Inspection Reports for
O’neill Healthcare Lakewood
1381 BUNTS ROAD, CLEVELAND, OH, 44107
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
196% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 1
Date: Oct 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate care for acute changes in condition for two residents who died.
Complaint Details
This deficiency represents noncompliance investigated under Complaint Number 2621899.
Findings
The facility failed to provide appropriate treatment and care according to orders and standards for Residents #116 and #123, both of whom died. Deficiencies included improper CPR procedures, lack of rescue breathing, absence of an Ambu bag on the crash cart, and inconsistent staff responses during emergency codes.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences for Residents #116 and #123 who experienced acute changes in condition and died. CPR was not performed according to American Heart Association guidelines, including lack of rescue breathing and improper chest compressions. The crash cart was missing an Ambu bag, preventing proper ventilation during resuscitation attempts.
Report Facts
Residents affected: 2
Facility census: 106
CPR rounds performed: 3
Oxygen liters per minute: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #515 | Registered Nurse | Performed CPR on Resident #116 and called 911; noted for stopping compressions after three rounds without rescue breathing |
| LPN #507 | Licensed Practical Nurse | Assessed Resident #116 during code and assisted with pronouncement |
| RN #460 | Registered Nurse | Nurse assigned to Resident #123 during code; initiated CPR and called 911 |
| LPN #425 | Licensed Practical Nurse | Brought crash cart during Resident #123 code; performed chest compressions incorrectly |
| LPN #484 | Licensed Practical Nurse | Performed chest compressions on Resident #123; noted absence of Ambu bag |
| LPN #512 | Licensed Practical Nurse | Assisted with compressions during Resident #123 code; reported concerns about CPR quality |
| CNA #401 | Certified Nursing Assistant | Found Resident #116 unresponsive and notified RN #515 |
| CNA #409 | Certified Nursing Assistant | Found Resident #123 unresponsive and notified RN #460; assisted with CPR |
| CNA #505 | Certified Nursing Assistant | Assisted with compressions during Resident #123 code; reported concerns about CPR quality |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 1
Date: Aug 27, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about appropriate incontinence care for residents.
Complaint Details
This deficiency represents noncompliance investigated under Complaint Number 2577547.
Findings
The facility failed to ensure appropriate incontinence care for Resident #87, including not using soap or approved cleaning products during care. This noncompliance was confirmed through observation, record review, and staff interview.
Deficiencies (1)
F 0690: The facility failed to provide appropriate incontinence care for Resident #87 by not using soap or approved cleaning products during care, contrary to facility policy. This affected one resident of three reviewed for incontinence care.
Report Facts
Residents reviewed for incontinence care: 3
Total census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #501 | Observed and interviewed regarding incontinence care procedure for Resident #87 |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Date: May 14, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to ensure a resident's advance directives were concise and readily retrievable for staff.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00164259.
Findings
The facility failed to ensure Resident #100's advance directives were clear and accessible. The resident's code status was inconsistent between hospital paperwork and facility forms, with an undated DNRCCA form signed by a physician.
Deficiencies (1)
F 0578: The facility failed to honor the resident's right to request, refuse, or discontinue treatment and to formulate an advance directive. Resident #100's advance directives were not concise or readily retrievable, with conflicting code status documentation.
Report Facts
Facility census: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Corporate Registered Nurse (CRN) #202 | Interviewed regarding Resident #100's DNRCCA status |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 4
Date: May 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about resident rights, admission assessments, nutrition, and physician follow-up for wound care.
Complaint Details
The deficiencies were identified during a complaint investigation under Complaint Number OH00153495 and involved issues with resident rights, admission assessments, nutrition, and physician services.
Findings
The facility failed to ensure blood draws were conducted in private, complete accurate admission assessments, provide diet orders and baseline height and weight, and ensure physician follow-up for a complicated wound. These deficiencies affected specific residents and were substantiated during the complaint investigation.
Deficiencies (4)
F 0550: The facility failed to ensure Resident #9 had her blood drawn in a private area, as blood was drawn in the hallway contrary to policy.
F 0636: The facility failed to complete an accurate admission assessment for Resident #97, omitting documentation of an abdominal wound, colostomy site, pain assessment, and height and weight.
F 0692: The facility failed to provide a diet order or baseline height and weight for Resident #97 during his stay.
F 0710: The facility failed to provide wound physician follow-up for Resident #97's complicated abdominal wound as ordered on admission.
Report Facts
Facility census: 95
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Phlebotomist #621 | Named in blood draw privacy deficiency | |
| Registered Nurse (RN) #563 | Named in blood draw privacy deficiency | |
| Corporate Registered Nurse (RN) #623 | Named in admission assessment, nutrition, and physician follow-up deficiencies | |
| Dietary Manager #531 | Named in nutrition deficiency | |
| Administrator | Interviewed regarding deficiencies |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 1
Date: Feb 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide proper training and education on insulin administration to Resident #98's representative during discharge planning.
