Cleveland Care: Latex Catheter Caused Skin Injury - OK
Cleveland Care and Rehab Center staff placed the latex catheter in the resident on April 6, despite the person's allergy being documented in their medical record since admission in March. The facility's own care plan, dated March 18, specifically stated the resident was allergic to latex and "would not receive medications and/or substances known to cause allergic reactions."
The resident had been cognitively intact with a brief interview mental status score of 15, according to their admission assessment. Their allergy to latex was documented in an allergy tab dated March 5. A physician had ordered a silicone catheter to be maintained and changed monthly.
Three days after the latex catheter insertion, staff discovered redness on the resident's right thigh where the catheter tubing had been touching their leg. A progress note from April 9 documented that the catheter was "removed and replaced with a silicone catheter due to a latex allergy."
The facility contacted the physician about the skin reaction and obtained orders for hydrocortisone cream to be applied twice daily for seven days.
During the August inspection, the resident told investigators they were allergic to latex and described what happened months earlier. "The facility had inserted a latex indwelling urinary catheter into them a few months ago which caused redness and irritation to their right leg," the resident said. "The facility should have known better because their allergies had been listed in their medical record since they were admitted."
The infection preventionist who changed the catheter on April 9 told inspectors they noticed the redness on the resident's thigh where the catheter tube was touching their skin. "The catheter was removed immediately once they realized it was latex and not silicone," according to the inspection report.
The infection preventionist acknowledged that "staff had inadvertently inserted a latex catheter" and said "staff should have verified all allergies prior to the insertion of the catheter."
The director of nursing confirmed that "a urinary catheter containing latex was placed in error" and agreed that "staff should have verified all allergies prior to the placement of the catheter."
Of the facility's 54 residents, only one had a documented latex allergy, making the error particularly notable given how easily it could have been prevented through basic allergy verification procedures.
The resident's medical records showed a clear timeline of the facility's failure to follow its own protocols. The allergy was documented March 5. The physician ordered a silicone catheter March 8. The care plan March 18 specifically prohibited giving the resident substances that could cause allergic reactions. Yet staff inserted a latex catheter April 6.
The mistake went unnoticed for three days until staff observed the skin reaction. The resident experienced unnecessary pain and required medication treatment for an entirely preventable injury.
Federal inspectors cited the facility for failing to provide appropriate treatment and care according to orders and the resident's medical needs. The violation was classified as causing minimal harm or potential for actual harm.
The case highlights a basic breakdown in communication and safety protocols at Cleveland Care and Rehab Center. Despite multiple documentation points warning staff about the latex allergy, the information failed to reach the person responsible for catheter insertion.
The resident's frustration was evident during the inspection interview. They understood that their allergy information was readily available in their medical record and expected staff to check it before inserting medical devices.
The facility's own policies required staff to avoid giving residents substances known to cause allergic reactions, yet those same staff members inserted exactly the type of catheter that would trigger the documented allergy.
The infection preventionist's admission that staff should have verified allergies before the procedure suggests the facility recognizes the error was preventable through standard safety protocols that were not followed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cleveland Care and Rehab Center from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
CLEVELAND CARE AND REHAB CENTER in CLEVELAND, OK was cited for violations during a health inspection on August 21, 2025.
Their allergy to latex was documented in an allergy tab dated March 5.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.