Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hopkins Rehabilitation And Care Center during CMS and state inspections, most recent first.
A facility failed to provide timely care for a resident who fell during physical therapy, resulting in a delayed fracture diagnosis. The PTA did not report the fall, and the resident was not assessed until days later. Another resident with an eye infection was not properly assessed or reported, leading to a delay in treatment. These deficiencies affected two residents and highlighted lapses in following facility policies.
A resident at risk for falls sustained a fracture during a physical therapy session when the PTA released the gait belt to pick up an object, leading to a fall. The resident expressed significant pain, but the incident was not reported, and the resident was instructed not to disclose the fall. The facility's fall management policy was not followed, delaying appropriate medical intervention.
The facility failed to maintain adequate staffing levels, resulting in unmet resident needs. Observations revealed that only two CNAs were present for a night shift meant to have five, leading to delays in care. Residents experienced long waits for assistance, with one found in a soiled state and another unable to return to bed as requested. The facility's staffing did not align with its assessment, contributing to the deficiency.
The facility failed to maintain a clean and safe environment, with issues such as bent heater covers, chipped paint, stained curtains, and torn fall mats. Additionally, a cracked toilet seat, unsecured toilet, dusty blinds, and a significant wall hole were observed. The laundry area had a dryer filter 80% covered in lint, verified by a housekeeper.
The facility failed to prevent staff from using personal devices in resident care areas, affecting ten residents. Observations and resident interviews revealed delays in call light responses and inappropriate phone usage by staff. Despite policies prohibiting such behavior, enforcement was lacking, impacting care quality and resident satisfaction.
The facility failed to maintain accurate records of controlled drugs, affecting five residents. Several LPNs reported forged signatures on narcotic sheets, falsely indicating medication administration or wastage. Discrepancies were found in the records for Oxycodone and Hydrocodone/APAP, with signatures that were later denied by the nurses. The facility's policies on controlled medication guidelines and medication administration were not followed.
Two residents were left in soiled conditions due to staff prioritizing meal service over incontinence care. One resident, dependent on staff for ADLs, was found covered in feces, while another was left in a urine-soaked brief. Staff interviews revealed a practice of delaying care during meal times, contrary to the facility's dignity policy.
A resident with severe cognitive impairment expressed a desire to return to bed after getting up too early, but staff informed him he could not do so until later. This decision was made despite the resident's request and was due to staff needing to finalize their assignment sheets, contradicting the facility's policy to honor resident choices.
A facility failed to convey a resident's personal funds in a timely manner after the resident's death. The resident's funds, totaling $1,134.54, were dispensed to the family beyond the required 30-day period, as confirmed by the Business Manager.
A facility failed to document advanced directives for a resident with end-stage renal disease, peripheral vascular disease, and type II diabetes mellitus. Despite being cognitively intact, the resident's medical record lacked any advanced directives, leading to the assumption of a full code status without proper documentation. An LPN confirmed the absence of directives, contradicting the facility's policy requiring such documentation during admission.
A facility failed to complete a baseline care plan for a resident admitted with chronic obstructive pulmonary disease and muscle weakness. Despite being cognitively intact, the resident's medical record lacked the required care plan, as confirmed by the Regional Clinical Service Director. This omission was contrary to the facility's policy, which requires a baseline care plan within 48 hours of admission.
A resident with chronic conditions and a language barrier did not receive appropriate therapeutic activities as per her care plan. The activities calendar was in English, and no suitable Spanish activities were provided. Volunteers visited weekly, but there was no daily staff interaction outside of ADL care. The resident's TV remote was missing, and she lacked a magnifying glass to read materials, contributing to unmet needs.
The facility failed to provide timely incontinence care for two residents, leading to significant discomfort and unsanitary conditions. One resident was found in a severely soiled state despite having a care plan requiring regular checks. Another resident was left sitting in a saturated brief with urine running down his leg. Staff interviews revealed a systemic issue where residents were made to wait for incontinence care until after meal service, contradicting the facility's policy on timely assistance.
