Inspection visit
Inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, resident and staff interviews, and policy review the facility failed implement its abuse and
neglect policy and procedure related abuse reporting to the state agency. This affected one (Resident #35)
of one resident reviewed for abuse and neglect. The facility census was 54.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses
including dementia, schizophrenia, and anxiety disorder. Review of the most recent Minimum Data Set
(MDS) 3.0 assessment dated [DATE] revealed Resident #35 was cognitively intact and required extensive
assistance of two staff for the completion of her activities of daily living.
Interview with Residents #35 on 05/22/22 at 11:59 A.M. revealed approximately one week ago (exact date
and time unable to be recalled by the resident) State Tested Nursing Assistant (STNA) #900 yelled at
Resident #35 after refusing to put a topical powder on her buttocks. Resident #35 stated STNA #900 was
rude and abusive in the way that she talked to me. Resident #35 stated she had not told any facility staff
about the incident and really did not want STNA #900 to take care of her anymore.
The Administrator was notified of Resident #35's verbal abuse allegation on 05/22/22 at 12:12 P.M. by the
surveyor.
Review of the Ohio Department of Health's Enhanced Information Dissemination and Collection (EIDC)
system (system used by facilities to report allegations of abuse, neglect, misappropriation, and exploitation)
on 05/24/22 at 8:11 A.M. revealed no self-reported incident had been initiated by the facility as required to
address Resident #35's verbal abuse allegation.
Interview with the Administrator and Director of Nursing on 05/24/22 between 8:40 A.M. and 8:50 A.M.
verified no self-reported incident was initiated and that the facility conducted their own investigation
interviewing Resident #35, and the resident recanted her story and thus they did not feel any abuse had
occurred.
Review of the policy titled Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation
of Resident Property, dated 11/28/16, under the sub section initial reporting revealed all allegations of
abuse, neglect, injuries of unknown source, and misappropriation of resident property must be reported
immediately (2 hours if abuse allegation or serious injury; all other incidents not later than 24 hours) to both
the Administrator and the Ohio Department of Health (ODH). When possible, ODH will be notified using by
using the online EIDC system.
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 7
Event ID:
366057
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
366057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/25/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Middleburg Heights Health & Rehabilitation Center
19530 Bagley Road
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, resident and staff interviews, and policy review the facility failed to report and allegation of
verbal abuse to the state agency as required. This affected one (Resident #35) of one resident reviewed for
abuse and neglect. The facility census was 54.
Findings include:
Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses
including dementia, schizophrenia, and anxiety disorder. Review of the most recent Minimum Data Set
(MDS) 3.0 assessment dated [DATE] revealed Resident #35 was cognitively intact and required extensive
assistance of two staff for the completion of her activities of daily living.
Interview with Residents #35 on 05/22/22 at 11:59 A.M. revealed approximately one week ago (exact date
and time unable to be recalled by the resident) State Tested Nursing Assistant (STNA) #900 yelled at
Resident #35 after refusing to put a topical powder on her buttocks. Resident #35 stated STNA #900 was
rude and abusive in the way that she talked to me. Resident #35 stated she had not told any facility staff
about the incident and really did not want STNA #900 to take care of her anymore.
The Administrator was notified of Resident #35's verbal abuse allegation on 05/22/22 at 12:12 P.M. by the
surveyor.
Review of the Ohio Department of Health's Enhanced Information Dissemination and Collection (EIDC)
system (system used by facilities to report allegations of abuse, neglect, misappropriation, and exploitation)
on 05/24/22 at 8:11 A.M. revealed no self-reported incident had been initiated by the facility as required to
address Resident #35's verbal abuse allegation.
Interview with the Administrator and Director of Nursing on 05/24/22 between 8:40 A.M. and 8:50 A.M.
verified no self-reported incident was initiated and that the facility conducted their own investigation
interviewing Resident #35, and the resident recanted her story and thus they did not feel any abuse had
occurred.
Review of the policy titled Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation
of Resident Property, dated 11/28/16, under the sub section initial reporting revealed all allegations of
abuse, neglect, injuries of unknown source, and misappropriation of resident property must be reported
immediately (2 hours if abuse allegation or serious injury; all other incidents not later than 24 hours) to both
the Administrator and the Ohio Department of Health (ODH). When possible, ODH will be notified using by
using the online EIDC system.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366057
If continuation sheet
Page 2 of 7
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
366057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/25/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Middleburg Heights Health & Rehabilitation Center
19530 Bagley Road
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview the facility failed to accurately code the pre-admission screening and
resident review (PASRR) accurately on the Minimum Data Set (MDS) 3.0 assessment. This affected five
(Resident's #5, #27, #32, #34 and #38) of eleven residents identified as having a level two mental illness or
intellectual disability. The facility census was 54.
Residents Affected - Some
Findings include:
1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses
including schizophrenia, bi-polar disorder, and major depressive disorder.
Review of the level two determination from the Ohio Department of Mental Health dated 03/01/22 revealed
Resident #5 had a serious mental illness.
Review of section A of the most recent comprehensive MDS 3.0 assessment for Resident #5 dated
12/31/21 revealed the facility answered no to the question, Is the resident currently considered by the state
level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?
2. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with
diagnoses including schizophrenia, anorexia, and major depressive disorder.
Review of the level two determination from the Ohio Department of Mental Health dated 03/01/22 revealed
Resident #5 had a serious mental illness.
