Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, interview, and policy review the facility failed to ensure equipment was
maintained and in good working condition to prevent a fall with injury for Resident #13. This affected one
resident, Resident #13, of two residents reviewed for falls. The facility census was 78.
Actual harm occurred on 01/28/21 when Resident #13 sustained a fall resulting in a neck fracture while
being assisted by one State Tested Nurse Assistant (STNA) during a shower in a shower bed.
Findings include:
Review of Resident #13's medical record revealed an admission date of 10/01/13 with diagnoses including
dementia without behavioral disturbance, major depressive disorder, hypertension, contracture, cerebral
infarction, and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left
non-dominant side.
Review of the plan of care dated 10/08/19 revealed Resident #13 required assistance for activities of daily
living (ADL) related to cognitive impairment, hemiparesis immobility and hemiplegia. Resident #13 was also
at risk for impaired communication related to dementia, and at risk for falls and injury related to cognitive
function and decreased physician function. Interventions included keep call light within reach while in bed,
total dependence for bathing, staff assist as needed with daily hygiene and with showering per facility
policy, anticipate resident needs, and assist with transfers as needed.
Review of the Fall Risk Evaluation dated 12/24/21, revealed Resident #13 had a fall risk score of nine
indicating the resident was a fall risk and interventions should be initiated.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had
a Brief Interview for Mental Status (BIMS) score of five indicating severe cognitive impairment. Further
review of the MDS assessment revealed Resident #13 was a two-person physical extensive assist for bed
mobility, two-person physical total dependence for transfers, one-person physical total dependence for
locomotion on and off the unit, dressing, toileting, personal hygiene, and one-person physical total
dependence for bathing.
Review of the progress note dated 01/28/22 at 9:05 A.M. revealed Licensed Practical Nurse (LPN) #762
was called into the shower room located on the 200 unit by nursing staff. LPN #762 observed blood and
Resident #13 on the floor. Resident #13 was assessed and appeared to have a head injury with a
laceration on the left side of his head. LPN #762 informed STNA #904 to call 911 (emergency medical
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 13
Event ID:
365753
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Oak Nursing & Rehab Ctr
6973 Pearl Rd
Middleburg Heights, OH 44130
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Actual harm
Residents Affected - Few
services) and to get the other nurse. LPN #762 held pressure to Resident #13's head and applied a
bandage to the head while awaiting the ambulance. Resident #13 was covered and dried off while LPN
#762 kept him talking. Nurse Practitioner (NP) #915 and Power of Attorney (POA) #920 were notified that
Resident #13 was alert and aware of going to the hospital with an immediate intervention of staff education
of two State Tested Nurse Aides (STNAs) while showering resident in the shower bed.
Review of the progress note dated 01/28/22 at 9:07 A.M. revealed Resident #13 was admitted to the local
hospital with a subdural hematoma and a fractured neck.
Review of the fall investigation for the fall that occurred on 01/28/22 at 6:46 A.M. revealed STNA #904 was
assigned to Resident #13 and witnessed the fall. STNA #904 was bathing Resident #13 in the chair/table
and turned him on his right side to wash his bottom and back. STNA #904 washed his backside for about
15 minutes, walked around to wash his left side and to rinse with water, and as he was turned, she heard a
snap. The right side bar broke or came loose and Resident #13 fell. STNA #904 attempted to reach for
Resident #13 but was unable to prevent the fall. Resident #13 fell straight down with his knees and his head
hitting the ground with a loud thump. STNA #904 yelled for the nurse.
Review of the progress note dated 01/29/22 at 11:00 P.M. revealed Resident #13 returned from the local
hospital via ambulance on stretcher with a cervical collar.
Review of the hospital discharge instructions dated 01/29/22 revealed Resident #13 had a diagnosis of
acute subdural hematoma and closed C3 fracture (fracture of an upper cervical vertebra).
