Middleburg Heights, OH

Middleburg Heights Health & Rehabilitation Center

3-star overall rating with 2-star inspections with $76,040 in total fines with 15 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle

19530 Bagley Road, Middleburg Heights, OH

(440) 816-7500

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

90

Certified beds

Average residents

63

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Optalis Health & Rehabilitation

Operator or chain grouping

Approved since

1996-05-15

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

37 facilities

Chain averages 3 overall / 2 health / 3 staffing / 5 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.67

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.18

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.05

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.90

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.85

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

2.97

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.52

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.58

CMS adjusted RN staffing hours

Adjusted total hours

3.40

CMS adjusted total nurse staffing hours

Case-mix index

1.57

Higher values indicate more complex resident acuity

RN turnover

58%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

65%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,275

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

13.07

Composite VBP score used to determine payment impact.

Payment multiplier

0.9812

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.30

Baseline 18.25% · Performance 20.83% · Measure score 1.30 · Achievement 1.30 · Improvement 0

Healthcare-associated infections

2.19

Baseline 6.39% · Performance 7.18% · Measure score 2.19 · Achievement 2.19 · Improvement 0

Total nurse turnover

0.58

Baseline 69.05% · Performance 64.29% · Measure score 0.58 · Achievement 0 · Improvement 0.58

Adjusted total nurse staffing

1.15

Baseline 2.59 hours · Performance 3.12 hours · Measure score 1.15 · Achievement 0 · Improvement 1.15

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.49%
10.72%
1.2 pts better
No Different than the National Rate · Eligible stays 35 · Observed rate 5.71% · Lower 95% interval 5.98%
Discharge to community 49.1%
50.57%
1.5 pts worse
No Different than the National Rate · Eligible stays 33 · Observed rate 36.36% · Lower 95% interval 35.41%
Medicare spending per beneficiary 0.97
1.02
0.1 pts better
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 34 · Denominator 34
Falls with major injury 2.94%
0.77%
2.2 pts worse
Numerator 1 · Denominator 34
Discharge self-care score Not Available
53.69%
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Discharge mobility score Not Available
50.94%
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened 2.94%
2.29%
0.6 pts worse
Numerator 1 · Denominator 34 · Adjusted rate 3.51%
Healthcare-associated infections requiring hospitalization 7.18%
7.12%
0.1 pts worse
No Different than the National Rate · Eligible stays 32 · Observed rate 9.38% · Lower 95% interval 4.52%
Staff COVID-19 vaccination coverage 3.54%
8.2%
4.7 pts worse
Numerator 4 · Denominator 113
Staff flu vaccination coverage 43.48%
42%
1.5 pts better
Numerator 70 · Denominator 161
Discharge function score Not Available
56.45%
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Transfer of health information to provider 100%
95.95%
4 pts better
Numerator 23 · Denominator 23
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date 15%
25.2%
10.2 pts worse
Numerator 3 · Denominator 20

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 98.7%
92.4%
6.3 pts better
93.4%
5.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.2% · Q3 98.4% · Q4 98.2% · 4Q avg 98.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 91.9%
94.5%
2.6 pts worse
95.5%
3.6 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.9%
Percentage of long-stay residents experiencing one or more falls with major injury 4.8%
3.3%
1.5 pts worse
3.3%
1.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.5% · Q3 6.6% · Q4 5.4% · 4Q avg 4.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 83.3%
26.1%
57.2 pts worse
11.4%
71.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 69.6% · Q2 86.8% · Q3 96.5% · Q4 77.1% · 4Q avg 83.3%
Percentage of long-stay residents who lose too much weight 9.3%
6.2%
3.1 pts worse
5.4%
3.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 8.9% · Q3 21.3% · Q4 4.4% · 4Q avg 9.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 24.3%
25.4%
1.1 pts better
19.6%
4.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 22.9% · Q3 20.8% · Q4 27.7% · 4Q avg 24.3%
Percentage of long-stay residents who received an antipsychotic medication 7.1%
11.5%
4.4 pts better
16.7%
9.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 9.1% · Q3 7.7% · Q4 0.0% · 4Q avg 7.1% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.1%
0.1 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened 15.8%
7.7%
8.1 pts worse
16.3%
0.5 pts better
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 9.0%
6.2%
2.8 pts worse
14.9%
5.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 2.2% · Q3 10.4% · Q4 10.9% · 4Q avg 9.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
0.2%
0.2 pts better
1.0%
1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.0%
0.5%
0.5 pts better
1.7%
1.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 23.9%
21.7%
2.2 pts worse
19.8%
4.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 24.9% · Q3 25.7% · Q4 30.2% · 4Q avg 23.9%
Percentage of long-stay residents with pressure ulcers 5.2%
3.7%
1.5 pts worse
5.1%
0.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.2% · Q3 6.3% · Q4 6.0% · 4Q avg 5.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 74.8%
78.1%
3.3 pts worse
81.7%
6.9 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 82.9% · Q2 63.9% · Q3 69.7% · Q4 92.3% · 4Q avg 74.8%
Percentage of short-stay residents who had an outpatient emergency department visit 5.7%
12.5%
6.8 pts better
12.0%
6.3 pts better
Short Stay · 20240701-20250630 · Adjusted 5.7% · Observed 6.5% · Expected 12.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 0.7%
1.2%
0.5 pts better
1.6%
0.9 pts better
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.2% · 4Q avg 0.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 60.0%
75.6%
15.6 pts worse
79.7%
19.7 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 34.8%
25.1%
9.7 pts worse
23.9%
10.9 pts worse
Short Stay · 20240701-20250630 · Adjusted 34.8% · Observed 45.2% · Expected 31.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-04 · Fire 2024-12-04

