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 Royal Oak Nursing & Rehab Ctr during CMS and state inspections, most recent first.
A resident with multiple chronic conditions did not receive wound care as ordered by the physician, as the wound dressing was not changed on the scheduled date. An LPN confirmed the treatment was missed, which was not in accordance with facility policy requiring adherence to physician orders for wound care.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified during the survey.
A resident who was admitted for therapy after a hip replacement fell and was transferred to the ER without notifying her emergency contact. The resident had a hematoma and high blood sugar, and her daughter was not informed until later, which violated the facility's notification policy.
A resident with epilepsy was administered more than three times the prescribed dose of Topiramate due to an error in the electronic health record during admission. The overdose went unnoticed until the resident required emergency evaluation. The resident, who was nonverbal and had severe developmental delay, was sent to the hospital for monitoring after the error was discovered.
Failure to Perform Wound Care as Ordered by Physician
Penalty
Summary
A deficiency occurred when a resident's wound treatment was not performed as ordered by the physician. The resident, who had multiple diagnoses including hypertension, heart arrhythmias, heart failure with a pacemaker, hypothyroidism, osteoarthritis, atherosclerotic heart disease, and high cholesterol, had a skin tear on the left shin. The physician's order specified that the wound should be cleansed with normal saline, xeroform applied, and covered with border gauze every night shift on Tuesday, Thursday, and Saturday. Observation revealed that the wound dressing had not been changed as ordered, with the last documented treatment occurring two days prior to the scheduled change. The LPN confirmed that the wound treatment was not completed according to the physician's instructions. Review of facility policy indicated that wound treatments were to be provided in accordance with physician orders, including the specified cleansing method, dressing type, and frequency.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not specify particular actions, inactions, or events, nor does it mention any specific residents or staff involved in the deficiency.
Failure to Notify Emergency Contact After Resident Fall
Penalty
Summary
The facility failed to notify the emergency contact of a resident regarding a change in condition, specifically after a fall and subsequent transfer to the emergency room (ER). The resident, who was admitted for skilled therapy following a hip replacement, was found on the floor by a registered nurse after tripping on her oxygen tubing. The resident sustained a large hematoma on her forehead and was transferred to the ER for evaluation, as ordered by a nurse practitioner. However, there was no documentation indicating that the resident's daughter was informed of the fall or the ER transfer at the time of the incident. The resident returned from the ER with a negative CT scan, high blood sugar, and edema in both legs. A licensed practical nurse later left a voicemail for the resident's daughter, but the daughter reported not being notified of the fall or ER transfer and expressed concerns about the communication. The facility's policy requires notifying the responsible party of any accident resulting in injury or requiring physician intervention, which was not adhered to in this case. This deficiency was confirmed by the Director of Nursing during an interview.
Significant Medication Error Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in actual harm. Resident #69, who had spastic cerebral palsy with epilepsy, was admitted for a respite stay and was prescribed Topiramate, an anti-epileptic medication, at a dose of 100 mg twice daily. However, due to an error during the admission process, the resident received 625 mg twice daily, which is more than three times the recommended dose, from July 24 to July 29, 2024. The error was discovered on July 29, 2024, when the resident required evaluation and treatment in the emergency room due to the overdose. The resident's medical records indicated that the incorrect dosage was entered into the electronic health record, and the error was not caught until another nurse identified it. The resident was nonverbal and had severe developmental delay, which made it difficult for them to communicate any adverse effects they might have been experiencing. Interviews with the nursing staff and the nurse practitioner confirmed the medication error and the incorrect dosage entry. The nurse practitioner noted that the resident had tolerated the overdose without a change in condition, possibly due to their long-term use of the medication, but acknowledged the potential for a more severe outcome. The facility's Director of Nursing confirmed the error and stated that it was corrected on July 29, 2024, after the resident was sent to the hospital for monitoring.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,270 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| East Park Care Center | 0.9 mi | ★★★★★ | 7 | 0 |
| North Park Care Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Greenbrier Health Center | 1.4 mi | ★★★★★ | 25 | 1 |
| Parkside Villa | 2 mi | ★★★★★ | 0 | 0 |
| O'neill Healthcare Middleburg Heights | 2.1 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.