Review of the physician orders dated 01/30/22 revealed Resident #13 had an order to have left resting
hand splint on after morning ADLs and remove at night for range of motion and hygiene, mat to the floor
next to bed while occupied, may be up in tilt-in-space wheelchair with customized seating system when out
of bed, and bilateral grab bars to bed for positioning and mobility.
Review of the physician orders dated 02/01/22 revealed an order for shower every Tuesday and Friday
11:00 A.M. to 7:00 P.M. and to document any refusals.
Review of the physician orders dated 02/02/22 revealed an order to have two STNAs when using shower
bed.
Review of the physician orders dated 02/03/22 revealed an order for Hoyer (mechanical) lift with two-person
assistance to transfer, cleanse scabbed area scalp injury with betadine every shift as needed and leave
open to air, may remove hard neck brace for small periods of time while eating only with supervision, and
staff to assess neck under brace every shift.
Review of the physician orders dated 02/05/22 revealed an order for follow-up computerized tomography
(CT) scan on 02/21/22.
Review of the incident log dated 02/07/21 to 02/07/22, revealed Resident #13 had a history of falls with one
fall sustained on 12/24/21.
During initial tour of the facility on 02/07/22 from 8:30 A.M. to 10:30 A.M. Resident #13 was observed at
9:29 A.M. lying in bed with his head facing the wall. Resident #13 was observed to have a neck brace
around his neck and grimaced in pain when making slight movements. STNA #884 was observed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365753
If continuation sheet
Page 2 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Oak Nursing & Rehab Ctr
6973 Pearl Rd
Middleburg Heights, OH 44130
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
assisting Resident #13 with repositioning.
Level of Harm - Actual harm
Interview on 02/07/22 at 9:29 A.M. with STNA #884 revealed Resident #13 sustained a fall and broke his
neck. STNA #884 revealed Resident #13 was using the shower bed in the shower room when it broke and
he fell.
Residents Affected - Few
Interview on 02/09/22 at 8:46 A.M. with the Director of Nursing (DON) revealed Resident #13 was getting a
shower at approximately 6:00 A.M. The STNA had Resident #13 on the shower bed, washing him up, rolled
him over to one side, washed his back, when he rolled out of the shower bed. The DON revealed the
shower bed snapped near the prongs, leaving the top side moveable. The STNA was giving Resident #13 a
shower alone and because she was an agency aide the facility could not provide disciplinary action. Staff
were in-serviced on providing showers using the shower bed with two-person assist. The DON was
unaware if there was a policy related to maintaining shower and bath equipment.
Interview on 02/09/22 at 9:38 A.M. with Maintenance Director (MD) #595 revealed he was made aware of
Resident #13's fall related to the broken shower bed. MD #595 revealed the shower bed had four corners
that were held together using pins. One of the pins was not properly seated in the hole which resulted in
one of the corners coming off and breaking. MD #595 removed the shower bed immediately and a new
shower bed was ordered. MD #595 revealed he was a recent hire and was responsible for making sure the
facility equipment was in working order. MD #595 used paper forms and lists to keep track of maintenance
upkeep in the facility and was trying to become acclimated to the facility and systems. MD #595 revealed he
had not provided any maintenance to the shower bed.
Review of the facility document titled Facility/Non-Facility Equipment/Appliances Guidelines revised
September 2018, revealed the facility was responsible for equipment, appliances, or other items used by
residents whether they were provided by the facility, vendors, hospice, or families. Review of the policy
revealed staff should be alert for equipment such as wheelchairs, Geri-chairs, walkers, etc. with loose parts,
torn or cracked materials, squeaky items, or other issues and if found, should be brought to the attention of
the maintenance department or the vendor, resident, representative for repair and/or replacement.
