O'neill Healthcare Middleburg Heights

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and facility policy review, the facility failed to ensure oxygen tubing was dated for Residents #76 and #36. This affected two residents (#76 and #36) of five residents reviewed for oxygen therapy. The facility census was 65.Findings include:1. Review of Resident #76's medical record revealed an admission date of 11/28/25 with diagnoses of acute respiratory failure with hypoxia and hypertensive heart disease. Review of a physician's order dated 11/28/25 revealed Resident #76 was ordered oxygen at two liters/minute via nasal cannula continuously, and the oxygen tubing was to be changed weekly on Sunday.Observation on 12/01/25 at 12:45 P.M. revealed Resident #76's oxygen tubing was not dated. Interview with Licensed Practical Nurse (LPN) #579 on 12/01/25 at 12:50 P.M. confirmed Resident #76's oxygen tubing was not dated.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview the facility failed to maintain the services of a registered nurse for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 70 residents currently residing in the facility. Findings include: Review of the nursing staff information and staff schedule for 11/10/22 revealed no registered nurse (RN) was present working in the facility on 11/10/22. Interview on 12/20/22 at 2:30 P.M. with the Director of Nursing (DON) verified no RN was scheduled on 11/10/22. Interview on 12/21/22 at 10:04 A.M. with Scheduler #229 revealed staffing is based on census and uses agency when there is not enough facility staff. Scheduler #229 stated she just learned from the survey, that a RN must be scheduled daily.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review the facility to ensure medications were always secure from unauthorized access. This affected one (Resident #26) of four (Residents #1, #26, #35 and #58) observed for medication administration. The facility census was 70. Findings include: Review of the medical record for Resident #26 revealed an admission date of 09/01/21 with diagnoses including major depressive disorder, pulmonary fibrosis, chronic obstructive pulmonary disease, and hypotension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 was severely cognitively impaired. Review of the December 2022 physician's orders revealed orders for Depakote (Divalproex Sodium) 125 milligrams (mg) three times a day for depression. Observation on 12/18/22 at 9:40 A.M. revealed an orange oblong pill with a plastic cup with water in Resident #26's room. Resident #26 could not state what date the pill was from. Observation and interview on 12/18/2 at 9:50…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, medical record review, and staff interviews, the facility failed to ensure a resident received the correct thickened consistency of fluids per physician orders. This affected two Residents (#124 and #129) of two residents reviewed for thickened liquids. The facility identified four Residents (#45, #124, #129 and #130) who received thickened liquids. The facility census was 70. Findings include: 1. Review of Resident #124's medical record revealed and admission date of 12/07/22 with diagnoses including pneumonia, multiple sclerosis, and atrial fibrillation. Review of the admission Minimum Data Set (MDS) 3.0 assessment revealed the assessment was in progress. Review of the physician's orders for December 2022 revealed Resident #124's diet order was a no added salt, mechanical soft with ground meat texture, and nectar thickened liquids consistency. Observation on 12/20/22 at 7:26 A.M. revealed a 16-ounce (oz) Styrofoam cup filled halfway filled with thin liquids on the Resident #124's nightstand. This was verified at the time of the observation by Central Supply…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, review of resident records, review of infection control policy and procedures, review of the facilities Influenza timeline for December 2022, the Center for Disease Control (CDC) Interim Guidance for Influenza Outbreak Management in Long Term Care Facilities, dated 11/21/22, the facility failed to maintain acceptable infection control practices in the area of isolation procedures for influenza outbreaks after Resident #24 tested positive for Influenza A (highly contagious respiratory infection) by placing her in the dining room at the table with Resident #45. This affected two (Residents #24 and #45) and had the potential to affect all 70 residents residing in the facility. Findings include 1. Review of the medical record for Resident #24 revealed an admission date of 09/09/22. Diagnosis included dementia, acute kidney failure, and heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 was severely impaired cognitively.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation and interview the facility failed to ensure Resident #68's dignity was maintained. This affected one resident (#68) of one reviewed for dignity. Findings include: Review of Resident #68's medical record revealed an admission date of 02/16/20. Diagnoses included acute renal (kidney) failure, disorientation, and hemiplegia (paralysis on one side of the body) affecting the left non-dominant side. The admission Minimum Data Set (MDS) assessment was in progress. Observation on 02/18/20 at 10:59 A.M. revealed Resident #68 in a wheelchair in the common area wearing a hospital gown, with a blanket laid across his lap, with his feet bare, and his catheter bag, not in a privacy bag. Observation on 02/18/20 at 11:03 A.M. revealed Licensed Practical Nurse (LPN) #430 wheeling Resident #68 from the common area to his room. Interview at that time with LPN #430 revealed Resident #68 was alert to name, but not alert to time. LPN #68 verified the observation and the dignity concerns and stated Resident #68 should have been taken to his room and assisted.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop comprehensive care plans for Resident #34 related to transmission-based precautions and for Resident #54 related to a wanderguard. This affected two of 18 residents reviewed for care plans. Findings include: 1. Record review of Resident #34 revealed a re-entry date of 01/04/20. Diagnoses included congestive heart failure and amputation of right toes. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, required extensive assistance of two staff for bed mobility and transfers, and was totally dependent on two staff for toilet use. Resident #34 was always incontinent of bowel and bladder and was not on isolation precautions. Review of the nursing notes dated 01/19/20 at 4:19 P.M. revealed Resident #34 was acting slightly sluggish and eating little. The physician was notified of his condition and tests were ordered including a stool sample. Review of the laboratory results for a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure accurate and complete documentation in the medical records for Residents #34 and Resident #680. This affected two residents (#34 and #680) of 18 residents whose medical records were reviewed. Findings include: 1. Record review of Resident #34 revealed a re-entry date of [DATE]. Diagnoses included (congestive) heart failure, amputation of right toes, and infectious disease. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, required extensive assistance of two staff for bed mobility and transfers, and was totally dependent on two staff for toilet use. Resident #34 was always incontinent of bowel and bladder and was not on isolation precautions. Review of the nursing notes dated [DATE] at 4:19 P.M. revealed Resident #34 was acting slightly sluggish and eating little. The physician was notified of his condition and tests were ordered including a stool sample. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview and record review the facility failed properly alert staff, visitors and other residents to see nursing staff prior to entering the room of Resident #117, who was on isolation precautions. This affected one of two residents reviewed for isolation precautions. Finding include: Record review for Resident #117 revealed an admission date of 01/28/20 with diagnosis of a dementia, depression, high blood pressure and malnutrition. The admission Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #117 was cognitively impaired and required extensive assistance from staff for bed mobility, transfers and toileting. The resident was incontinent of bowel and bladder. Review of February 2020 physician orders revealed an order dated 02/17/20 for Vancomycin, an antibiotic, for clostridium difficile (C. diff) infection, a highly contagious infection which causes diarrhea and inflammation of the colon. Observation on 02/18/20 at 9:30 A.M. of Resident #117's room revealed a cart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.