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Complaint Investigation

Cleveland Care And Rehab Center

August 21, 2025 · Cleveland, OK · 900 N Division St
Citations 1
CMS Rating 4/5
Beds 90
Provider ID 375443
Healthcare Facility
Cleveland Care And Rehab Center
Cleveland, OK  ·  View full profile →
Inspection Summary

CLEVELAND CARE AND REHAB CENTER in CLEVELAND, OK — inspection on August 21, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0684
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

Based on record review and interview, the facility failed to ensure a resident with an allergy to latex did not receive an indwelling latex urinary catheter for 1 (#1) of 1 sampled resident reviewed for a latex allergy.The administrator identified 54 residents resided in the facility.

The DON identified one resident with a latex allergy.Findings:An Allergy tab, dated 03/05/25, showed Res #1 had an allergy to latex.A physician order, dated 03/08/25, showed to maintain an indwelling silicone urinary catheter and to change monthly on the 6th of each month.An admission assessment, dated 03/12/25, showed Res #1 had a brief interview for mental status score of 15 and was cognitively intact.

The assessment showed Res #1 had an indwelling urinary catheter.A care plan, dated 03/18/25, showed Res #1 was allergic to latex.

The care plan showed Res #1 would not receive medications and/or substances known to cause allergic reactions.A treatment administration record, dated 04/06/25, showed Res #1 had a new indwelling urinary catheter placed.A progress note, dated 04/09/25, showed Res #1's catheter was removed and replaced with a silicone catheter due to a latex allergy.

The note showed Res #1 had some redness on the right thigh where the latex catheter tubing had been touching their leg.

The note showed the physician was notified of the redness and orders were obtained to apply hydrocortisone cream (medication lotion/ointment) twice daily for seven days.On 08/18/25 at 2:00 p.m., Res #1 stated they were allergic to latex.

They stated the facility had inserted a latex indwelling urinary catheter into them a few months ago which caused redness and irritation to their right leg.

Res #1 stated the facility should have known better because their allergies had been listed in their medical record since they were admitted .On 08/20/25 at 11:36 a.m. the IP stated they had changed Res #1's catheter on 04/09/25 after noticing redness on Res #1's right thigh where the catheter tube was touching their skin.

They stated the catheter was removed immediately once they realized it was latex and not silicone.

The IP stated staff had inadvertently inserted a latex catheter.

They stated the staff should have verified all allergies prior to the insertion of the catheter.On 08/20/25 at 12:46 p.m., the DON stated a urinary catheter containing latex was placed in error.

They stated staff should have verified all allergies prior to the placement of the catheter.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CLEVELAND, OK, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CLEVELAND CARE AND REHAB CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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