Below 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 Life Care Center Of Cleveland during CMS and state inspections, most recent first.
Kitchen Sanitation and Food Storage Deficiencies: The facility failed to keep the kitchen and food storage areas clean and sanitary. During observation, the floor around the stove and griddle was visibly soiled, and opened containers of barbecue sauce and Caesar dressing were found in the walk-in refrigerator with old residue, no opened dates, and one expired item available for resident use. Logs also showed missing daily cleaning entries, incomplete dish machine sanitizer testing, and missing food temperature documentation.
Improper medication storage was found in several med carts, a med room, and a resident room. An opened ipratropium/albuterol package was not dated, unopened insulin was not refrigerated, discontinued eye drops remained in a cart, semaglutide pens were not dated, and expired supplies were available for use. A resident with intact cognition had multiple unsecured meds and topical products at bedside without a self-administration assessment or MD order. Two med carts were also left unattended, with one unlocked and another holding polyethylene glycol on top of the cart.
Two residents with significant medical conditions were found to have personal fans in their rooms that were not maintained in a clean and sanitary condition, with visible dust and debris on the blades and grilles. Facility policy required daily cleaning of rooms and equipment, but observations and staff interviews confirmed this was not done for the fans.
A facility failed to keep resident PHI private when a skilled med cart was left in the hallway with a laptop screen facing outward and open to one resident's eMAR, while an open narcotic sign-out book exposed another resident's controlled substance reconciliation log. An LPN confirmed the information was visible to passersby, and the ADON stated the residents' sensitive health information should not have been open to view.
Inaccurate MDS Assessment Missing PASRR Level II Coding: A resident with dementia, depression, and anxiety had a PASRR Level II outcome for serious mental illness, but the significant change MDS did not include the Level II PASRR coding. The resident’s MDS also showed severe cognitive impairment with a BIMS score of 3, and the RN MDS Coordinator confirmed the assessment was inaccurate.
An LPN crushed and administered an ER isosorbide mononitrate tablet to a resident with dementia and a swallowing problem, despite the medication card stating not to crush it and the resident's order allowing crushing only unless contraindicated. The resident had heart disease, diabetes, and hypertension, and the ADON confirmed the facility failed to follow the physician's order when the ER medication was crushed and given with applesauce.
Failure to Assist Residents With Hand Hygiene Before Meals: During breakfast tray delivery, staff brought meal trays to four residents and allowed them to begin eating without offering or assisting with hand hygiene. Two residents had severe cognitive impairment and all four required substantial/maximal help with personal hygiene; staff confirmed the hand hygiene was not performed, and the ED stated infection prevention and control practices were not maintained during the meal.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, with findings based on policy reviews, documentation reviews, observations, and interview. Facility policies required the Food and Nutrition Services department to be maintained in a clean and sanitary manner, food to be stored in sanitary containers and labeled with dates, and opened packages to be resealed tightly to prevent contamination. During a kitchen observation with the FSD, the floor under and around the stove and cook top griddle was visibly soiled with thick debris, dried food debris, and accumulated grime. The walk-in refrigerator contained an opened 1-gallon container of Barbecue Sauce with less than one-quarter remaining, old residue on the container, no opened date, and a manufacturer expiration date of 10/2025; it was available for resident use. The refrigerator also contained an opened 1-gallon container of Caesar Dressing with less than one-quarter remaining, old residue with gray/black spots on the outside, no opened date, and a manufacturer expiration date of 8/1/2024; it was also available for resident use. Review of daily cleaning logs showed no documentation for cleaning on 12/13/2025 or 12/14/2025, the dish machine temperature log lacked sanitizer testing entries for all 3 meals on 12/14/2025, and the food temperature log had 9 of 42 meals without recorded temperatures. The FSD confirmed the expired barbecue sauce and Caesar dressing were available for resident use, the floor had not been cleaned, and the kitchen and food storage were not maintained in a clean and sanitary condition.