Complaint Details
This deficiency represents non-compliance investigated under Master Complaint Number OH00149727 and Complaint Number OH00149724.
Findings
The facility failed to provide adequate training and instructions on insulin pen use to Resident #98's family when the resident was discharged against medical advice. Resident #98 exhibited combative and exit-seeking behaviors, and the family was not properly educated on insulin administration, posing a risk to the resident's safety.
Deficiencies (1)
F 0660: The facility failed to provide Resident #98's representative proper training and education on insulin administration to ensure a safe and orderly discharge. This affected one resident out of three reviewed for discharge planning.
Report Facts
Facility census: 96
Residents affected: 1
Residents reviewed for discharge planning: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #503 | Licensed Practical Nurse | Named in relation to failure to provide insulin pen training and involvement in Resident #98's discharge |
| NP #603 | Nurse Practitioner | Involved in providing orders and evaluation related to Resident #98 |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident #98's behavior and discharge |
| Administrator | Administrator | Notified about Resident #98's situation and discharge |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 1
Date: Sep 28, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to use a gait belt during resident transfers as required by care plans and facility policy.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00146146.
Findings
The facility failed to use a gait belt when transferring Resident #30, despite care plans and facility policy requiring its use. This non-compliance was confirmed through observation, interviews, and record reviews.
Deficiencies (1)
F 0684: The facility failed to transfer Resident #30 using a gait belt as required by care plans and facility policy. This affected one resident and posed minimal harm or potential for actual harm.
Report Facts
Facility census: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| State Tested Nursing Assistant (STNA) #465 | Observed transferring Resident #30 without a gait belt and confirmed non-use | |
| Director of Nursing (DON) | Interviewed regarding gait belt policy and staff compliance |
Inspection Report
Census: 96
Deficiencies: 4
Date: Aug 31, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident funds, advanced directives, food safety, and environmental cleanliness at the nursing home.
Findings
The facility failed to return resident funds timely, did not ensure advanced directives were documented properly, failed to store and label food appropriately, and did not maintain clean privacy curtains and carpeting. These issues affected multiple residents and posed potential risks.
Deficiencies (4)
F 0569: The facility failed to ensure resident funds were returned to the resident or estate in a timely manner, affecting one resident. Resident funds were delayed for approximately 19 months after discharge.
F 0578: The facility failed to ensure advanced directives were present in the electronic medical record and lacked physician orders for code status for one resident. The facility did not implement its advance directive policy.
F 0812: The facility failed to ensure food was labeled, dated, and stored properly, with open and moldy food items found in storage areas. This had the potential to affect all residents receiving meals.
F 0921: The facility failed to maintain clean privacy curtains and carpeting, with stained curtains and worn carpeting observed. This had the potential to affect all 96 residents.
Report Facts
Residents affected: 96
Resident funds balance: 2931.95
Residents with privacy curtain issues: 15
Residents receiving no food by mouth: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Accounts Receivable Coordinator (ARC) #914 | Confirmed delay in returning resident funds | |
| Licensed Practical Nurse (LPN) #844 | Confirmed advanced directive documentation requirements | |
| Dietary Manager (DM) #806 | Verified food storage and labeling deficiencies | |
| Director of Nursing (DON) | Verified carpet replacement due to stains | |
| State Tested Nurse Assistants (STNAs) #887 and #900 | Verified stained privacy curtains | |
| Office Staff (OS) #944 | Verified cleaning schedules and environmental observations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 13, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to injuries sustained by a resident during mechanical lift transfers.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Numbers OH00140820, OH00140819, OH00140818, and OH00135604.
Findings
The facility failed to ensure residents were transferred via mechanical lift without injury, affecting one resident who sustained an abrasion on the left arm likely caused by the mechanical lift sling. The facility initiated an investigation and provided staff training on transfers and injury reporting.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents. One resident sustained an abrasion on the left arm during mechanical lift transfer.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #161 | Registered Nurse | Interviewed regarding family observation of resident wound. |
| Licensed Practical Nurse #154 | Licensed Practical Nurse | Observed resident's arm condition during transfer. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 30, 2020
Visit Reason
The inspection was conducted to investigate complaints regarding failure to promptly notify the physician and provide appropriate care for Resident #15's nosebleeds, and failure to provide physician-ordered pressure ulcer care for Resident #82.
Complaint Details
The complaint investigation focused on Resident #15's untreated and undocumented nosebleeds and Resident #82's lack of pressure ulcer care. The complaints were substantiated based on observations, interviews, and record reviews confirming failures in care and documentation.
