Royal Oak Nursing & Rehab Ctr
6973 Pearl Rd, Middleburg Heights, OH 44130 · Cuyahoga County · 99 certified beds · avg 59 residents/day · certified since Oct 11, 1989
Part of chain: EMBASSY HEALTHCARE (33 facilities, chain avg rating 2.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Sep 16, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 30, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Feb 10, 2022 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 4, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (21)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Oct 23, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Sep 16, 2024 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Feb 10, 2022 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 10, 2022 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Feb 10, 2022 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Feb 10, 2022 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 10, 2022 | F · Potential for harm, facility-wide | The facility did not dispose of garbage and refuse properly. |
| Feb 10, 2022 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Feb 10, 2022 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Feb 10, 2022 | D · Potential for harm, one-off | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Jul 11, 2019 | E · Potential for harm, repeated | The facility did not properly notify residents about the balance of money it holds for them, or failed to return those funds when a resident was discharged, evicted, or died. |
| Jul 11, 2019 | E · Potential for harm, repeated | The facility did not properly protect the personal money residents deposited with it for safekeeping. |
| Jul 11, 2019 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Jul 11, 2019 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jul 11, 2019 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jul 11, 2019 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 11, 2019 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (8 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 7 | 0 | E |
| 2022 | 8 | 1 | G ▲ |
| 2024 | 4 | 1 | G ▲ |
| 2025 | 2 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $8,970.
| Date | Type | Amount / length |
|---|---|---|
| Sep 16, 2024 | Fine | $8,970 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Ohio avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.15 | 3.45 | 3.95 | bottom 37% in Ohio; bottom 19% in the U.S. |
| Registered Nurse hours | 0.47 | 0.60 | 0.69 | bottom 33% in Ohio; bottom 33% in the U.S. |
| Weekend total nurse staffing | 2.98 | 3.07 | 3.50 | top 46% in Ohio; bottom 30% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.48 | 0.42 | 0.48 | top 30% in Ohio; top 36% in the U.S. |
| Total nursing staff turnover (%) | 52.1 | 48.7 | 45.8 | bottom 40% in Ohio; bottom 32% in the U.S. |
| RN turnover (%) | 62.5 | 43.9 | 42.9 | bottom 21% in Ohio; bottom 19% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.31, RN 0.49, weekend 3.13. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| 2020 GSR Dynasty LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 01/01/2020 |
| Aaron Handler Family Dynasty Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 01/01/2020 |
| Ah Dynasty LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 01/01/2020 |
| Embassy Healthcare Holdings INC | Organization | Direct Ownership Interest | NOT APPLICABLE | 01/01/2020 |
| George S. Repchick 2020 Family Dynasty Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 01/01/2020 |
| Handler, Aaron | Individual | Indirect Ownership Interest | NOT APPLICABLE | 01/01/2020 |
| Repchick, George | Individual | Indirect Ownership Interest | NOT APPLICABLE | 01/01/2020 |
| Embassy Healthcare Management INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2020 |
| Embassy Healthcare Management INC | Organization | ADP of the SNF | NOT APPLICABLE | 06/12/2025 |
| Gebhard, Richard | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Gebhard, Richard | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Handler, Aaron | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2020 |
| Handler, Aaron | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2020 |
| Handler, Aaron | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2020 |
| Heritage Employment Services, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2020 |
| Heritage Employment Services, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/12/2025 |
| Mandat, Thomas | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Mandat, Thomas | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Repchick, George | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2020 |
| Repchick, George | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2020 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Do you have a qualified dietician on staff, and how involved are they in each resident's nutrition plan?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| East Park Care Center | 0.9 mi | Brook Park, OH | ★★☆☆☆ | 1/5 | |
| North Park Care Center | 1.4 mi | Brook Park, OH | ★★★★★ | 5/5 | |
| Greenbrier Health Center | 1.4 mi | Parma Heights, OH | ★★☆☆☆ | 1/5 | |
| Parkside Villa | 2.0 mi | Middleburg Heights, OH | ★★★★☆ | 3/5 | |
| O'Neill Healthcare Middleburg Heights | 2.1 mi | Middleburg Heights, OH | ★★★★★ | 4/5 | |
| Diplomat Healthcare | 2.4 mi | North Royalton, OH | ★★☆☆☆ | 1/5 | |
| Hopkins Rehabilitation and Care Center | 2.4 mi | Middleburg Heights, OH | ★★☆☆☆ | 2/5 | |
| North Royalton Post Acute | 2.9 mi | Parma, OH | ★☆☆☆☆ | 2/5 | |
| Aristocrat Berea Healthcare and Rehabilitation | 3.1 mi | Berea, OH | ★★☆☆☆ | 2/5 | |
| Pleasant Lake Villa | 3.1 mi | Parma, OH | ★★★☆☆ | 3/5 | |
| Pleasantview Care Center | 3.1 mi | Parma, OH | ★★★★★ | 4/5 | |
| Northwestern Healthcare Center | 3.3 mi | Berea, OH | ★★★☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 365753.