Improper Medication Storage and Unsecured Resident Medications
Penalty
Summary
The facility failed to properly store drugs and biologicals in multiple medication storage areas, including three medication carts, one medication room, and one resident room. Facility policy required opened medications and biologicals to be dated, multi-dose vials to be dated and discarded within 28 days unless otherwise specified, medications to be stored at appropriate temperatures, and discontinued or expired items to be destroyed or returned. The policy on self-administration also required an interdisciplinary assessment and physician involvement before a resident could safely store and administer medications in the room. On the South Even medication cart, an opened foil package of ipratropium/albuterol vials was not dated, unopened Lantus and lispro insulin vials that were labeled to refrigerate until opened were not stored in the refrigerator, and discontinued ofloxacin eye drops remained in the cart. In the South medication room, two semaglutide multi-dose pens were not labeled with an open date, and expired items including heparin lock flush solution, skin protective wipes, and a female Leur lock cap were available for resident use. Staff confirmed the items were improperly stored, the insulin should have been refrigerated, and the opened medications required dating because of shortened expiration after opening. Resident #2, who had diagnoses including spinal stenosis, lower femur fracture, lung disease, and bi-polar disorder, had a BIMS score of 15 indicating cognitive intactness, but medications were found unsecured at the bedside. These included an expired albuterol inhaler, clindamycin gel, triamcinolone cream, mupirocin ointment, fluticasone propionate, Tums in a container, an unidentified cream, isopropyl alcohol, and hydrogen peroxide. The ADON confirmed there was no assessment or physician order for self-administration and that the resident should not have had medications unsecured in the room. In addition, the South-Odd medication cart had polyethylene glycol left on top of the cart unattended, and the Skilled medication cart was left unlocked and unattended, with staff confirming both carts were improperly secured.
Failure to Maintain Cleanliness of Personal Fans in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for two residents by not ensuring the cleanliness of personal fans in their rooms. Facility policy requires housekeeping staff to maintain the cleanliness of each resident's room daily, including cleaning low-touch surfaces on a scheduled basis. Observations revealed that both residents had personal fans on their bedside tables, positioned to blow air toward their faces. The fans had visible gray dust on the blades and thick debris resembling clumped gray fibers on the protective grilles. Both residents were present in their rooms at the time of observation and confirmed the use of the fans. One resident had diagnoses including colon cancer, heart disease, chronic pain, and major depressive disorder, and was assessed as cognitively intact. The other resident had heart valve disease, heart failure, and chronic respiratory failure with hypoxia, and was assessed as having mild cognitive impairment. The Environmental Services Director confirmed that the fans in both rooms were not clean and acknowledged that rooms and equipment should be dusted and cleaned daily, as per facility policy.
Resident Health Information Left Visible on Medication Cart
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential for 2 residents on 1 skilled medication cart observed. Review of the facility policy titled, Safeguarding Electronic Health Information, showed that resident information is to be protected, access to electronic resident information is controlled by passwords and job-function restrictions, computer screen placement should be reviewed to prevent unauthorized viewing, users should log off when away from workstations, and laptops containing PHI should not be left unattended. Resident #73 had diagnoses including stroke with hemiplegia, right tibia fracture, and cognitive impairment, and an MDS assessment showed a BIMS score of 9 indicating moderate cognitive impairment. Resident #113 had diagnoses including diabetes, metabolic encephalopathy, fatty liver, and high blood pressure, and a BIMS assessment showed a score of 14 indicating cognitive intactness. During observation, the skilled medication cart was in the hallway with the laptop screen facing the hallway and open to Resident #113's eMAR with medications visible to passersby. The narcotic sign out book was also left open on top of the cart with Resident #73's controlled substance reconciliation log visible. An LPN confirmed the information was visible to passersby and stated the laptop should have been locked or closed and the narcotic book should have been closed. The ADON also confirmed the residents' sensitive health information should not have been open to view and that the nurse should have secured the information before leaving the cart.