Review of the facility document titled Preventative Maintenance Program undated, revealed the purpose of
the policy was to ensure the provision of a safe, functional, sanitary, and comfortable environment for
residents, staff, and the public. The policy indicated MD #595 was responsible for developing and
maintaining a schedule of maintenance services to ensure the buildings, grounds, and equipment was
maintained in a safe and operable manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365753
If continuation sheet
Page 3 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Oak Nursing & Rehab Ctr
6973 Pearl Rd
Middleburg Heights, OH 44130
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0801
Level of Harm - Minimal harm
or potential for actual harm
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.
Based on record review and interview, the facility failed to ensure the dietary manager completed
qualifications in a timely manner. This had the potential to affect all residents. The facility census was 78.
Residents Affected - Many
Findings include:
Review of the key personnel revealed Dietary Manager (DM) #610 as the kitchen director.
Interview on 02/08/22 at 11:14 A.M. with DM #610 revealed she had worked for the facility for 16 years,
seven as the dietary manager. DM #610 stated she was in the process of obtaining her certification as a
dietary manager but had not started the classes.
Interview on 02/08/22 at 12:24 P.M. with the Administrator verified DM #610 did not have the required
qualifications and the Administrator was going to enroll DM #610 into classes to become a certified dietary
manager.
Review of the Dietary Director Job description under education included must possess a minimum of a high
school diploma, be a graduate of an accredited course of dietetic training approved by the American
Dietetic Association or have certifications as a certified dietary manager from an approved organization.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365753
If continuation sheet
Page 4 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Oak Nursing & Rehab Ctr
6973 Pearl Rd
Middleburg Heights, OH 44130
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
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.
Based on review of the meal sheets, staff interview, resident interview, and review of the facility policy, the
facility failed to ensure there were alternative menu choices with variety to meet resident preferences. This
affected three residents (#16, #49, and #83) of four residents (#16, #49, #71, and #83) reviewed for food
and had the potential to affect all residents. The facility census was 78.
Findings include:
Review of the medical record for Resident #83 revealed an admission date of 06/03/21 and discharge date
of 06/25/21. Diagnoses included morbid obesity, hypertension (HTN), mild protein-calorie malnutrition, and
gastro-esophageal reflux disease (GERD). Review of physician orders for June 2021 identified orders for
regular diet, regular texture, and regular consistency.
Review of the medical record for Resident #16 revealed an admission date of 06/24/19. Diagnoses included
HTN, diabetes mellitus (DM), and GERD. Review of physician orders for February 2022 identified orders for
regular, no added salt diet, regular texture, and regular consistency.
Review of the medical record for Resident #49 revealed an admission date of 10/15/21. Diagnoses included
recurrent depressive disorder, anxiety disorder, and mild cognitive impairment.
Review of physician's orders for February 2022 identified orders for regular diet, regular texture, and regular
consistency.
Interviews on 02/07/22 at 1:22 P.M. and 2:19 P.M. with Residents #16 and #49 revealed they felt the menu
was repetitive and lacked choices or alternatives. Resident #49 stated they had a meal one day and the
next day it would be some combination of yesterday's meal.
Interview on 02/08/22 at 5:15 P.M. with Dietary Manager (DM) #610 revealed there were three items listed
on the always available menu but stated if residents wanted a side salad or soup those were also available.
DM #610 stated the dietary staff went around to the residents every morning to obtain their choice for lunch
and dinner and they chose between the main meal or the alternative. The dietary staff marked the menu
sheet with the resident's choice.
Review of the dinner meal sheet dated 02/08/22 revealed the resident name and room number. At the top
was the main meal which included barbeque chicken, fries, coleslaw and listed as the alternative was hot
dog, fries, coleslaw. DM #610 stated the staff would mark a H which indicated the resident chose the main
meal and an A to indicate the alternate.
Review of the meal sheets dated 02/01/22 through 02/08/22 revealed the following.
* Sloppy joes were offered as the main meal on 02/01/22 and as an alternative on 02/05/22.