The facility failed to follow physician orders for oxygen administration for two residents. One resident with COPD did not have their oxygen tubing changed as ordered, while another resident with respiratory failure received oxygen without a physician order. Staff interviews and observations confirmed these deficiencies, highlighting a lack of adherence to the facility's Oxygen Safety Policy.
A hospice CNA failed to follow a resident's care plan by manually lifting the resident instead of using a mechanical lift, resulting in bruising. The resident, who was severely cognitively impaired and required a two-person assist, was injured during a partial bed bath. The facility's investigation lacked a statement from the CNA and evidence of follow-up training.
Failure to Provide Timely Care and Report Changes in Condition
Penalty
Summary
The facility failed to provide timely and adequate care for Resident #34, who sustained a fall during a physical therapy session. The Physical Therapy Assistant (PTA) involved did not report the fall or document it, and instead, encouraged the resident not to disclose the incident. The resident experienced pain and swelling in the left leg, which was not immediately assessed or treated. An x-ray was ordered but not conducted until the following day, and the fracture was not diagnosed until two days after the fall. The resident was eventually sent to the emergency room and diagnosed with a left tibial fracture. Additionally, the facility did not adequately assess and report a change in condition for Resident #41, who had a noticeable eye infection. Despite visible symptoms such as redness, swelling, and discharge, the staff failed to notify the Certified Nurse Practitioner (CNP) or document the condition in the resident's records. The CNP was unaware of the condition until it was brought to his attention during an observation, at which point he diagnosed a bacterial infection and prescribed treatment. The deficiencies affected two residents out of four reviewed for quality of care and treatment for change of condition. The facility's policies on fall management and change in condition notification were not followed, leading to delays in treatment and potential harm to the residents involved.
Failure to Prevent Avoidable Fall Resulting in Injury
Penalty
Summary
The facility failed to provide necessary assistance to prevent an avoidable fall for a resident at risk for falls, resulting in a major injury. During a physical therapy session, the Physical Therapy Assistant (PTA) let go of the resident's gait belt and turned away, leading to the resident falling and sustaining a fracture to the left leg. The resident was known to have a history of muscle weakness, unsteadiness, and required physical assistance, as documented in their care plan. The incident occurred during a therapy session where the resident was ambulating with a forward wheeled walker. The PTA was providing contact guard assistance when a piece fell off the resident's wheelchair. The PTA turned to pick up the object, releasing the gait belt, which resulted in the resident falling to their knees. Despite the resident expressing significant pain, the PTA did not report the fall and instead provided ice packs, instructing the resident not to disclose the incident. The resident later reported pain and swelling, leading to an x-ray that confirmed a fracture. The facility's investigation revealed that the PTA admitted to the fall only after being terminated. The Director of Nursing and other staff were not immediately informed of the fall or the resident's change in condition, delaying appropriate medical intervention. The facility's policy on fall management was not followed, contributing to the deficiency.
Inadequate Staffing Levels Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure adequate staffing levels to meet the needs of its residents, as evidenced by observations and interviews conducted during a survey. On the night shift of 11/23/24, the facility was supposed to have three nurses and five CNAs for a census of 64 residents, but only two CNAs were present. This staffing shortage was confirmed by multiple staff members, including an LPN and an RN, who noted that two CNAs had called off for their night shift. The lack of sufficient staff led to delays in responding to residents' needs, as observed with Resident #55, who waited 10 minutes for assistance with a soiled brief, and Resident #20, who was found covered in a foul-smelling substance and had been waiting for help for an extended period. Further interviews and observations revealed that residents experienced significant delays in having their call lights answered, with one resident reporting waits of up to an hour. Another resident was unable to return to bed at their request due to staff being occupied with other tasks. The facility's staffing schedule and assessment indicated that at least four licensed nurses and six CNAs should be scheduled per shift, but this was not adhered to, resulting in unmet resident needs and unfinished tasks. The facility's failure to accurately staff according to the resident population and acuity levels contributed to the deficiency.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a clean, safe, and well-maintained environment for its residents, as observed during an environmental tour with the Maintenance Director. Several deficiencies were noted, including a bent baseboard heater cover in a resident's room, scuffed and chipped paint on walls, stained privacy curtains, and torn, tattered, and dirty fall mats. Additionally, a room had a cracked toilet seat, and another had a toilet that was not secured to the floor with caulking coming up. The window blinds in some rooms were covered in dust and dirt, and a significant hole was found in a wall, large enough to fit a fist through. Other issues included a baseboard heater cover that was off, a wheelchair with dried food and spills, and multiple light fixtures with dead insects inside. The handrails throughout the facility were also noted to have rough, chipped areas, posing a hazard to residents. In the laundry area, a large filter inside a dryer was found to be approximately 80% covered in lint, requiring force to be removed. This condition was verified by a housekeeper during an interview. These findings indicate a lack of proper maintenance and cleaning practices, potentially affecting all 64 residents residing in the facility.
