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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cleveland Health Care Center during CMS and state inspections, most recent first.
A resident admitted for hospice respite care, with no active discharge orders, was mistakenly transferred by ambulance after an LVN gave report and later realized the wrong individual had been taken. The error was identified and the resident was returned to the facility within about half an hour, with no injuries noted upon assessment. Facility policy requiring residents to remain unless discharge is necessary was not followed.
A resident with dementia and severely impaired cognition was prescribed antibiotic eye drops for an eye infection, but the facility failed to include this treatment in the resident's care plan. Although the medication was administered as ordered, the omission was attributed to a missed routine and staff absence, resulting in no documented interventions or monitoring related to the antibiotic therapy.
A resident with a suprapubic catheter developed a UTI and catheter obstruction due to the facility's failure to change the catheter as ordered by the physician. Despite orders for monthly changes, the catheter was not consistently changed, leading to calcification and obstruction. Interviews with staff revealed inconsistencies in catheter management and documentation, and the DON acknowledged the failure to follow physician orders.
A resident with a history of kidney stones and a urinary stent had lab tests ordered by a urologist, including a Basic Metabolic Panel and Stonerisk Diagnostic Profile. The facility failed to report the results to the urologist in a timely manner and did not obtain the Stonerisk Diagnostic Profile results. This oversight was confirmed by facility staff and led to the resident's hospitalization due to blood in urine and blood clots. The facility lacked a proper process for tracking lab orders and notifying physicians, resulting in a delay in treatment.
Resident Transferred in Error Without Discharge Order
Penalty
Summary
A deficiency occurred when a male resident with diagnoses including hypertension, dementia, anxiety, heart disease, and chronic kidney disease was admitted for hospice respite care. The resident's physician orders did not include any active discharge orders, and the care plan indicated a pre-discharge plan was to be established with family. Despite this, the resident was mistakenly transferred by ambulance after a report was given by an LVN, who later realized the wrong resident had been taken. The error was identified when the LVN went to the resident's room and found he was missing. Upon discovery, the resident was returned to the facility by ambulance within approximately 30 to 35 minutes. The LVN assessed the resident upon return and noted no apparent injuries or bruises. The incident was confirmed by interviews with the administrator and a hospice nurse, both of whom acknowledged that the resident was transferred in error and subsequently returned. The facility's policy states that residents are not to be transferred or discharged unless necessary for their welfare, but this policy was not followed in this instance.
Failure to Care Plan Antibiotic Eye Drops for Resident with Dementia
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's use of polymyxin b-trimethoprim ophthalmic solution prescribed for an eye infection. The resident, an elderly female with dementia and severely impaired cognition, was admitted and readmitted to the facility with a diagnosis of dementia and had adequate vision according to her most recent MDS assessment. Physician orders indicated she was to receive antibiotic eye drops three times daily for seven days, and the medication administration record confirmed that the drops were administered as ordered. Despite the administration of the antibiotic eye drops, the resident's care plan did not include any interventions or monitoring related to the use of this medication. Observations showed the resident with pink and irritated eyes, and she was unable to confirm receipt of the eye drops due to confusion. Interviews with facility staff, including the LVN, MDS nurse, ADON, DON, and Administrator, revealed that responsibility for care planning new antibiotics was assigned to the ADON, with backup from the IDT and DON. However, the care plan for the antibiotic eye drops was missed, reportedly due to the ADON's absence and a disruption in the facility's usual morning meeting routine. Staff acknowledged that the lack of a care plan for the antibiotic eye drops could result in staff not being aware of necessary assessments, follow-up, or interventions, and that the omission was an oversight. The facility's policy requires comprehensive care plans for all resident needs, including new medications, but this was not followed in this instance.
Inadequate Catheter Care Leads to UTI and Obstruction
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic catheter, leading to the development of a urinary tract infection (UTI) and catheter obstruction. The resident, who had multiple medical conditions including dementia and benign prostatic hyperplasia, was supposed to have their suprapubic catheter changed monthly as per physician orders. However, the facility did not adhere to this schedule, resulting in the catheter becoming obstructed and calcified, as noted during a urology appointment. Interviews with facility staff revealed inconsistencies in the management of the resident's catheter care. Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs) reported that the catheter was to be changed every three weeks or as needed if blocked, but there was a lack of documentation to support that these changes were consistently made. The Director of Nursing (DON) acknowledged that the catheter should have been changed according to physician orders and that any changes made during external appointments should have been documented in the resident's records. The facility's failure to follow physician orders and maintain proper documentation of catheter changes placed the resident at risk for infections and other complications. The Administrator was informed of the inadequate catheter management by the urologist and added the issue to the Quality Assurance and Performance Improvement (QAPI) program for monitoring. Despite this, the report highlights a significant lapse in the facility's adherence to care protocols and documentation practices.
Failure to Report Lab Results Timely
Penalty
Summary
The facility failed to provide or obtain laboratory services as ordered by a physician for a resident, leading to a deficiency in care. The resident, a male with multiple diagnoses including dementia, benign prostatic hyperplasia, and kidney stones, had laboratory tests ordered by a urologist to determine the etiology of stone formation. These tests included a Basic Metabolic Panel, Stonerisk Diagnostic Profile, PTH, intact and calcium, and Uric acid. However, the facility did not report the results of these tests to the urologist in a timely manner, nor did they obtain the results for the Stonerisk Diagnostic Profile. The resident had a history of kidney stones and a urinary stent in place, necessitating regular monitoring and testing. Despite the urologist's orders for specific lab tests, the facility failed to notify the urologist of the results from November 2023, which included a Basic Metabolic Panel and other tests. Additionally, the facility did not obtain the results for the Stonerisk Diagnostic Profile, which was crucial for determining the resident's treatment plan. This oversight was confirmed during interviews with facility staff, including an LVN and the Director of Nursing, who acknowledged the failure to report the lab results to the ordering physician. The deficiency was further highlighted by the resident's hospitalization due to blood in urine and blood clots, which could have been related to the unreported lab results. Interviews with the facility's medical director and administrator revealed that the facility lacked a proper process for tracking lab orders and notifying physicians of results. The facility's policy required prompt notification of lab results to the ordering physician, but this was not adhered to, resulting in a delay in the resident's treatment and care.
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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) |
|---|---|---|---|---|
| Woodland Park Nursing & Rehab | 10.9 mi | ★★★★★ | 0 | 0 |
| The Heights On Valley Ranch | 18.7 mi | ★★★★★ | 0 | 0 |
| Kingwood Rehabilitation And Healthcare Center | 22 mi | ★★★★★ | 0 | 0 |
| Dayton Nursing And Rehabilitation | 22.4 mi | ★★★★★ | 19 | 0 |
| Timberwood Nursing And Rehabilitation Center | 23.1 mi | ★★★★★ | 7 | 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.