* Meatballs in some form (meatballs, sweet and sour meatballs, meatball sub, spaghetti and
meatballs) were offered on 02/01/22, 02/02/22, 02/03/22 as the alternative for dinner and on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365753
If continuation sheet
Page 5 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Oak Nursing & Rehab Ctr
6973 Pearl Rd
Middleburg Heights, OH 44130
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
02/06/21 as the alternative for lunch, and on 02/07/22 as the main meal.
Level of Harm - Minimal harm
or potential for actual harm
* Ham was offered on 02/01/22 as the main meal at lunch, on 02/03/22 the main meal for dinner,
and on 02/08/22 as the main meal for lunch.
Residents Affected - Many
* Chicken patty was offered on 02/04/22 as the alternate meal for dinner, on 02/05/22 as the main
meal for lunch, and 02/07/22 as the alternate for lunch meal.
* Pork patty was offered on 02/04/22 as the alternate on lunch and on 02/06/22 as the main meal for
dinner.
Interview on 02/09/22 at 9:32 A.M. with DM #610 verified the repetitiveness of the menu options and
alternatives. DM #610 stated the cooks decided the alternate meal. The cooks utilized the leftovers and
food orders were based on the menu. The always available menu had been that way for a while and she
rarely heard complaints regarding the repetitiveness of the menu.
Interview on 02/09/22 at 9:43 A.M. with Registered Dietitian (RD) #950 stated he and DM #610 worked
together and RD #950's duties included monthly kitchen inspections, relaying resident preferences or
dislikes to DM #610, and tray ticket audits. RD #950 stated the menu recently switched to the new food
supplier's menu but was not sure how the alternates were created. During review of the menu sheets with
RD #950 he verified the receptiveness of the offered options. RD #950 stated he had heard resident
complaints regarding the receptiveness of the options.
Interview on 02/09/22 at 12:04 P.M. with Resident #70 revealed he was the resident council president.
Resident #70 stated he felt the menu was repetitive. Resident #70 said one week they had stuffed peppers
multiple times and he thought the facility must have gotten a good deal on them.
Review of facility policy titled Resident Selective Menus, dated 02/09/22, revealed a planned four week
menu plan was used along with always available menu items for selecting and providing alternates. the
policy indicated the facility could choose the always available options or could use the following standards.
For breakfast - hard-boiled egg, scrambled egg, cold cereal variety, yogurt, and peanut butter. For lunch
and dinner- chef salad, cottage cheese and fruit plate, hamburger, cheeseburger, hot dog, grilled cheese,
deli sandwich with or without cheese, soup of the day, alternative hot vegetable, canned or fresh fruit
(seasonal), peanut butter and jelly sandwich, and yogurt.
This deficiency substantiates Complaint numbers OH001129862 and OH00111655.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365753
If continuation sheet
Page 6 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Oak Nursing & Rehab Ctr
6973 Pearl Rd
Middleburg Heights, OH 44130
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure staff wore hair nets while in the
kitchen and the 100 hall nursing unit refrigerator was maintained in a clean and sanitary manner. This had
the potential to affect all residents. The facility census was 78.
Findings include:
1. Observation on 02/07/22 at 8:51 A.M. revealed Dietary Aide (DA) #796 scooping cooked ground beef out
of a pot and into a steam table pan. DA #796 was not wearing a hairnet. Interview at the time of the
observation with DA #796 verified DA #796 was not wearing a hair net.
Observation on 02/08/22 at 2:02 P.M. revealed DA #904 washing her hands then retrieving serving utensils
to puree food for the dinner meal. DA #904 was not wearing a hairnet. Interview at the time of the
observation with DA #904 verified DA #904 was not wearing a hair net.
Review of the undated facility policy titled Hair Restraints revealed hair restraints shall be worn by all
employees while in the kitchen to cover all hair.