15 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

13 fire-safety deficiencies

Top issue: Emergency Preparedness (5 deficiencies)

Cycle 2 Health 2022-05-25 · Fire 2022-05-25

6 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2019-04-12 · Fire 2019-04-12

9 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

11 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-04

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-12-04

E30 · Emergency Preparedness Deficiencies

Fire Safety

List the names and contact information of those in the facility.

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-12-04

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-12-04

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-12-04

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-12-04

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-12-04

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-12-04

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-12-04

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-12-04

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-12-04

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-12-27

E · Potential for more than minimal harm 2024-12-04

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2024-12-27

E · Potential for more than minimal harm 2024-12-04

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-12-27

F · Potential for more than minimal harm 2022-05-25

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2022-06-13

F · Potential for more than minimal harm 2022-05-25

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-06-13

E · Potential for more than minimal harm 2022-05-25

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2022-06-13

E · Potential for more than minimal harm 2022-05-25

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-06-13

E · Potential for more than minimal harm 2022-05-25

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2022-06-13

F · Potential for more than minimal harm 2019-04-12

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2019-05-28

F · Potential for more than minimal harm 2019-04-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-05-28

E · Potential for more than minimal harm 2019-04-12

K227 · Egress Deficiencies

Fire Safety

Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.

Corrected 2019-05-28

E · Potential for more than minimal harm 2019-04-12

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2019-05-28

E · Potential for more than minimal harm 2019-04-12

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-05-28

E · Potential for more than minimal harm 2019-04-12

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2019-05-28

E · Potential for more than minimal harm 2019-04-12

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-05-28

C · Minimal harm 2019-04-12

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2019-05-28

C · Minimal harm 2019-04-12

E24 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for volunteers.

Corrected 2019-05-28

C · Minimal harm 2019-04-12

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2019-05-28

C · Minimal harm 2019-04-12

E35 · Emergency Preparedness Deficiencies

Fire Safety

Provide family notifications of emergency plan.

Corrected 2019-05-28

Inspection history

Recent health citations

G · Actual harm 2024-12-04

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-12-27

G · Actual harm 2024-12-04

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-12-04

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-12-04

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2024-12-27

E · Potential for more than minimal harm 2024-12-04

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-12-27

E · Potential for more than minimal harm 2024-12-04

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-04

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-04

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-04

F569 · Resident Rights Deficiencies

Health

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-04

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-04

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-04

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-04

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-04

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-04

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2024-12-27

G · Actual harm 2024-02-01

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-02-29

D · Potential for more than minimal harm 2024-02-01

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-02-29

D · Potential for more than minimal harm 2024-02-01

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-02-29

G · Actual harm 2023-10-31

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-11-20

F · Potential for more than minimal harm 2023-08-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-08-25

E · Potential for more than minimal harm 2023-08-10

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2023-08-25

E · Potential for more than minimal harm 2022-05-25

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2022-06-13

D · Potential for more than minimal harm 2022-05-25

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2022-06-13

D · Potential for more than minimal harm 2022-05-25

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2022-06-13

D · Potential for more than minimal harm 2022-05-25

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2022-06-13

D · Potential for more than minimal harm 2022-05-25

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2022-06-13

D · Potential for more than minimal harm 2022-05-25

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2022-06-13

D · Potential for more than minimal harm 2019-04-12

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2019-05-28

D · Potential for more than minimal harm 2019-04-12

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2019-05-28

D · Potential for more than minimal harm 2019-04-12

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2019-05-28

Penalties and ownership

What sits behind the stars

$43,865 2024-12-04

Fine

Fine · fine $43,865

Fine

$32,175 2024-02-01

Fine

Fine · fine $32,175

Fine

Ownership

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