Cityview Healthcare: Resident Found in Basement Laundry Chute - OH
Federal inspectors classified the incident as Immediate Jeopardy.
Resident #51 lived on the Connections unit, a secured floor at Cityview designed specifically for residents with mental health diagnoses who require increased supervision and protection from self-harm. The doors to the unit used coded keypads. Staff were trained in managing aggression and behavioral episodes. The unit's stated purpose, according to facility policy, was to offer "a safe living environment" and reduce "the potential for self-harm or escalation of negative behaviors."
On the morning of August 7, Resident #51 was found in the basement, inside a locked laundry chute room.
The nurse practitioner on call that day, identified in the inspection report as NP #343, described what she was told when a staff member phoned her. The information was vague. She was told Resident #51 had been found in the basement and had some scratches on him. She recalled asking how a resident from a secured unit had gotten to the basement. The caller could not explain it.
NP #343 was not told about any fractures. She was not told about any serious injuries. Based on what she had been given, she advised the caller that if they felt Resident #51 needed to go to the hospital, they should send him. She did not receive any follow-up calls after that.
Nobody called her back.
The facility's administrator at the time, identified as Former Administrator #500, said he was in his office when a message came in from MD #400. He did not see the message immediately. When he eventually got it and went to the basement, he found Resident #51 standing upright behind the door of the laundry chute room. Resident #51 told him he had been looking for a soda.
Former Administrator #500 said he observed cuts on Resident #51's arms. He went upstairs to find the Director of Nursing. He did not go back to the basement.
Instead, he went to the units and told staff to conduct a head count of all residents. Then he and MD #400 walked the doors on each floor and found that the door on the third floor, the one leading to the soiled utility room containing the laundry chute, had not been closing properly. He told MD #400 to get the lock repaired.
A certified nursing assistant, identified as CNA #275, told inspectors during a September 4 interview that the third-floor soiled utility room door had not been functioning properly from time to time before the incident involving Resident #51. The problem with that door was not new.
Former Administrator #500 said he began an investigation on August 7. On August 8, he submitted his resignation, effective immediately. He did not provide any additional information about why he resigned.
Resident #51 was transferred to a local long-term acute care hospital on September 3, nearly four weeks after the fall. Inspectors were informed he had numerous fractures on his back and had remained at the hospital for continued medical care.
The gap between what happened on August 7 and what the on-call clinician was told that same day is the center of what inspectors found. NP #343 was managing the situation based on scratches. The actual injury was a broken back. Whether that information was withheld, misunderstood, or simply never assessed in the hours after Resident #51 was found, the inspection report does not resolve. What it documents is that the nurse practitioner who made the clinical call about hospitalization did not know the severity of what she was deciding about, and received no follow-up once Resident #51 was sent out.
The inspection report also does not explain how Resident #51 accessed the laundry chute. Former Administrator #500 said the laundry chute room required a code to enter, and he was unsure how Resident #51 had gotten inside. The door on the third floor, the one that staff knew had been intermittently failing, is the most direct answer the record offers. A resident on a secured psychiatric unit, on a floor with a door that did not reliably close or lock, ended up in a basement laundry chute room with a broken back.
The Connections unit policy reviewed by inspectors described the floor's purpose in careful terms: structured activities, smaller environment, increased supervision, reduction of external stressors. It described staff trained to support residents with aggression and behavioral needs. It described a locked unit with coded keypads.
On August 7, a resident from that unit was found in the basement.
Inspectors cited the deficiency under Immediate Jeopardy, the most serious classification in the federal inspection system, indicating the facility's failures placed residents at risk of serious injury, harm, or death. The complaint that triggered the inspection was filed under Complaint Number 2594724.
Resident #51 was still at the long-term acute care hospital when inspectors completed their interviews in early September.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cityview Healthcare and Rehabilitation from 2025-09-17 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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: September 23, 2026 · Our methodology
CITYVIEW HEALTHCARE AND REHABILITATION in CLEVELAND, OH was cited for violations during a health inspection on September 17, 2025.
Federal inspectors classified the incident as Immediate Jeopardy.
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.