Cleveland Health Care Center: Wrong Resident Transferred - TX
He was supposed to stay. He was there for hospice respite care. His care plan, dated two days earlier, outlined a pre-discharge plan to be established with family before he went anywhere. None of that happened. The ambulance came, and he left anyway.
The nurse who gave report to the ambulance crew was LVN B. After the handoff, she walked to the room and realized what had happened. The wrong resident was gone. The man who had been taken, Resident #1, was not the resident who was supposed to be transferred. His roommate was.
LVN B notified the administrator. The administrator called the hospice service and told them to bring him back. According to the administrator, Resident #1 was never taken out of the ambulance during the roughly 30 to 35 minutes he was gone. When he was returned to his bed, LVN B assessed him and documented no apparent injuries or bruises. The physician was notified. Family, according to the administrator, were at his bedside when he came back.
That account comes entirely from the administrator. LVN B, who works for an outside agency, did not speak to inspectors. The agency nursing services did not answer or return calls on December 30 at 11 a.m. or 3 p.m., or on December 31 at 8:30 a.m. A detailed message was left each time. Family members of Resident #1 did not answer calls on December 30 at 10 a.m. or 2 p.m., or on December 31 at 10 a.m. or 1 p.m. Detailed messages were left for them as well.
Nobody called back.
The hospice nurse who spoke with inspectors on December 31 was not the nurse on duty the day of the transfer. That nurse was on maternity leave. The hospice nurse who was interviewed said she was aware of what happened, confirmed the wrong resident had been transferred, and confirmed the ambulance brought him back after the administrator called.
Resident #1 was a man whose age was redacted from the public record. His diagnoses included high blood pressure, dementia, anxiety, heart disease, and chronic kidney disease. He had been admitted for respite care, a short-term stay designed to give his regular caregivers a temporary break. His physician's orders from November 2025 contained no active discharge orders. The care plan written on November 26 described the work still to be done before any discharge could happen, including building a pre-discharge plan with his family.
None of that work was complete on November 28 when the ambulance arrived.
The nurse note from 1:00 p.m. that day recorded the transfer as an error and noted that LVN B had given report before going to the room and discovering what had happened. The note from 1:32 p.m. recorded the assessment when he was returned.
Federal inspectors cited the facility for failing to ensure Resident #1 remained in the facility when no transfer had been ordered, a violation of discharge requirements that exist to prevent residents from being uprooted from their care without medical justification. The harm level was classified as minimal harm or potential for actual harm.
The administrator told inspectors her expectation was that the correct resident would have been transferred. She did not describe what safeguards existed to prevent the mix-up, or why a nurse giving ambulance report did not confirm the identity of the resident being moved before the crew left.
The facility's own transfer and discharge policy states that residents are to remain in the facility and not be transferred or discharged without proper process. That policy did not stop an ambulance from leaving with a man who had dementia and no discharge order on a Thursday afternoon in November.
He was back in his bed within the hour. Whether he understood what had happened, where he had been taken, or why he was suddenly returned, the inspection report does not say. The notes record no apparent injuries. They record nothing about what the experience was like for a man with dementia and anxiety who was loaded into an ambulance without anyone who knew him being told it was coming.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cleveland Health Care Center from 2025-12-31 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 20, 2026 · Our methodology
CLEVELAND HEALTH CARE CENTER in CLEVELAND, TX was cited for violations during a health inspection on December 31, 2025.
He was there for hospice respite care.
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.