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

Certified beds

Average residents

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

Staffing

Hours and turnover

RN hours / resident day

0.67

Registered nurse staffing

LPN hours / resident day

1.18

Licensed practical nurse staffing

Aide hours / resident day

2.05

Nurse aide staffing

Weekend hours

2.97

Weekend nurse staffing

RN turnover

58%

Annual RN turnover

Total nurse turnover

65%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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

Nearby options

Other facilities in reach

O'neill Healthcare Middleburg Heights

Middleburg Heights, OH

5-star overall rating with 4-star inspections with $166,764 in total fines with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

Overall: 5 / 5
Health: 4 / 5
Staffing: 2 / 5
Fines: $166,764