Cycle 1
Health 2024-03-28 · Fire 2024-03-28
4 health deficiencies
Top issue: Infection Control (1 deficiency)
12 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Middleburg Heights, OH
Royal Oak Nursing & Rehab Ctr
3-star overall rating with 3-star inspections with $8,970 in total fines with 4 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
6973 Pearl Rd, Middleburg Heights, OH
(440) 884-9191
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Embassy Healthcare
Operator or chain grouping
Approved since
1989-10-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
37 facilities
Chain averages 3 overall / 2 health / 2 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
0.36
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.30
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.91
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.34
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,048
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9862
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.22
Performance 46.43% · Measure score 4.22 · Achievement 4.22 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.97
Baseline 2.76 hours · Performance 3.50 hours · Measure score 1.97 · Achievement 1.49 · Improvement 1.97
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.53% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 25% · Lower 95% interval 7.95% |
| Discharge to community | 49.73% |
50.57%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 40.63% · Lower 95% interval 35.99% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 33 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 6.06% |
2.29%
3.8 pts worse
|
Numerator 2 · Denominator 33 · Adjusted rate 5.26% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 95 |
| Staff flu vaccination coverage | 11.76% |
42%
30.2 pts worse
|
Numerator 18 · Denominator 153 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · 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 | 94.9% |
92.4%
2.5 pts better
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 88.3% · Q2 94.8% · Q3 100.0% · Q4 96.7% · 4Q avg 94.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.9% |
94.5%
2.4 pts better
|
95.5%
1.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.3%
0.7 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 1.8% · Q4 4.9% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.2% |
26.1%
18.9 pts better
|
11.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 5.3% · Q3 5.9% · Q4 8.6% · 4Q avg 7.2% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
6.2%
About the same
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 3.9% · Q3 9.8% · Q4 3.6% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.6% |
25.4%
2.8 pts better
|
19.6%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 21.2% · Q3 21.6% · Q4 25.5% · 4Q avg 22.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.8% |
11.5%
4.3 pts worse
|
16.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 17.1% · Q3 14.3% · Q4 12.8% · 4Q avg 15.8% · 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 | 2.1% |
7.7%
5.6 pts better
|
16.3%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 0.0% · Q3 3.9% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.0% |
6.2%
0.2 pts better
|
14.9%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 6.1% · Q3 6.2% · Q4 3.9% · 4Q avg 6.0% · 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 | 0.4% |
0.5%
0.1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.3% |
21.7%
7.6 pts worse
|
19.8%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 24.6% · Q3 16.6% · Q4 47.9% · 4Q avg 29.3% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
3.7%
0.3 pts worse
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.0% · Q3 5.6% · Q4 5.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.9% |
78.1%
5.8 pts better
|
81.7%
2.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 76.1% · Q2 77.1% · Q3 85.2% · Q4 92.7% · 4Q avg 83.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
12.5%
4.4 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 9.4% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.5% |
75.6%
3.9 pts better
|
79.7%
0.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.6% |
25.1%
7.5 pts worse
|
23.9%
8.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.6% · Observed 37.5% · Expected 27.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-02-10 · Fire 2022-02-10
10 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2019-07-11 · Fire 2019-07-11
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-28
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-28
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-28
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-28
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 2024-04-17
F · Potential for more than minimal harm
2024-03-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-17
F · Potential for more than minimal harm
2022-02-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-03-04
F · Potential for more than minimal harm
2022-02-10
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 2022-03-04
F · Potential for more than minimal harm
2022-02-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-03-04
F · Potential for more than minimal harm
2022-02-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-03-04
F · Potential for more than minimal harm
2022-02-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-03-04
F · Potential for more than minimal harm
2022-02-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-03-04
F · Potential for more than minimal harm
2022-02-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-04
E · Potential for more than minimal harm
2022-02-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-03-04
E · Potential for more than minimal harm
2022-02-10
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-03-04
E · Potential for more than minimal harm
2022-02-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-03-04
E · Potential for more than minimal harm
2022-02-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-03-04
F · Potential for more than minimal harm
2019-07-11
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2019-08-19
F · Potential for more than minimal harm
2019-07-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-08-19
E · Potential for more than minimal harm
2019-07-11
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 2019-08-19
E · Potential for more than minimal harm
2019-07-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-08-19
E · Potential for more than minimal harm
2019-07-11
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-08-19
E · Potential for more than minimal harm
2019-07-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2019-08-19
E · Potential for more than minimal harm
2019-07-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-08-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-08
D · Potential for more than minimal harm
2024-10-23
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 2024-10-24
G · Actual harm
2024-09-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-30
D · Potential for more than minimal harm
2024-03-28
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 2024-04-17
D · Potential for more than minimal harm
2024-03-28
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 2024-04-17
G · Actual harm
2022-02-10
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 2022-03-04
F · Potential for more than minimal harm
2022-02-10
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2022-03-04
F · Potential for more than minimal harm
2022-02-10
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-03-04
F · Potential for more than minimal harm
2022-02-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-03-04
F · Potential for more than minimal harm
2022-02-10
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-02-10
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 2022-03-04
D · Potential for more than minimal harm
2022-02-10
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-02-10
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 2022-03-04
E · Potential for more than minimal harm
2019-07-11
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2019-08-19
E · Potential for more than minimal harm
2019-07-11
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2019-08-19
D · Potential for more than minimal harm
2019-07-11
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2019-08-19
D · Potential for more than minimal harm
2019-07-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-08-19
D · Potential for more than minimal harm
2019-07-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-08-19
D · Potential for more than minimal harm
2019-07-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-08-19
D · Potential for more than minimal harm
2019-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-19
Penalties and ownership
What sits behind the stars
$8,970
2024-09-16
Fine
Fine · fine $8,970
Fine
Ownership
Embassy Healthcare Management Inc
Operational/Managerial Control · Organization
Gebhard, Richard
Operational/Managerial Control · Individual
Handler, Aaron
Operational/Managerial Control · Individual
Heritage Employment Services, LLC
Operational/Managerial Control · Organization
Mandat, Thomas
Operational/Managerial Control · Individual
Repchick, George
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
East Park Care Center
Brook Park, OH
1-star overall rating with 1-star inspections with $48,822 in total fines with 25 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#2
North Park Care Center
Brook Park, OH
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#3
Greenbrier Health Center
Parma Heights, OH
1-star overall rating with 1-star inspections with $9,750 in total fines with 24 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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