Maintain Head-of-Bed Elevation During Continuous Tube Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the head of the bed was elevated for a resident receiving continuous tube feeding. Surveyors observed on multiple occasions that the resident’s bed was flat without elevation while tube feeding was ongoing, including observations on four separate dates and times. The resident had diagnoses of severe protein calorie malnutrition and gastro-esophageal reflux disease and had moderate cognitive impairment with a BIMS score of 10. An LPN who had worked at the facility for one week reported never seeing the resident’s head of bed elevated. The resident stated they did not want the head of the bed elevated because they liked to sleep and could not sleep with the bed raised. The ADON stated the resident should have the head of the bed elevated 45 degrees and could aspirate if it was not elevated, and also stated that the resident would put the head of the bed down if it were elevated and had not been educated on the possible complications of not having the head of the bed elevated. This sequence of observations and statements shows that, despite the resident receiving continuous tube feeding and having relevant medical conditions, the facility did not maintain the required head-of-bed elevation and did not provide education to the resident about the complications of refusing elevation, leading to the cited deficiency.
Improper Storage of Respiratory Equipment and Failure to Bag Oxygen and Nebulizer Supplies
Penalty
Summary
The deficiency involves the facility’s failure to ensure respiratory equipment was properly stored and bagged when not in use, as required by physician orders and infection control practices. During observation, a resident who was not in their room had a nasal cannula lying loose on a recliner and a nebulizer mask with attached tubing lying on a cart under the window, both unbagged. Physician orders dated 01/10/25 directed that the resident receive albuterol sulfate inhalation solution via nebulizer, and orders dated 07/04/25 specified continuous oxygen at two liters via an oxygen concentrator, including instructions to store tubing and mask in a dry protective cover when not in use. The resident’s significant change assessment, dated 11/17/25, documented admission with diagnoses including congestive heart failure and anemia, moderately impaired cognition with a BIMS score of 11, dependence for transfers, wheelchair use for ambulation, and use of oxygen therapy. When interviewed, an LPN confirmed the resident had continuous oxygen and routine breathing treatments and acknowledged the nasal cannula was lying on the chair and should have been hung on the machine. The ADON, after viewing the room, confirmed that both the nasal cannula and nebulizer mask were not bagged and stated they should have been bagged when not in use for infection control and that the resident required staff assistance for transfers and portable oxygen use.
Failure to Prevent Latex Exposure in Resident with Documented Allergy
Penalty
Summary
A resident with a documented latex allergy was given an indwelling latex urinary catheter, contrary to physician orders specifying the use of a silicone catheter. The resident's allergy to latex was clearly indicated in their medical record, care plan, and allergy documentation. Despite this, staff failed to verify the allergy prior to the catheter insertion, resulting in the use of a latex catheter. The resident was cognitively intact and able to communicate their allergy, which had been listed since admission. Following the insertion of the latex catheter, the resident developed redness and irritation on their right thigh where the catheter tubing had been in contact with the skin. The issue was identified when staff noticed the redness and realized the catheter was latex rather than silicone. The physician was notified, and treatment for the skin irritation was ordered. Interviews with staff confirmed that the error occurred due to a failure to check the resident's allergies before the procedure.
Failure to Provide Adequate Bed and Adaptive Devices for Resident with Paraplegia
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident with paraplegia, anxiety, depression, and multiple Stage 4 pressure ulcers by not providing a bed wide enough for safe repositioning and by not supplying requested adaptive devices such as side rails and a trapeze bar. Observations showed the resident lying on an air mattress with only about four inches of space from their hips to the edge of the mattress, without side rails or a trapeze bar present. The resident reported being accustomed to using these devices for bed mobility and expressed feeling claustrophobic and restrained due to the bed's size and lack of support, resulting in complete dependence on staff for repositioning and a fear of falling during transfers. The facility's policy required evaluation and ongoing review of residents' needs for adaptive devices and environmental modifications. Despite the resident's requests for side rails upon admission and a trapeze bar shortly thereafter, the facility did not provide these accommodations, citing a policy against full side rails and a delay in providing the trapeze bar. The DON stated they relied on nursing and therapy staff to communicate such needs and were unaware that the resident's bed did not adequately accommodate them.
Failure to Involve Resident in Care Plan Development
Penalty
Summary
The facility failed to ensure a resident and/or their representative participated in the development and implementation of a person-centered care plan. The facility's policy required the Interdisciplinary Team, along with the resident and/or their representative, to identify resident problems, needs, strengths, life history, preferences, and goals. However, for one resident with diagnoses including chronic obstructive pulmonary disease and kidney failure, there was no documentation showing their involvement in care plan meetings. Despite having intact cognition, the resident reported not having had a care plan meeting and expressed a desire to participate. The Director of Nursing admitted reliance on the MDS coordinator for scheduling care plan meetings but acknowledged a lack of follow-up procedures. The MDS coordinator confirmed that care plan meetings were not being conducted due to staff being too busy, despite the requirement for quarterly meetings.
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Illustrative
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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) |
|---|---|---|---|---|
| Cimarron Pointe Care Center | 11.5 mi | ★★★★★ | 1 | 0 |
| Southern Oaks Care Center | 18.7 mi | ★★★★★ | 9 | 0 |
| Fairfax Behavioral Health & Memory Care Community | 22.1 mi | ★★★★★ | 4 | 0 |
| Sand Springs Nursing And Rehabilitation | 23.3 mi | ★★★★★ | 5 | 2 |
| Drumright Nursing Home | 23.7 mi | ★★★★★ | 6 | 1 |
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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 July 2026) and official state health department websites.