Inaccurate MDS Assessment Missing PASRR Level II Coding
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident reviewed for MDS accuracy. Review of the MDS 3.0 RAI Manual and facility policy showed that residents with a PASRR Level II determination related to serious mental illness may require specific coding on the assessment, and that the assessment must accurately reflect the resident’s medical status. Resident #3 had diagnoses including dementia, depression, and anxiety, and a PASRR dated 8/16/2024 identified a Level II outcome related to serious mental illnesses of dementia, depression, and anxiety. A significant change in status MDS dated 11/20/2025 showed the resident had a BIMS score of 3, indicating severe cognitive impairment, and also documented active diagnoses of dementia, depression, and anxiety. However, the assessment was not coded for the Level II PASRR condition. During review on 12/16/2025, the RN MDS Coordinator reviewed the assessment and the PASRR and confirmed the significant change in status MDS was inaccurate because it did not include the Level II PASRR. An observation on 12/15/2025 found the resident sitting in a wheelchair in her room, stating she was happy there, and requiring assistance with toileting and transfers, with no behaviors noted.
Crushed Extended-Release Medication Despite Do-Not-Crush Label
Penalty
Summary
The facility failed to follow a physician's order and its medication administration policy for a resident with heart disease, diabetes, dementia, and a documented swallowing problem. The resident's care plan noted complaints of difficulty or pain with swallowing, and the resident had severe cognitive impairment on the BIMS assessment. The physician's order allowed medications to be crushed unless contraindicated, and the resident was ordered Isosorbide Mononitrate ER 24 Hour 30 mg once daily for hypertension. During observation, an LPN removed the resident's medications from the original packaging, placed Isosorbide Mononitrate ER into a plastic sleeve used for crushing medications, crushed it, mixed it with applesauce, and administered it to the resident. The LPN stated the resident swallowed medications better crushed in applesauce and acknowledged the medication card said not to crush it, but she normally crushed it every morning. The ADON later confirmed the facility failed to follow the physician's order by crushing and administering the extended-release medication. The order for Isosorbide Mononitrate ER was later discontinued because it was not to be crushed, and a PA note documented that cardiology recommended discontinuing the medication because it should not be crushed.
Failure to Assist Residents With Hand Hygiene Before Meals
Penalty
Summary
The facility failed to ensure proper infection control practices related to hand hygiene during breakfast meal service for 4 residents observed on one hallway. The facility policy titled, Hand Hygiene for Residents, stated residents should be educated about hand hygiene, encouraged to perform it frequently, and assisted physically or through reminders before meals. During the meal tray distribution observation, CNA A brought meal trays to Residents #74 and #24 and placed them on the bedside tables, and both residents began eating without being offered or assisted with hand hygiene. CNA A confirmed hand hygiene had not been performed for either resident and stated the small hand sanitizer bottle carried for resident use was unopened and had not been used. Resident #74 had diagnoses including diabetes, dementia, and blindness in one eye, and a significant change MDS assessment showed a BIMS score of 1, indicating severe cognitive impairment; the resident was dependent on staff for personal hygiene. Resident #24 had diagnoses including diabetes, dementia, and delusional disorder, and a quarterly MDS assessment showed a BIMS score of 3, indicating severe cognitive impairment; the resident required substantial/maximal assistance with personal hygiene. Resident #92 had diagnoses including cervical spinal cord fracture, heart failure, and high blood pressure, scored 15 on the BIMS, and required substantial/maximal assistance with personal hygiene; CNA B brought the meal tray to the room and the resident began eating without hand hygiene assistance. Resident #19 had diagnoses including brain hemorrhage, dysphagia, and respiratory failure with hypoxia, scored 15 on the BIMS, and required substantial/maximal assistance with personal hygiene; the Director of Admissions brought the meal tray to the room and the resident began eating without hand hygiene being performed. The Executive Director confirmed staff were to offer hand hygiene assistance to all residents before meals and stated infection prevention and control practices were not maintained during the breakfast meal.
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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) |
|---|---|---|---|---|
| Bradley Health Care & Rehab | 0.6 mi | ★★★★★ | 3 | 0 |
| Signature Healthcare Of Cleveland | 1.4 mi | ★★★★★ | 6 | 0 |
| Tennessee State Veterans Home- Cleveland | 3.1 mi | ★★★★★ | 5 | 0 |
| Life Care Center Of Ooltewah | 12.6 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Collegedale | 13.6 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 July 2026) and official state health department websites.