Cleveland Health Care Center
CLEVELAND HEALTH CARE CENTER in CLEVELAND, TX — inspection on December 31, 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.
Inspection Findings
During attempted interviews on 12/30/25 at 11:00 a.m. and 3:00 p.m., the agency nursing services did not answer or return calls for interview with LVN B.
During attempted interview on 12/31/25 at 8:30 a.m., the agency nursing services did not answer or return calls for interview with LVN B. A detailed message was left for request of interview with LVN B.
During attempted interviews on 12/31/25 at 10:00 a.m. and 1:00 p.m., Family members of Resident #1 did not answer the phone call and left detailed message for a return call.
During an interview on 12/31/25 at 11:00 a.m., The administrator said when the Resident #1 was mistakenly transferred.
She said LVN B had notified her of the incident of Resident #1 being transferred instead of his roommate.
She said she immediately called the hospice service and told them to return Resident #1 to the facility.
She said Resident #1 was never taken out of the ambulance and returned to the facility within 30 to 35 minutes.
She said LVN B assessed Resident #1 when he was returned, and no apparent injuries and the physician was notified, and family were at bedside when Resident #1 returned to this facility.
She said her expectation was for the correct resident to be transferred.
During an interview on 12/31/25 at 11:45 a.m., Hospice nurse C said she was not the nurse for the 11/28/25 and that nurse was on maternity leave, however she was aware of the event of 11/28/25.
She said the wrong resident had been transferred and the ambulance service brought Resident #1 back to the facility after hospice was notified by the Administrator of the incident.
Record review of the undated policy titled Transfer and Discharge indicated . It is the policy of this facility to permit each resident to remain in the facility, and not transferred or discharged from the facility .
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.