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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Royalton Post Acute during CMS and state inspections, most recent first.
Two residents experienced unmet needs when staff failed to provide timely assistance with mobility and incontinence care for one, and failed to supply wheelchair foot pedals for another, resulting in one resident remaining in bed for hours and another being transported backwards in a wheelchair with his feet dragging, despite repeated requests and staff awareness of the issues.
A resident with diabetes, neuropathy, and Alzheimer's disease missed multiple scheduled medications, including insulin, on two occasions. Nursing staff did not promptly notify the physician or monitor the resident for adverse effects as required by facility policy. The DON confirmed that monitoring and notification were not completed after the errors.
A resident with physical and cognitive impairments who required extensive assistance for toileting was left waiting for nearly an hour after requesting to use the bathroom. Despite repeated requests and interactions with multiple staff members, the resident was not assisted in a timely manner, resulting in partial incontinence and discomfort. Staff interviews confirmed that timely assistance was not provided, particularly during busy periods, and that the resident was usually continent when helped promptly.
A resident with severe cognitive impairment and a PEG tube did not receive the prescribed amount of enteral nutrition when the tube feeding pump repeatedly indicated a clog and was not infusing. The LPN on duty had not yet checked on the resident and was unaware of the issue, resulting in the resident missing the ordered nutrition.
Two residents with diabetes received insulin injections from LPNs who failed to prime the insulin pens as required by manufacturer instructions and facility policy. This resulted in a medication error rate of 6.45%, exceeding the acceptable threshold. The DON confirmed that insulin pens must be primed after attaching a new needle and before administering the prescribed dose.
A resident requiring Enhanced Barrier Precautions due to a gastrostomy and impaired skin integrity did not receive proper infection control during incontinence and wound care. Two CNAs provided high-contact care without wearing required gowns, and an LPN failed to perform hand hygiene and glove changes while treating a PEG tube site, contrary to facility policy and physician orders.
A CNA was found asleep while on duty, leading to potential neglect of a resident. The resident, who had a history of multiple medical conditions, reported hearing noises and later discovered the CNA asleep in the adjacent bed. This incident violated the facility's policy on resident protection from neglect.
A facility failed to develop a comprehensive discharge care plan for a resident with multiple diagnoses, including a femur fracture and Parkinson's disease. The resident required extensive assistance for mobility and toileting, yet the care plan lacked discharge planning. An LSW confirmed the absence of the plan, violating the facility's policy requiring care plans within seven days of assessment.
The facility failed to properly assess, monitor, and document skin impairments for three residents, leading to deficiencies in care. A resident with a surgical incision had no initial dressing order, and weekly skin checks for all three residents lacked necessary descriptions and measurements. Staff interviews revealed inconsistencies in understanding the facility's skin management policy.
Failure to Timely Assist Residents and Provide Wheelchair Foot Pedals
Penalty
Summary
The facility failed to timely assist a resident with mobility and incontinence care, as well as failed to provide necessary wheelchair foot pedals for another resident, resulting in unmet needs for both individuals. One resident, who was moderately cognitively impaired and dependent on staff for transfers and mobility, requested to be changed and to get out of bed. Despite asking his assigned CNA for assistance, he remained in bed for several hours, with staff citing the unavailability of a Broda chair and competing priorities as reasons for the delay. The resident continued to wait for assistance, expressing his needs to both staff and the surveyor, and was not assisted out of bed until much later in the day. Another resident, also moderately cognitively impaired and with significant lower extremity impairment, returned from a doctor appointment in a manual wheelchair without foot pedals. His elderly brother had to pull the wheelchair backwards through the facility, causing the resident distress and fear, as his feet dragged on the floor. The resident reported having repeatedly requested foot pedals for several days without receiving them. Staff interviews confirmed that foot pedals were not readily available or installed, and that the resident was typically pushed backwards in the wheelchair due to the lack of footrests. Staff interviews further revealed a lack of clear procedures for ensuring wheelchair foot pedals were available and installed, as well as inconsistent understanding of when residents required such equipment. The maintenance director indicated that foot pedals were stored in various locations, making them difficult to locate, while the DON acknowledged that residents should not be pulled backwards in wheelchairs. These failures resulted in the residents' needs and requests not being accommodated in a timely and appropriate manner.
