Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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 facility failed to ensure MDS assessments accurately reflected resident status for three residents. Two residents were coded as having daily bedrail restraints even though observations, interviews, and record review showed no bedrails on their beds, and one resident was coded as not PASRR positive despite care plan and PASRR documentation showing an ID/DD-related positive status. Staff acknowledged the MDS entries were incorrect and that the assessments did not match the residents’ actual conditions.
Hair restraint not used while serving soup in the main dining room. An MA plated soup from an electric soup warmer and served it to 3 residents without wearing a hair net. She said she had not been trained to wear one while serving soup. The ADM and DM stated CNAs or MAs served the soup in the dining room and had not been trained that hair nets were needed there, although the facility policy and Food Code addressed hair restraints for food handling.
Care plans not revised after bedrails were removed: Two residents had MDSs that still coded daily bedrail use as a restraint even though observations and staff interviews showed no bedrails on their beds. One resident’s care plan still described bedrails as an enabling device, and the other resident’s care plan still stated bedrails were to remain on the bed per request. The MDS Coordinator stated the care plans and MDSs were not accurate and should have been revised when the bedrails were removed or discontinued.
Unattended IV Medication Left on Top of Medication Cart: An LVN left an IV antibiotic on top of a locked med cart and walked away to get a marker, leaving the medication out of view while a resident in a wheelchair was nearby and staff passed by. The LVN later stated she should not have left the Rocephin unattended, and the DON and Administrator stated meds should remain in view or locked in the cart during a med pass.
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.
Inaccurate MDS Coding for Bedrails and PASRR Status
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected resident status for 3 of 21 residents reviewed. Resident #16’s quarterly MDS, dated 05/14/2026, coded physical restraints as bedrails used daily, even though record review, observation, and staff interviews showed no bedrails on the resident’s bed. Resident #16 had diagnoses including vascular dementia, type 2 diabetes mellitus, and hypertensive heart disease with heart failure, had a BIMS score of 06, and was observed ambulating independently with a walker in the memory care unit. The resident stated she got up on her own and did not have or need bedrails. Multiple staff members also observed that the resident’s bed had no bedrails and said they did not recall her having bedrails in the memory care unit. Resident #58’s quarterly MDS, dated 04/30/2026, also coded physical restraints as bedrails used daily, although observations and interviews showed no bedrails on the resident’s bed. Resident #58 had diagnoses including dementia, schizoaffective disorder, and COPD, and had a BIMS score of 03. The resident was observed in a wheelchair and stated she did not have side rails on her bed and could get out of bed without them. An LVN caring for the resident stated the resident did not have bed rails, did not remember her ever having bed rails, and was unsure why the MDS was marked for restraints or bed rails. Resident #62’s annual MDS, dated 11/06/2025, coded PASRR as 0, indicating no ID/DD-related condition, even though the care plan identified the resident as PASRR positive with intellectual disability and the PASRR evaluation indicated suspected intellectual disability and developmental disability. Resident #62 had diagnoses of quadriplegia and intellectual disability and a BIMS score of 06. The MDS Coordinator stated she coded Residents #16 and #58 based on care plan documentation showing bedrails, acknowledged they should not have been coded for restraints because they did not have bedrails, and stated Resident #62 was PASRR positive and the MDS coding was incorrect. The DON, Regional Nurse, Regional MDS Consultant, and Administrator all stated the MDSs were expected to be accurate and that the resident assessments were marked incorrectly.
Hair restraint not used while serving soup in main dining room
Penalty
Summary
The facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 3 dining rooms reviewed, the main dining room. During the lunch meal observation on 06/15/2026 at 12:15 p.m., MA F was plating soup from an electric soup warmer in the main dining room without wearing a hair net. She filled 3 bowls with a ladle and served the soup to 3 unidentified residents. During interviews, MA F stated on 06/16/2026 that she served the soup at lunch the previous day and had never been trained to wear a hair net while serving soup. The Administrator stated on 06/17/2026 that CNAs served the soup from the electric soup warmer and did not need hair nets because they were not behind the steam table, not in the kitchen, and were not in the kitchen area. The DM stated that dietary staff cooked the soup and gave the electric soup warmer to nursing, and that the nurse aide or med aide served the soup into bowls; she also stated she had never trained that CNAs or MAs needed hair nets in the dining room to serve soup. The facility policy stated dietary staff must wear hair restraints to prevent hair from contacting food, and the Food Code cited hair restraints for food employees when appropriate.
