O'Neill Healthcare Middleburg Heights

In the surveyor’s words

From the most serious findings on record at O'Neill Healthcare Middleburg Heights, in the surveyor’s own words.

• Immediate jeopardy, isolatedF690Oct 29, 2024

  Based on closed medical record review, Emergency Medical Service (EMS) run sheet review, hospital record review, review of Medscape guidance, facility policy review and interview, the facility failed to ensure comprehensive monitoring and timely identification of a change in Resident #80's condition related to the use of an indwelling urinary catheter. This resulted in Immediate Jeopardy, actual harm and subsequent death beginning on [DATE] at approximately 7:00 A.M. when Resident #80 had decreased urine output with only a total of 200 milliliters (ml) over three nursing shifts. […]

• No harm, potential for more than minimal, widespreadF727Dec 27, 2022

  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.

• No harm, potential for more than minimal, isolatedF695Dec 4, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF689Jul 6, 2023

  Based on interview and record review, the facility failed to ensure appropriate fall interventions were used for Resident #100. This affected one of one resident reviewed for neglect. The facility census was 69 Findings include: A record review for Resident #100 revealed he was admitted on [DATE] with diagnoses of dementia, metabolic encephalopathy, history of urinary tract infections (UTI), and hypotension. His care plan dated 04/20/23 revealed he was at increased risk of falls. […]

• No harm, potential for more than minimal, isolatedF761Dec 27, 2022

  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 admitted [DATE] 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. […]