2. Observation on 02/08/22 at 2:27 P.M. with Dietary Manager #610 of the 100 hall nursing unit refrigerator
revealed the freezer portion had various food stains and on the top shelf and inside of the door there was a
strand of hair. The refrigerator portion had various food stains, the seal at the bottom of the inside of the
refrigerator door was in disrepair, and stained with a yellowish dark brownish [NAME] as well as on the floor
underneath the door of the refrigerator. Interview at the time of the observation with DM #610 verified the
observations. DM #610 said the nurses on the unit were responsible for maintaining the cleanliness of the
refrigerator.
This deficiency substantiates Complaint number OH00113336.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365753
If continuation sheet
Page 7 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Oak Nursing & Rehab Ctr
6973 Pearl Rd
Middleburg Heights, OH 44130
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0814
Dispose of garbage and refuse properly.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation and interview, the facility failed to maintain a clean and uncluttered area surrounding
the outside dumpster. This had the potential to affect all residents. The facility census was 78.
Residents Affected - Many
Findings include:
Observation on 02/07/22 at 8:56 A.M. with Dietary Aide (DA) #796 of the outside dumpsters revealed
garbage bags piled high and a moderate amount of debris and empty cardboard boxes in the snow
surrounding the dumpsters. Interview at the time of the observation with DA #796 verified the observations.
DA #796 stated the dumpsters always looked like this and the nursing aides threw trash around the
dumpsters instead of putting trash inside of them. DA #796 stated the maintenance department was
responsible for keeping the dumpster area clean.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365753
If continuation sheet
Page 8 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Oak Nursing & Rehab Ctr
6973 Pearl Rd
Middleburg Heights, OH 44130
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview, the facility failed to ensure the resident record contained current and
accurate information for Residents #67 and #82. This affected two residents (#67 and #82) of two reviewed
for accurate medical records. The facility census was 78.
Findings include:
1. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with
diagnoses that included type 2 diabetes mellitus with chronic kidney disease, chronic obstructive
pulmonary disease, and dysphagia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment
dated [DATE] revealed Resident #67 was alert with cognitive impairment and required assistance of at least
two persons for activities of daily living.
Observation on 02/07/22 at 9:06 A.M. revealed no operational call light designated for Resident #67.
Review of the progress note dated 02/07/22 at 12:25 A.M. revealed Resident #67's call light was within
reach.
Review of the progress note dated 02/07/22 at 11:41 A.M. revealed Resident #67's call light was within
reach and safety maintained.
Review of the progress note dated 02/08/22 at 2:23 A.M. revealed Resident #67's call light was within reach
and all safety measures maintained.
Interview on 02/08/22 at 8:30 A.M. with Licensed Practical Nurse (LPN) #762 revealed Resident #67 did not
use a call light and would not use it, if she had one in place. Resident #67 would yell out if she needed
anything. LPN #762 revealed the call light designated for Resident #67 was attached to her roommate's
(Resident #57) bed.
Observation and interview on 02/08/22 at 8:35 A.M. with the Director of Nursing (DON) and Maintenance
Director (MD) #595 confirmed there was no call light in place for Resident #67.
Interview on 02/08/22 at 2:30 P.M. with the DON revealed she was unsure why Resident #67's progress
notes indicated she had a call light in place.
2. Review of the medical record for Resident #82 revealed an admission date of 12/23/21. Diagnoses
included weakness, hypertension, and dementia without behavioral disturbances.
Review of the nurses' note dated 12/23/21 at 11:15 P.M. revealed Resident #82 arrived at facility via
emergency medical services (EMS) on a stretcher. Vital signs were obtained, head to toe assessment
completed, orders verified with certified nurse practitioner (CNP). Resident noted with area to right thumb,
treated with Ciclopirox.
Further review of the medical record revealed no further nurses' notes documenting Resident #82's fungal
infection to the right thumb.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365753
If continuation sheet
Page 9 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Oak Nursing & Rehab Ctr
6973 Pearl Rd
Middleburg Heights, OH 44130
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the skin observation sheets dated 01/01/22, 01/11/22, 01/18/22, 01/25/22, and 02/01/22 revealed
no documentation of the resident's fungal infection on her right thumb.
