Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at O'neill Healthcare Lakewood during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of dementia and other medical conditions was sent alone to an outside VA medical appointment without an escort or spokesperson, despite facility practice of normally sending escorts with such residents. The facility had no documentation of the outing, did not maintain records of assigned escorts for past appointments, and the resident was unable to meaningfully participate in the visit, being oriented only to name and unaware of the reason for the appointment. Facility leadership and nursing staff confirmed the lack of escort and the resident’s limited cognition, leading to the cited deficiency.
Surveyors found that the facility failed to follow its infection prevention and control program when a resident with confirmed Influenza A, on droplet precautions and with cognitive impairment, was sent unaccompanied to a VA appointment without advance verbal notice to the receiving provider of the resident’s flu and isolation status, contrary to facility policy to limit transport for residents on droplet precautions. In a separate incident, another resident with stage 4 pressure injuries under ordered enhanced barrier precautions had wound care performed by an LPN who did not wear a gown during the high-contact dressing change, despite posted EBP signage and a written policy requiring gown and glove use for wound care.
Two residents with complex medical conditions experienced acute changes in condition and were not provided with appropriate CPR according to facility policy and AHA guidelines. In one case, a nurse performed only chest compressions without rescue breathing and stopped before EMS arrived. In the other, staff failed to provide ventilations due to a missing Ambu bag on the crash cart, and chest compressions were initially performed incorrectly. Both cases involved lapses in emergency response and equipment readiness.
A resident with dementia and incontinence did not receive proper incontinence care when a CNA used only water and towels, omitting soap or approved cleansers as required by facility policy. The CNA incorrectly believed the resident had allergies to soap, but no such restriction was documented in the medical record.
A resident's advance directives were not concise or readily retrievable for staff, resulting in conflicting documentation between hospital paperwork and facility records. The resident's chart included both a Full code status from the hospital and an undated DNRCCA form signed by a physician, leading to confusion among staff and family regarding the resident's code status.
A resident with moderate cognitive impairment had her blood drawn in the hallway instead of her room, violating privacy and infection control protocols. The phlebotomist misunderstood the RN's instructions, leading to the inappropriate location for the procedure.
The facility failed to complete an accurate admission assessment for a resident, missing documentation on an abdominal wound, colostomy site, and skin assessment despite complaints of pain. The interim care plan and MDS assessment were also incomplete, and the responsible nurse was no longer employed. This deficiency was identified during a complaint investigation.
The facility failed to provide a diet order or baseline height and weight for a resident with multiple diagnoses, including chronic obstructive pulmonary disorder and end stage renal disease. The resident was admitted without a diet order, and the physician's orders and admission assessment lacked necessary dietary and measurement information. Interviews confirmed the absence of an official diet order and baseline measurements, and the facility's policy was not followed.
The facility failed to provide wound physician follow-up for a resident with a complicated abdominal wall wound as ordered on admission. Despite the resident's history of severe medical conditions and the need for wound care, the facility did not arrange for necessary follow-up appointments, and an order for wound care assessment was canceled without explanation.
Failure to Escort Cognitively Impaired Resident to Outside Medical Appointment
Penalty
Summary
The facility failed to provide appropriate supervision and support for a cognitively impaired resident during an outside medical appointment. The resident, admitted with diagnoses including prostate cancer and neuromuscular bladder, had a minimum data set assessment identifying moderate cognitive impairment. There was no facility documentation of the resident going out to an appointment on 12/31/25. Despite this cognitive status, the resident was sent alone to a Veterans Affairs (VA) appointment without an escort or spokesperson. VA staff, including a social worker and RN, reported that the resident arrived unaccompanied, was oriented only to name, did not know why he was there, and was unable to participate in conversation or answer questions beyond his name. Interviews with facility staff, including unit managers, the DON, and the Administrator, confirmed that the resident had limited cognition, that the facility normally sent escorts with cognitively impaired residents, and that no escort accompanied this resident to the appointment. Facility staff also stated they did not maintain a record of assigned escorts for past appointments. VA documentation, including a physician note and social worker note, identified the resident as having a history of dementia and described the appointment as ineffective due to the resident’s inability to exchange substantial information. The Administrator verified that the resident was sent to the appointment with limited cognition and no escort, resulting in the cited deficiency.