Review of section A of the most recent comprehensive MDS 3.0 assessment for Resident #27 dated
03/10/22 revealed the facility answered no to the question, Is the resident currently considered by the state
level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?
3. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with
diagnoses including chronic pain syndrome, personality disorder, and major depressive disorder.
Review of the level two determination from the Ohio Department of Mental Health dated 08/30/18 revealed
Resident #32 had a serious mental illness.
Review of section A of the most recent comprehensive MDS 3.0 assessment for Resident #32 dated
01/01/22 revealed the facility answered no to the question, Is the resident currently considered by the state
level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?
4. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with
diagnoses including schizophrenia, unspecified intellectual disabilities, and anxiety disorder.
Review of the level two determination from the Ohio Department of Developmental Disabilities dated
04/11/22 revealed Resident #34 had a level intellectual disability
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366057
If continuation sheet
Page 3 of 7
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
366057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/25/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Middleburg Heights Health & Rehabilitation Center
19530 Bagley Road
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 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of section A of the most recent comprehensive MDS 3.0 assessment for Resident #34 dated
04/05/22 revealed the facility answered no to the question, Is the resident currently considered by the state
level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?
5. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with
diagnoses including schizoaffective disorder, dementia, and post-traumatic stress disorder.
Review of the level two determination from the Ohio Department of Mental Health dated 07/13/21 revealed
Resident #38 had a serious mental illness.
Review of section A of the most recent comprehensive MDS 3.0 assessment for Resident #38 dated
04/04/22 revealed the facility answered no to the question, Is the resident currently considered by the state
level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?
Social Worker #631 verified the incorrect coding of the above resident PASRR statuses during an interview
on 05/24/22 at 10:12 A.M.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366057
If continuation sheet
Page 4 of 7
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
366057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/25/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Middleburg Heights Health & Rehabilitation Center
19530 Bagley Road
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 0645
PASARR screening for Mental disorders or Intellectual Disabilities
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview the facility failed to complete a preadmission screen and resident review
(PASRR) timely as required. This affected one (Resident #42) of six residents reviewed for PASRR status.
The facility census was 54.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses
including schizoaffective disorder, seizures, violent behavior, anoxic brain damage, and bipolar disorder.
Review of the medical record revealed Resident #42's PASRR screen was not completed until 05/23/22.
The screen noted Resident #42 as having a level two developmental disability requiring further review from
the Ohio Department of Developmental Disabilities.
Social Worker #631 verified that Resident #42's PASRR was not completed timely as required during an
interview on 05/24/22 at 2:15 P.M.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366057
If continuation sheet
Page 5 of 7
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
366057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/25/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Middleburg Heights Health & Rehabilitation Center
19530 Bagley Road
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview the facility failed to develop a comprehensive resident centered activities
care plan for Resident #24. This affected one (Resident #24) of one resident review for activities. The facility
census was 54.
Findings Include:
Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses
including aphasia, major depressive disorder, and dysphagia.
Review of the care plan for Resident #24 reviewed no evidence of any care plan to addresses activities and
recreational needs for Resident #24.
Activities Director #629 verified the lack of activities care plan during an interview on 05/25/22 at 10:10
A.M.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366057
If continuation sheet
Page 6 of 7
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
366057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/25/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Middleburg Heights Health & Rehabilitation Center
19530 Bagley Road
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure the pharmacy recommendations were addressed by
the physician in a timely manner. This affected one (Resident #16) of five residents reviewed for
unnecessary medications. The facility census was 54.
Findings include:
Review of Resident #16's medical record revealed an admission date of 02/27/22 with diagnoses including
diabetes mellitus type two with hyperglycemia, schizophrenia, squamous cell carcinoma, protein-calorie
malnutrition, pulmonary fibrosis, dementia with behavior disturbance, psychosis, and hypertension.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had
impaired cognition, behavioral symptoms directed towards others, history of falls, and decreased mobility
requiring wheelchair.
Review of the monthly pharmacy recommendations to the attending physician dated 02/28/22 and again on
03/29/22, revealed the pharmacist made a recommendation to discontinue the use of one of two multiple
vitamin supplements namely the Thera M Plus (multiple vitamins-minerals) or the Multivitamin tablet
(multiple vitamin). The physician addressed the pharmacist recommendations to discontinue the Thera M
Plus tablet on 04/04/22.
Review of the monthly pharmacy recommendations to the attending physician dated 02/28/22 and again on
03/29/22, revealed the pharmacist made a recommendation to change the frequency of MiraLax Powder 17
grams (laxative) from one scoop by mouth for constipation PRN (as needed) to one scoop by mouth every
24 hours (once daily) for constipation. The physician addressed the pharmacist recommendations to
change the specific frequency on 05/24/22.
On 05/25/22 at 9:58 A.M. the Director of Nursing (DON) verified the recommendation was not addressed in
a timely manner and stated Certified Nurse Practitioner (CNP) #667 was responsible to address the
recommendations on Thursdays. The DON verified that the facility expectation was for physicians to
respond within 30 days of pharmacy recommendations.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366057
If continuation sheet
Page 7 of 7
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Back to topCitations
11 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.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0222GeneralS&S Fpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0341GeneralS&S Epotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the May 25, 2022 survey of Hopkins Rehabilitation and Care Center?
This was a inspection survey of Hopkins Rehabilitation and Care Center on May 25, 2022. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Hopkins Rehabilitation and Care Center on May 25, 2022?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement policies and procedures to prevent abuse, neglect, and theft."
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.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.