Hillcrest Hospital
An acute care hospital in Mayfield Heights, Ohio 44124
6780 Mayfield Road, Mayfield Heights, Ohio 44124. (440) 312-4500.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 5of 5 CMS’s overall rating
- 3of 5 patient survey rating
- 2 deficiencies cited in the last three years (needs attention)
- 532 beds
Each figure’s source sits beside it, in its section below.
What these words mean4
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
- Condition-level deficiency
- For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.
What did inspectors find?
The last inspection on record was on Jan 29, 2026: a complaint inspection.
2 deficiencies cited in the last three years, 1 of them at condition level, the most serious.
1 deficiency at condition level, the more serious of CMS’s two levels
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
2 deficiencies in 1 month of the last 36. Last cited Jan 2026. Most serious: Condition-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Jan 29, 2026: complaint inspection2 deficiencies
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Nursing Services
“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 44810 Based on medical record review, staff interview and review of facility policy, the facility failed to ensure patients presenting to the emergency department (ED) with complaints of pain were adequately assessed. Additionally, the facility failed to ensure Patient #1 received physician ordered pain medication. See A395”
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Rn Supervision Of Nursing Care
The inspectors’ words, 645 words
“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 44810 Based on medical record review, staff interview and review of facility policy, the facility failed to ensure patients presenting to the emergency department (ED) with complaints of pain were adequately assessed. Additionally, the facility failed to ensure Patient #1 received physician ordered pain medication. This affected four (#1, #7, #14, and #15) of 20 patients reviewed for pain. Findings include: 1. Review of the medical record for Patient #1 revealed she arrived at the ED on 12/15/25 at 8:35 P.M. via ambulance with a chief complaint of vomiting. Patient #1’s triage began at 8:36 P.M. Additional review of the medical record revealed no evidence a pain assessment was completed. Further review revealed Patient #1 was assessed by the physician at 8:56 P.M. and orders were placed for fentanyl (pain medication). There was no evidence fentanyl was administered to Patient #1. Interview on 01/29/26 at 9:30 A.M. with Registered Nurse (RN) Staff G confirmed she provided care for Patient #1 on 12/15/25. Further interview with Staff G verified she did not administer fentanyl to Patient #1 as ordered by the physician. Staff G stated the ED was busy during that time and she was not comfortable administering fentanyl unless she could closely monitor the patient. Staff G stated Patient #1 had to wait in the hallway for a bed to become available and she was not able to closely monitor her. Staff G verified she did not contact the physician to request a different pain medication order that could be provided to Patient #1. Additionally, Staff G confirmed a pain assessment was not completed for Patient #1. A telephone interview on 01/29/26 at 10:42 A.M. with Staff I revealed he was the assigned physician on 12/15/25, when Patient #1 presented to the ED. Staff I stated he did not recall Patient #1 but added he would only prescribe fentanyl if a patient reported extreme pain to him. Staff I stated if a nurse was uncomfortable administering a medication, he would discuss the case with the nurse to find alternatives. 2. Review of the medical record for Patient #7 revealed she arrived at the ED on 12/14/25 at 10:30 P.M. with complaints of stomach pain. Her vitals were assessed at 10:35 P.M. Additional review of the medical record revealed no evidence a pain assessment was completed. Patient #7 was seen by the triage physician at 10:35 P.M. and ordered pain medication, which was administered on 12/14/25 at 10:55 P.M. 3. Review of the medical record for Patient #14 revealed he arrived at the ED on 12/15/25 at 3:28 P.M. with complaints of chest pain. His triage began at 3:33 P.M. Further review of the medical record revealed no evidence a pain assessment was completed. 4. Review of the medical record for Patient #15 revealed she arrived at the ED on 12/15/25 at 1:41 P.M. with complaints of urinary frequency which was updated to chest pain at 1:45 P.M. Her triage began at 1:45 P.M. Further review of the medical record revealed no evidence a pain assessment was completed. Interview on 01/29/26 at 11:30 A.M. with Assistant Emergency Room (ER) Nurse Managers, Staff E and Staff F, confirmed Patient #7, Patient #14, and Patient #15 presented to the ED with complaints of pain. Further interview with Staff E and Staff F verified Patient #7, Patient #14, and Patient #15 were not assessed for pain. Review of the facility policy titled, Routine Care, Emergency Department Protocol, effective 09/23/24, revealed when a patient came to the emergency department seeking medical care, collect and document a complete set of vital signs, which included temperature, heart rate, respirations, blood pressure, pulse oximetry, and pain level, using appropriate pain scale, during the initial assessment.”