Failure to Notify Physician and Monitor Resident After Medication Errors
Penalty
Summary
The facility failed to notify the physician in a timely manner and did not monitor a resident for adverse effects after medication errors occurred. Specifically, a resident with diagnoses including type 2 diabetes mellitus, diabetic neuropathy, and Alzheimer's disease missed scheduled doses of insulin and other medications on two separate occasions. On both occasions, the medication errors were not promptly identified by nursing staff, and the resident's physician was not notified as required. Additionally, there was no evidence in the medical record that the resident was monitored for adverse effects following the missed doses, despite facility policy requiring monitoring for 24 to 72 hours after a medication error. The resident involved was cognitively impaired, unable to complete mental status interviews, and dependent on staff for medication administration. The errors included missed doses of insulin, allergy medication, neuropathy medication, blood pressure medication, pain medication, and others, as well as missed blood glucose monitoring. The Director of Nursing confirmed that the required monitoring and physician notification did not occur after the medication errors, which was inconsistent with the facility's own policy on managing medication errors.
Failure to Provide Timely Toileting Assistance Resulting in Incontinence
Penalty
Summary
A deficiency was identified when a resident with Parkinson's disease and muscle wasting, who was moderately cognitively impaired and frequently incontinent of bowel and bladder, did not receive timely assistance to maintain continence. The resident required extensive assistance for toileting, as documented in the care plan. On the day of the incident, the resident requested to use the bathroom while being transported from the Activities room by two Activities Aides. Instead of assisting or notifying appropriate staff, the aides left the resident across from the nurses' station without informing anyone of her need to urinate. For over 35 minutes, the resident remained unattended and was not assisted to the bathroom, despite her repeated requests. Multiple staff, including the Activities Director and CNAs, interacted with the resident but did not provide or arrange for toileting assistance. The resident was eventually assisted to the bathroom nearly an hour after her initial request, at which point her brief was found to be wet with urine, though she was able to urinate in the toilet as well. Interviews with staff confirmed that the resident was usually continent if assisted in a timely manner, but delays often occurred, especially during busy periods such as mealtimes. The facility's policy on Activities of Daily Living emphasized the importance of preserving function, promoting independence, and maintaining dignity. However, observations and interviews revealed that staff failed to follow this policy, resulting in the resident experiencing discomfort and partial incontinence due to delayed toileting assistance. The deficiency was substantiated through direct observation, staff interviews, and review of facility records and policies.
Failure to Provide Ordered Tube Feeding Due to Unresolved Pump Clog
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dysphagia following cerebral infarction, hemiplegia, hemiparesis, and aphasia did not receive the ordered amount of tube feeding. The resident was dependent for all activities of daily living and had a physician order for continuous enteral nutrition at 75 cc per hour, with specific instructions for formula type and flushes. Observations revealed that the resident's tube feeding pump was repeatedly beeping and displaying a 'clog in line downstream' error, with 370 ml remaining in a 1000 ml container that had been initiated earlier that day. The tube feeding was not infusing as ordered. Further review and interviews confirmed that the tube feeding should have been completed by early afternoon, but the resident had not received the full prescribed amount. The LPN on duty at the time had not yet checked on the resident and was unaware that the tube feeding had not been infusing. This resulted in the resident not receiving the ordered nutrition, as confirmed by both observation and staff interview.
Failure to Prime Insulin Pens Results in Medication Error Rate Above 5%
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with a calculated error rate of 6.45% based on 31 observed medication administrations and two identified errors. Both errors involved the administration of insulin using pen injectors for two residents with diabetes and chronic kidney disease. In both cases, the LPNs administering the insulin did not prime the insulin pens prior to dialing the prescribed dose and administering the medication, contrary to manufacturer instructions and facility policy. The LPNs confirmed during interviews that they did not prime the pens, with one stating she only primes if air bubbles are visible and the other stating she did not believe priming was necessary. The residents involved were cognitively intact and had care plans and physician orders specifying insulin administration for diabetes management. The facility's policy and the insulin pen manufacturer’s instructions both require priming the pen after attaching a new needle and before setting the prescribed dose. The DON confirmed that the correct procedure was not followed in these instances. The deficiency was identified during a complaint investigation and was substantiated by direct observation, record review, and staff interviews.