Staff Personal Device Usage Affects Resident Care
Penalty
Summary
The facility failed to ensure that staff refrained from personal conversations and the use of personal electronic devices in resident rooms and care areas, affecting ten residents. Observations revealed a cellular phone playing loud music at the nurses' station, and resident interviews indicated that staff frequently used their phones, leading to delays in responding to call lights. One resident reported waiting for hours for assistance, while another had to resort to making noise with objects in his room to get attention. Residents expressed concerns about staff phone usage during a Resident Council meeting, noting that these issues had been raised multiple times. The job descriptions for the Administrator and Director of Nursing (DON) outlined their responsibilities for ensuring quality care and compliance with regulations. However, the facility's employee handbook and electronic communication policy, which prohibit personal device usage during work hours unless authorized, were not adhered to. This lack of enforcement contributed to the deficiency, as staff were observed using personal devices inappropriately, impacting the quality of care and resident satisfaction.
Controlled Drug Discrepancies and Forged Signatures
Penalty
Summary
The facility failed to maintain an accurate account of controlled drugs, affecting five residents. The issue was identified through a review of facility policy, records, staff interviews, and self-reported incidents. Several Licensed Practical Nurses (LPNs) reported that their signatures had been forged on narcotic sheets, falsely indicating that they had administered or wasted medications. The investigation revealed that the dates of these alleged forgeries ranged over several days, and the suspended nurse, LPN #323, was implicated in multiple instances of signature forgery. For Resident #27, discrepancies were found in the narcotic sheet for Oxycodone, with signatures of LPNs that were later denied by the nurses themselves. Similar issues were found for Resident #29, where the narcotic sheet for Hydrocodone/APAP showed signatures that did not match the nurse's known signature. Resident #47's records indicated an over-administration of Oxycodone/APAP, with signatures that were later denied by the LPNs. Resident #48's narcotic sheet also showed forged signatures for Hydrocodone/APAP administration. Resident #60's records revealed that Oxycodone was signed out and documented as administered, but the Medication Administration Record (MAR) showed no such administration. The facility's policies on controlled medication guidelines and medication administration were not adhered to, as evidenced by the lack of proper validation and documentation by the licensed nurses. This deficiency was investigated under Control Number OH00159967.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to ensure residents were treated with dignity, affecting two residents. Resident #20, who was admitted with orthopedic aftercare following surgical amputation and type II diabetes mellitus, was found in a state of neglect. She was alert and oriented but had cognitive impairment and was dependent on staff for activities of daily living (ADLs). On the morning of 11/24/24, Resident #20 was observed covered in feces, with a foul odor emanating from her room. Despite her call light being activated, staff did not respond promptly. A registered nurse acknowledged seeing the call light but did not attend to it, as it was not his assigned responsibility. A certified nursing assistant (CNA) also failed to respond, citing her task of passing breakfast trays as a reason. Resident #55, who was cognitively intact and required assistance for personal hygiene, was found sitting in a urine-soaked brief. He expressed discomfort and embarrassment, stating he had to wait until after breakfast to be changed. Staff interviews revealed a practice of not attending to residents' incontinence needs during meal times, as they prioritized passing trays. This practice was confirmed by multiple CNAs, who stated they were instructed to wait until after meals to change residents. The facility's policy on dignity, dated 09/21/23, emphasized the importance of promptly responding to residents' requests for assistance and maintaining their privacy and dignity. However, the actions and inactions of the staff, as observed and reported, were contrary to this policy, resulting in residents being left in soiled conditions and feeling undignified. The Director of Nursing and Regional Clinical Service Director later stated that residents should be changed when needed, regardless of meal times, but this was not the practice observed during the survey.