All 6 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jan 29, 2026 | Complaint inspection | 2 deficiencies cited |
| Jun 2, 2025 | Complaint inspection | No deficiencies cited |
| Jun 25, 2024 | Complaint inspection | No deficiencies cited |
| Mar 14, 2024 | Complaint inspection | No deficiencies cited |
| Jan 24, 2024 | Complaint inspection | No deficiencies cited |
| Nov 28, 2023 | Complaint inspection | No deficiencies cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 5 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 3 better and 0 worse of 8; safety of care, 5 better and 0 worse of 7; readmission, 1 better and 1 worse of 11.
- Patients rate it 3 of 5 in CMS’s patient survey (2,161 surveys completed, Oct 1, 2024 to Sep 30, 2025): 67% rated it 9 or 10 out of 10, and 70% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), better than the national benchmark; catheter urinary tract infections (CAUTI), no different than national benchmark; surgical site infections after colon surgery, no different than national benchmark; MRSA bloodstream infections, no different than national benchmark; C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: better than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 10.1%, heart failure 7.1%, pneumonia 11.1%, COPD 7.7%, stroke 8.5%, heart bypass surgery 1.5%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 13.5%, heart failure 21.6%, pneumonia 18.4%, COPD 20.4%, heart bypass surgery 10.6%, hip or knee replacement 5.3%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, better than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 200 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 2% left before being seen.
- 57% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 0.99 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 5 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 3 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Nov 23, 1968.
- Ownership: voluntary non-profit - private.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- Cited at For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. in the last three years: it didn’t meet a whole condition of Medicare’s rules for hospitals.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 2 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 3 of 5.
- 87% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- The Cleveland Clinic Foundation owns 100% directly since Feb 7, 1997.
- The Cleveland Clinic Foundation runs it.
- 44 owners or officers are people: Ronald Weinberg (corporate director, 0%); Marianne Crosley (corporate director, 0%); Deborah Crawford (corporate director, 0%); Marcia Ballinger (corporate director, 0%); Catherine M. Kilbane (corporate director, 0%); Dan Schulman (corporate director, 0%); Beth Mooney (corporate officer, 0%); Beth Mooney (corporate director, 0%); Melinda Rich (corporate director, 0%); Spencer Kowal (corporate officer, 0%); Betty Kemper (corporate director, 0%); Mark Ross (corporate director, 0%); Doreen Meredith (managing employee (on the payroll)); Dennis L Laraway (corporate officer, 0%); Carole Hoover (corporate director, 0%); Stewart Kohl (corporate director, 0%); Bonnie Gwin (corporate director, 0%); Hiroyuki Fujita (corporate director, 0%); Larry Pollock (corporate director, 0%); Richard J. Kramer (corporate director, 0%); Tomislav Mihaljevic (corporate director, 0%); Michael Petras (corporate director, 0%); Mark P Malloy (corporate officer, 0%); Stephanie Santin (managing employee (on the payroll)); Jessica Mcardle (managing employee (on the payroll)); Miguel Regueiro (corporate director, 0%); John Waldron (corporate director, 0%); Jorge Alberto Guzman (corporate director, 0%); Brian Jeffrey Harte (managing employee (on the payroll)); Albert Salvatore (corporate director, 0%); Thomas Paumier (corporate director, 0%); Lorraine Vega (corporate director, 0%); Pamela Miller (corporate director, 0%); Alex Gorsky (corporate director, 0%); Heidi Sathre (managing employee (on the payroll)); Michael E. Maroone (corporate director, 0%); Mark Lerner (corporate director, 0%); Rachel Byrnes (managing employee (on the payroll)); Frederick Nance (corporate director, 0%); Dragana Rodic (managing employee (on the payroll)); Omar Ishrak (corporate director, 0%); Patricia A Warther (corporate director, 0%); Robert Oblander (corporate officer, 0%); Umberto Fedeli (corporate director, 0%).
- CMS’s Provider of Services file records 1 change of ownership, the latest on May 23, 1996.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| The Cleveland Clinic Foundation | Owns 5% or more directly | 100% | Feb 7, 1997 |
| The Cleveland Clinic Foundation | Runs it (operational or managerial control) | 100% | Feb 7, 1997 |
How does it compare nearby?
- Of the 18 hospitals CMS lists in Cuyahoga County, 14 have an overall star rating from CMS: 4 rated 5 of 5, 6 rated 4 of 5, 4 rated 3 of 5.
- CMS rates this one 5 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.