Care plans not revised after bedrails were removed
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after assessment changes for two residents whose bedrails had been removed from their beds. For Resident #16, the quarterly MDS dated 05/14/2026 indicated severe cognitive impairment with a BIMS score of 06 and documented daily bedrail use as a physical restraint, while the care plan dated 11/26/2025 still described bed rails as an enabling device with interventions to observe and report changes in effectiveness or possible reduction. However, physician orders did not indicate bedrails, and the bed rail safety review dated 05/08/2026 recommended alternatives such as a low bed and education on turning and positioning. During observations on 06/15/2026 and 06/16/2026, Resident #16 was seen ambulating with a walker and her bed had no bedrails. Staff interviewed stated she did not have bedrails or any restraint device on her bed and did not recall her ever having bedrails in the memory care unit. The MDS Coordinator later stated that if bedrails were removed, they should have been removed from the MDS and care plan, and that Resident #16 should not have been coded for restraints because she did not have bedrails. She also stated the quarterly MDS and care plan were not accurate and should have been revised when the bedrails were removed or discontinued. For Resident #58, the quarterly MDS dated 04/30/2026 showed severe cognitive impairment with a BIMS score of 03 and daily bedrail use as a physical restraint, while the care plan with a target date of 07/02/2036 stated that bedrails were to remain on the bed per the resident’s request for bed mobility. Physician orders did not indicate bedrails, and the bed rail safety review dated 02/16/2026 recommended alternatives such as a low bed and education on turning and positioning. During observation on 06/17/2026, Resident #58 was in her room with no bedrails on the bed and stated she did not have side rails and could get out of bed without them. Staff also stated she did not have bed rails and did not remember her ever having them. The MDS Coordinator, ADON, DON, Regional Nurse, and Administrator all acknowledged that care plans should be reviewed and revised with assessment changes, and the MDS Coordinator stated the bedrail care plan had been overlooked for Resident #58.
Unattended IV Medication Left on Top of Medication Cart
Penalty
Summary
The facility failed to ensure medications were properly secured and stored in locked compartments for 1 of 7 medication carts reviewed on Nurse Hall 100. During an observation and interview, an LVN pulled the medication cart to the doorway of a resident's room, locked the cart and the electronic medical record, and then walked away to the nurse station room, leaving an intravenous medication on top of the cart and out of her visual sight. While the cart was unattended, a resident in a wheelchair self-propelled next to the cart and multiple staff members walked past and attended to the resident. The LVN returned about a minute later and stated she had left to get a black marker from the nurse station room so she could write the date and time on the outside of the IV bag. During interview, the LVN stated she should not have left the IV medication on the cart and said she should have kept the Rocephin 2 grams in 100 ml normal saline in the locked medication cart while she went to get the marker. She stated the medication was not in her view when she left and acknowledged it could have been taken and could have caused someone to become sick. The DON stated nurses and medication aides needed to always maintain a view of the medication cart and never walk away with medications left on top for resident safety, and the Administrator stated medications should never be left on top of a medication cart unattended. The facility policy stated all drugs and biologicals must be stored in locked compartments and that during a medication pass, medications must be under direct observation or locked in the medication storage area or cart.
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 | ★★★★★ | 1 | 0 |
| The Heights On Valley Ranch | 18.7 mi | ★★★★★ | 2 | 0 |
| Kingwood Rehabilitation And Healthcare Center | 22 mi | ★★★★★ | 1 | 0 |
| Dayton Nursing And Rehabilitation | 22.4 mi | ★★★★★ | 1 | 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 October 2026) and official state health department websites.