Review of the CNP's progress note dated 01/24/22 revealed, under plan and assessment, Resident #82
had thickened, yellow, flaky nails with no drainage or discharge. The progress note further indicated to
ensure Resident #82 was on the podiatry list to have nail care. There was no documentation regarding the
fungal infection to Resident #82's right thumb.
Review of the podiatrist note dated 01/28/22 revealed the podiatrist provided care to Resident #82's
toenails. There was no documentation regarding the fungal infection to Resident #82's right thumb.
Review of Resident #82's physician orders for February 2022 revealed an order for Ciclopirox Solution 8%
(topical antifungal), to apply to right thumb topically at bedtime for fungal infection. Remove with alcohol
every seven days with a start date of 12/24/21.
Observation on 02/07/22 at 11:44 A.M. of Resident #82 reveal a large growth on her right thumb. Interview
at this time with Resident #82 revealed the growth was somewhat painful and that she was supposed to
have it removed on 01/14/22 but the appointment was canceled due to insurance.
Interview on 02/09/22 at 4:23 P.M. with Wound Nurse (WN) #721 revealed Resident #82 had a fungal
infection that was being treated with a topical antifungal solution. WN #721 stated Resident #82 was
admitted with the fungal infection and because it wasn't a wound it was not documented on the skin
assessments. WN #721 stated Resident #82 was on the list for the podiatrist to look at the right thumb.
Interview on 02/10/22 at 9:43 A.M. with the Director of Nursing (DON) revealed Resident #82 was seen by
the CNP who wrote an order for Resident #82 to see the podiatrist, but a treatment was in place. The DON
stated because the thumb nail was still intact, and the growth had not fallen off staff would only document if
there were changes. The DON stated the podiatrist had seen the resident on 01/28/22 but only for her
toenail.
Review of the plan of care initiated on 12/24/21 for potential for alteration in skin integrity revealed a
revision dated 02/10/22 which included chronic fungal area to right thumb.
Interview on 02/10/22 at 9:48 A.M. with Regional MDS Nurse #657 verified the care plan was revised on
02/10/22 because the fungal infection to the right thumb was missed.
Review of the facility document titled Charting and Documentation revised July 2017, revealed that all
services provided to the resident, progress toward the care plan goals, or any changes in the resident
medical, physical, functional, or psychosocial condition, shall be documented in the resident medical
record. Further review revealed the documentation in the medical record would be objective, complete, and
accurate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365753
If continuation sheet
Page 10 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Oak Nursing & Rehab Ctr
6973 Pearl Rd
Middleburg Heights, OH 44130
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation and staff interview the facility failed to ensure it had a functional and accessible call light in
place. This affected two (Resident #42 and #67) of two residents reviewed for call light function. The facility
census was 78.
Residents Affected - Few
Findings Include:
1. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with
diagnoses that included type 2 diabetes mellitus with chronic kidney disease, chronic obstructive
pulmonary disease, and dysphagia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment
dated [DATE] revealed Resident #67 was alert with cognitive impairment and required assistance of at least
two persons for activities of daily living.
Observation on 02/07/22 at 9:06 A.M. revealed no operational call light designated for Resident #67.
Interview on 02/07/22 at 9:06 A.M. with Resident #67 revealed she had no call light.
Interview on 02/07/22 at 9:07 A.M. with Licensed Practical Nurse (LPN) #762 confirmed Resident #67 did
not have a call light. LPN #762 revealed she would inform the Director of Nursing (DON).
Observation on 02/08/22 at 8:30 A.M. revealed no operational call light designated for Resident #67.
Interview on 02/08/22 at 8:30 A.M. with LPN #762 revealed Resident #67 did not use a call light and would
not use it, if she had one in place. LPN #762 revealed Resident #67 would yell out if she needed anything.
LPN #762 revealed the call light designated for Resident #67 was attached to her roommate's (Resident
#57) bed.