Failure to Follow Enhanced Barrier Precautions and Infection Control During Resident Care
Penalty
Summary
Surveyors identified a failure to maintain infection control practices during incontinence and wound care for one resident. The resident, who had diagnoses including dysphagia, polyneuropathy, and a gastrostomy, required substantial assistance for mobility and personal hygiene. The care plan indicated the resident was at risk for complications related to a PEG site infection and required Enhanced Barrier Precautions (EBP), including the use of gowns and gloves during high-contact care activities such as dressing, hygiene, and wound care. During observation of incontinence care, two CNAs provided care without donning isolation gowns, despite the resident's care plan and facility policy requiring gown and glove use for high-contact activities under EBP. One CNA stated gowns were only necessary for residents with a Foley catheter, while the other was unaware of the requirement. This demonstrated a lack of adherence to established infection control protocols for residents requiring EBP. Additionally, an LPN performed wound care on the resident's PEG tube site without following proper hand hygiene or glove-changing procedures. The LPN used the same gloves to clean the soiled wound and to apply a sterile dressing, without washing hands or using hand sanitizer between steps. The DON confirmed that sterile technique was not used as ordered and that clean technique, including hand hygiene and glove changes, should have been followed. Facility policies reviewed by surveyors outlined the correct procedures, which were not adhered to during the observed care.
CNA Found Asleep on Duty, Leading to Potential Neglect
Penalty
Summary
The facility failed to ensure residents were free from potential neglect when a Certified Nurse Aide (CNA) was found asleep while on duty. This incident involved Resident #97, who reported that CNA #403 was asleep in the bed adjacent to her in her room. The resident initially heard noises but could not see who it was due to a curtain blocking her view. Upon inquiry, CNA #403 revealed herself and asked the resident not to be upset. This incident was reported to the Assistant Director of Nursing (ADON) and led to the suspension of CNA #403. Resident #97, who was affected by this incident, had a medical history that included cellulitis of the left lower limb, chronic obstructive pulmonary disease, anxiety disorder, polyneuropathy, neurogenic bowel, depression, and essential hypertension. The facility's policy on abuse, mistreatment, neglect, exploitation, and misappropriation of resident property emphasizes the residents' right to be free from such issues. However, the actions of CNA #403, as reported, were in violation of this policy, leading to a deficiency being noted under Master Complaint Number OH00159766.
Failure to Develop Comprehensive Discharge Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive discharge care plan was in place for a resident, identified as Resident #99, who was reviewed for comprehensive care plans. The resident had a range of diagnoses, including a displaced intertrochanteric fracture of the left femur, Parkinson's disease, and a history of falling, among others. The resident's Admission Minimum Data Set (MDS) assessment indicated intact cognition and required extensive assistance for bed mobility and substantial assistance for toileting hygiene. Despite these needs, the comprehensive care plan dated 07/19/24 did not include a discharge care plan for the resident. An interview with Licensed Social Worker (LSW) #167 confirmed the absence of a comprehensive discharge care plan for the resident. The facility's policy, revised on 11/13/19, mandates the development of an individualized comprehensive care plan within seven days of completing the resident assessment, which was not adhered to in this case.
Inadequate Skin Impairment Documentation and Treatment
Penalty
Summary
The facility failed to ensure timely and thorough assessment, monitoring, and treatment of skin impairments for three residents. Resident #99 was admitted with a surgical incision on the left thigh, but there was no detailed documentation or physician order for the dressing change upon admission. The weekly skin checks lacked descriptions and measurements of the skin impairments, despite the facility's policy requiring such documentation. Interviews with staff revealed inconsistencies in understanding and executing the skin assessment procedures. Resident #71 also experienced inadequate documentation of a surgical incision on the lower back. The weekly skin checks for this resident similarly lacked detailed descriptions and measurements, contrary to the facility's policy. Interviews with nursing staff indicated a misunderstanding of the requirements for documenting skin assessments, with some staff believing that only circling the affected area was necessary. Resident #93's records showed a lack of initial documentation for skin assessments upon admission. Subsequent weekly skin checks identified bruising on the elbows, but again, there was no detailed description or measurement of these areas. The facility's policy clearly stated the need for comprehensive documentation of skin breakdowns, yet the staff interviews highlighted a gap in adherence to these procedures.
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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 Parma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasantview Care Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Pleasant Lake Villa | 1.4 mi | ★★★★★ | 0 | 0 |
| Diplomat Healthcare | 1.9 mi | ★★★★★ | 8 | 0 |
| Greenbrier Health Center | 2.5 mi | ★★★★★ | 25 | 1 |
| The Pavilion Rehabilitation And Nursing Center | 2.7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.