Findings
The facility failed to promptly notify the physician and document assessments related to Resident #15's nosebleeds, despite multiple observations and staff interviews confirming the incidents. The facility also failed to provide and apply physician-ordered heel protectors for Resident #82's stage II pressure ulcer, as verified by observations and staff interviews.
Deficiencies (3)
F 0580: The facility failed to promptly notify the physician of Resident #15's nosebleeds and document assessments, despite multiple occurrences and staff awareness.
F 0684: The facility failed to provide appropriate care and services for Resident #15's nosebleeds, including assessment and physician notification, as required by the care plan and physician orders.
F 0686: The facility failed to utilize physician-ordered pressure relieving heel protectors for Resident #82, resulting in inadequate pressure ulcer care.
Report Facts
Residents reviewed for unnecessary medications: 5
Residents affected by deficiencies: 1
Residents affected by pressure ulcer deficiency: 1
Stage II pressure ulcer measurement: 4
Stage II pressure ulcer measurement: 3
Stage II pressure ulcer measurement: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #201 | Witnessed Resident #15's nosebleeds and confirmed lack of documentation and physician notification. | |
| Housekeeper #202 | Witnessed Resident #15's nosebleeds on different occasions. | |
| State Tested Nursing Assistant (STNA) #203 | Confirmed Resident #15 had occasional nosebleeds caused by picking. | |
| Unit Manager Registered Nurse (UMRN) #204 | Confirmed expectations for documentation and physician notification for Resident #15's nosebleeds and verified lack of documentation. | |
| Director of Nursing (DON) | Verified expectations for care, documentation, and physician notification for Resident #15's nosebleeds and confirmed physician contact on 01/30/20. | |
| State Tested Nurse Assistant (STNA) #210 | Did not apply heel protectors to Resident #82 as ordered. | |
| Registered Nurse (RN) #211 | Verified Resident #82 did not have physician-ordered heel protectors in place. |
Inspection Report
Annual Inspection
Census: 89
Deficiencies: 7
Date: Nov 8, 2018
Visit Reason
Annual inspection survey conducted to assess compliance with healthcare regulations and standards at O'Neill Healthcare Lakewood nursing home.
Findings
The facility was found deficient in multiple areas including failure to prevent hiring staff with assault convictions, incomplete significant change assessments, inadequate fall prevention interventions, improper nutritional and therapeutic diet management, incomplete resident documentation, infection control lapses during wound care and catheter management.
Deficiencies (7)
F 0606: The facility failed to prevent hiring a State Tested Nurse Aide convicted of assault, affecting one of eight staff reviewed and potentially impacting 89 residents.
F 0637: The facility failed to complete a Significant Change assessment within 14 days for Resident #6 admitted to hospice care, affecting one of five residents screened for hospice.
F 0689: The facility failed to ensure adequate supervision and fall prevention interventions for Residents #34 and #38, resulting in multiple falls without proper staff response or evaluation.
F 0803: The facility failed to follow the menu for pureed diets, serving insufficient portions of puree cornbread dressing and wheat roll, affecting six residents on pureed diets.
F 0808: Resident #68 was served thin-consistency liquids instead of physician-ordered nectar-thickened liquids, risking aspiration.
F 0842: The facility failed to maintain accurate and complete medical records for Residents #38, #41, and #49, including documentation of medication use, hospital transfers, and resident death.
F 0880: Infection control practices were inadequate during a dressing change for Resident #7 and catheter care for Resident #38, risking infection transmission.
Report Facts
Facility census: 89
Staff reviewed for criminal record screening: 8
Residents screened for hospice services: 5
Residents reviewed for falls: 5
Residents on pureed diet affected: 6
Residents who ate in second-floor dining room: 14
Calories lacking in puree diet meal: 118
Carbohydrates lacking in puree diet meal: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #502 | State Tested Nurse Aide | Named in finding for hiring despite assault conviction |
| Human Resources Director #5 | Human Resources Director | Interviewed confirming hiring violation |
| LPN #20 | Licensed Practical Nurse | Interviewed regarding lack of Significant Change assessment |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding fall investigations and other findings |
| STNA #500 | State Tested Nursing Assistant | Involved in resident altercation and fall incident |
| LPN #501 | Licensed Practical Nurse | Provided statement on resident incident and catheter observation |
| RN #12 | Registered Nurse | Observed performing dressing change with infection control lapses |
| Dietary Manager #2 | Dietary Manager | Interviewed regarding pureed diet serving sizes |
| DTR #19 | Dietetic Technician, Registered | Interviewed regarding nutritional adequacy of pureed diet |
| STNA #16 | State Tested Nurse Aide | Observed and interviewed regarding incorrect liquid consistency served |
| Dietary Manager #7 | Dietary Manager | Verified incorrect liquid consistency served to Resident #68 |
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