Failure to Honor Resident's Choice to Return to Bed
Penalty
Summary
The facility failed to honor a resident's right to self-determination and personal preference, as evidenced by the incident involving Resident #268. The resident, who was admitted with chronic obstructive pulmonary disease, dementia, and type II diabetes mellitus, had a severe cognitive impairment with a BIMS score of five. On the day of the incident, the resident expressed a desire to return to bed after getting up too early, but staff informed him that he could not do so until 11:00 A.M. This decision was made despite the resident's clear request and was attributed to the staff needing to finalize their assignment sheets. The facility's policy titled 'Dignity' emphasizes that residents should be cared for in a manner that promotes their well-being and honors their choices and preferences, including when to sleep. However, the actions of the CNAs, who were unable to accommodate the resident's request to return to bed, directly contradicted this policy. The CNAs confirmed that the resident could not be put back into bed at his request, highlighting a failure to facilitate resident choice and self-determination as outlined in the facility's policy.
Delayed Conveyance of Resident Funds
Penalty
Summary
The facility failed to ensure the timely conveyance of resident funds upon discharge, affecting one resident. The resident was admitted to the facility and later expired there. A review of the business records showed that a check for the resident's personal funds, amounting to $1,134.54, was dispensed to the resident's family outside the required 30-day timeframe. This was confirmed during an interview with the Business Manager.
Failure to Document Advanced Directives for a Resident
Penalty
Summary
The facility failed to ensure that advanced directives were accurately recorded in the medical record of a resident, identified as Resident #169. This resident, who was cognitively intact with a BIMS score of 15, was admitted with diagnoses including end-stage renal disease, peripheral vascular disease, and type II diabetes mellitus. Upon review, it was found that there were no advanced directives noted in the resident's care plan or physician's orders, nor were they documented in the electronic medical records. This omission meant that the resident would be treated as a full code, implying all life-saving measures would be used in the event of cardiac arrest, despite the absence of a documented order for such a code status. An interview with an LPN confirmed the lack of advanced directives in the resident's medical record, and the LPN stated that in the event of cardiac arrest, the resident would be treated as a full code. The facility's policy, revised in June 2022, mandates that discussions about advanced directives occur during the admission process, with the physician being notified of the resident's wishes and the completion of updated code status paperwork as needed. However, this policy was not followed, as evidenced by the absence of documentation in the resident's electronic medical record.
Failure to Complete Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to ensure a baseline care plan was completed upon admission for a resident. This deficiency was identified during a review of records, staff interviews, and facility policy. Specifically, a resident who was admitted with diagnoses of chronic obstructive pulmonary disease and muscle weakness did not have a baseline care plan documented in their medical record. The resident was noted to be cognitively intact according to a quarterly Minimum Data Set (MDS) assessment. The absence of a baseline care plan was confirmed during an interview with the Regional Clinical Service Director, who verified that the care plan was not completed as required by the facility's policy, which mandates the development of a baseline care plan within 48 hours of admission.