Observation and interview on 02/08/22 at 8:35 A.M. with the DON and Maintenance Director (MD) #595
confirmed Resident #67 did not have a call light.
2. Review of the medical record for Resident #82 revealed an admission date of 12/23/21. Diagnoses
included weakness, hypertension, and dementia without behavioral disturbances. Review of the admission
Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had intact cognition, required
extensive assistance of one staff for bed mobility, transfers, and toilet use.
Interview on 02/07/22 at 11:36 A.M. with Resident #82 revealed she did not have a call light and that her
roommate used her call light for her. Observation at the time of the interview revealed Resident #82's call
light was on the floor behind her bed and not in reach.
Interview on 02/07/22 at 12:30 P.M. with Hydration Aide (HA) #836 verified Resident #82's call light was on
the floor behind her bed. HA #836 said the call light fell behind her bed because of the placement of
Resident #82's phone
Review of the facility document titled Call Lights revised October 2018, revealed the facility would provide
an operational call light system for residents.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365753
If continuation sheet
Page 11 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Oak Nursing & Rehab Ctr
6973 Pearl Rd
Middleburg Heights, OH 44130
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0919
This deficiency substantiates Complaint number OH00129862.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365753
If continuation sheet
Page 12 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Oak Nursing & Rehab Ctr
6973 Pearl Rd
Middleburg Heights, OH 44130
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation, staff interview, and policy review the facility failed to ensure Resident #67's and
#75's walls were maintained in good repair. This affected two of three residents (#67, #75 and #82)
reviewed for environment. The facility census was 78.
Findings include:
1. Observation on 02/07/22 at 9:06 A.M. revealed a large significant hole with scrapes, chipped paint,
furniture markings, and scratches located on the wall directly behind the headboard of Resident #67's bed.
Interview on 02/07/22 at 9:07 A.M. with Licensed Practical Nurse (LPN) #762 revealed the hole had been in
the wall for a while and was related to the furniture being moved around in the room.
Interview on 02/08/22 at 8:35 A.M. with Maintenance Director (MD) #595 confirmed the hole, scrapes, and
chipped paint in Resident #67's room. MD #595 said he was aware of the hole in the wall but had just
started his role a few months ago and was trying to catch up on the needs of the facility.
2. Observation on 02/07/22 at 12:13 P.M. revealed a large hole in the wall behind Resident #75's bed.
Interview on 02/08/22 at 11:52 A.M. with Resident #75 revealed he wasn't sure how long the hole was there
and wasn't sure if it was there when he arrived in the room. Resident #75 stated no one had been in his
room to look at the hole.
Observation on 02/08/22 at 11:57 A.M. with Maintenance Assistant (MA) #573 confirmed the hole behind
Resident #75's bed.
Interview on 02/08/22 at 12:09 P.M. with Maintenance Supervisor (MS) #595 revealed he was aware of
some of the residents' rooms where the walls behind the beds needed to be repaired. MS #595 stated he
had not started an audit yet to see which rooms were affected.
Review of the facility document titled Preventative Maintenance Program undated, revealed the policy was
to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and
the public. Further review of the policy revealed MD #595 was responsible for developing and maintaining a
schedule of maintenance services to ensure that the buildings, grounds, and equipment was maintained in
a safe and operable manner.
This deficiency substantiates Complaint Number OH00129862 and is a recite to the complaint survey
completed 01/19/22.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365753
If continuation sheet
Page 13 of 13
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Back to topCitations
8 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F801 - Staffing
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.
F803 - Menus and nutritional adequacy
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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F919 - Resident Call System
Make sure that a working call system is available in each resident's bathroom and bathing area.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
FAQ · About this visit
Common questions about this visit
What happened during the February 10, 2022 survey of ROYAL OAK NURSING & REHAB CTR?
This was a inspection survey of ROYAL OAK NURSING & REHAB CTR on February 10, 2022. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ROYAL OAK NURSING & REHAB CTR on February 10, 2022?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.