Failure to Provide Appropriate Therapeutic Activities for a Resident
Penalty
Summary
The facility failed to provide appropriate therapeutic activities for a resident who was admitted with diagnoses including chronic kidney disease, major depression, anxiety, type II diabetes, and peripheral vascular disease. The resident, who is cognitively intact and speaks only Spanish, had a care plan that included the use of an interpretation line and engagement in leisure activities to promote socialization and stimulation. However, the activities calendar in the resident's room was in English, and there were no appropriate Spanish activities planned or carried out during the week. The Activities Director confirmed that volunteers visit the resident once weekly, but there was no one-on-one interaction or daily visits from facility staff outside of ADL care. The resident's son confirmed that the resident's television remote had been missing for approximately one and a half weeks, and the facility had not provided a replacement. The resident also stated she does not own a magnifying glass, which affects her ability to read materials provided to her. The lack of appropriate activities and support, as well as the missing remote control, contributed to the deficiency in meeting the resident's needs as outlined in her care plan.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to significant discomfort and unsanitary conditions. Resident #20, who was admitted with orthopedic aftercare following surgical amputation and type II diabetes mellitus, was found in a severely soiled state. Despite having a care plan that required regular checks and assistance with toileting and hygiene, Resident #20 was left unattended with feces covering her body and bed. Staff interviews revealed a lack of responsibility and urgency in addressing her needs, with a registered nurse and a certified nursing assistant failing to respond promptly to her call light. Resident #55, diagnosed with chronic obstructive pulmonary disease and muscle weakness, was also neglected in terms of incontinence care. Despite being cognitively intact and requiring assistance for toileting, Resident #55 was left sitting in a saturated brief with urine running down his leg. Staff interviews indicated a systemic issue where residents were made to wait for incontinence care until after meal service, leading to prolonged periods of discomfort and exposure to unsanitary conditions. The facility's policy on incontinence care was not adhered to, as evidenced by the experiences of Residents #20 and #55. The policy required timely assistance based on resident requests or needs, but staff practices during meal times contradicted this, resulting in residents being left in soiled conditions. The Director of Nursing's expectations were not met, as staff prioritized meal service over immediate resident care needs, contributing to the deficiencies observed.
Failure to Adhere to Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents by not adhering to physician orders regarding oxygen tubing changes and lacking physician orders for oxygen administration. Resident #19, diagnosed with shortness of breath, obstructive sleep apnea, and COPD, had physician orders to change oxygen tubing weekly, which were not followed. Observations revealed that the oxygen tubing had not been changed for approximately 21 days, despite the resident's daily use of oxygen. Interviews with staff confirmed the oversight in changing the tubing as per the physician's orders. Resident #43, with diagnoses including end-stage renal disease and acute and chronic respiratory failure, was admitted with oxygen in place but lacked a physician order for its administration. Despite the absence of documented orders, the resident received oxygen on multiple occasions, as evidenced by the oxygen saturation level summary and staff interviews. The Director of Nursing confirmed the absence of a physician order for oxygen, despite the resident's continuous use since admission. The facility's Oxygen Safety Policy was not adhered to, as there were no orders or care plans indicating the use of oxygen for Resident #43.
Failure to Coordinate Hospice Care Leads to Resident Injury
Penalty
Summary
The facility failed to ensure proper coordination of care for a resident receiving hospice services, resulting in a deficiency. The resident, who was severely cognitively impaired and had multiple diagnoses including vascular dementia and hemiplegia, required a two-person assist with a mechanical lift for transfers. However, during a partial bed bath, the hospice CNA manually lifted the resident from the bed to a Broda chair, contrary to the resident's care plan, which led to bruising on the resident's inner right thigh. The facility's investigation into the incident was incomplete, as it did not include a statement from the hospice CNA involved, nor was there evidence of any training or follow-up with the CNA after the incident. An LPN confirmed that the hospice CNA did not follow the resident's care plan and transferred the resident without using the mechanical lift, despite the resident's need for such assistance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Middleburg Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| O'neill Healthcare Middleburg Heights | 0.4 mi | ★★★★★ | 7 | 0 |
| Parkside Villa | 0.4 mi | ★★★★★ | 0 | 0 |
| Aristocrat Berea Healthcare And Rehabilitation | 0.7 mi | ★★★★★ | 5 | 0 |
| Northwestern Healthcare Center | 1.1 mi | ★★★★★ | 30 | 1 |
| Berea Center | 1.5 mi | ★★★★★ | 0 | 0 |
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