Failure to Notify Receiving Provider of Influenza Status and Improper Use of Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not appropriately notifying an outside provider of a resident’s infectious status and not following enhanced barrier precautions during wound care. One resident with prostate cancer, neuromuscular bladder, moderate cognitive impairment, and a documented positive nasal swab for Influenza A was placed on droplet precautions per facility orders. Despite this, the resident was sent unaccompanied to a Veterans Affairs (VA) appointment while still on droplet isolation, with no advance verbal notice to VA staff that he had tested positive for Influenza A. VA staff reported that they were not informed of the resident’s flu status until after the appointment, and facility leadership confirmed that it was not their process to call report before sending residents out and that the resident was sent with paper orders only. The facility’s droplet isolation policy required limiting unnecessary transport of residents on droplet precautions and using masks during essential transport, but there was no documentation of the appointment in the facility record and no evidence that the VA was notified in advance of the resident’s isolation status. A second deficiency involved the facility’s failure to follow its own enhanced barrier precautions (EBP) policy during wound care for a resident with prostate cancer, cerebral palsy, and two stage four pressure sores present on admission that had improved and had no documented current infection. The resident had EBP ordered, and a sign on the door instructed staff to wear a gown and gloves for high-contact activities, including wound care. During an observed wound care procedure, an LPN performed the entire dressing change, including removal of old dressings, wound cleansing, and application of new dressings, without wearing a gown. The LPN confirmed this practice during interview. The facility’s EBP policy required the use of gowns and gloves during high-contact care activities for residents under EBP, including wound care for pressure sores, but this was not followed during the observed procedure.
Failure to Provide Appropriate CPR and Emergency Response for Full Code Residents
Penalty
Summary
The facility failed to provide appropriate care for acute changes in condition for two residents who were full code and subsequently died. In the first case, a resident with multiple complex medical conditions, including end-stage renal disease, congestive heart failure, and chronic respiratory failure, was found unresponsive by a CNA. The RN assessed the resident, found no pulse or vital signs, and initiated chest compressions. However, the RN performed only three rounds of compressions, did not provide rescue breathing, and stopped CPR before EMS arrived, contrary to both facility policy and American Heart Association (AHA) guidelines, which require continuous CPR with compressions and ventilations until advanced help arrives or the resident is pronounced dead by a physician. The RN stated she learned the method of three rounds of compressions from a journal, and the LPN who assisted did not provide rescue breathing either. EMS arrived to find the resident cold, pulseless, and with rigor mortis, and did not initiate further resuscitation. In the second case, another resident with significant comorbidities, including heart failure, COPD, and dependence on dialysis and supplemental oxygen, was found unresponsive by a CNA. The nurse assessed the resident, confirmed the absence of pulse and breathing, and called a code. Staff responded, chest compressions were initiated, and the AED was applied. However, no ventilations were provided during CPR because the crash cart was missing an Ambu bag, which is required for providing manual ventilation. Multiple staff members noted that one LPN was performing compressions incorrectly over the left breast instead of the sternum, and other staff had to take over. The AED advised no shock, and CPR continued until EMS arrived and took over, but the resident could not be revived. Interviews revealed that the crash cart was not fully stocked as required, and staff were unaware of the missing Ambu bag until the code event. Both incidents demonstrated failures to follow established CPR protocols and facility policies, including the requirement for continuous compressions and ventilations for full code residents, proper stocking of emergency equipment, and correct technique during resuscitation. Staff interviews and documentation confirmed that these deficiencies occurred, and that the facility's policies and AHA guidelines were not followed during the response to both residents' acute changes in condition.
Failure to Provide Proper Incontinence Care per Facility Policy
Penalty
Summary
A deficiency was identified when a certified nurse aide (CNA) provided incontinence care to a resident with significant cognitive impairment, dementia, diabetes, and who was always incontinent. During the observed care procedure, the CNA used only water to wet towels and wiped the resident’s perineal area without using any soap or approved cleansing product, contrary to the facility’s incontinence care policy. The CNA then used the dry half of the same towel to dry the area and repeated the process on the resident’s backside. Upon interview, the CNA stated she believed the resident had allergies and could not use soap, but a review of the resident’s chart confirmed there were no listed allergies or orders restricting the use of soap for incontinence care. The facility’s policy required staff to wash affected areas with body wash, cleanser, or soap and water after each incontinence episode, which was not followed in this instance.
Failure to Maintain Clear and Accessible Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directives were clear and easily accessible to staff. Specifically, the medical record for a resident with a history of kidney transplant complications, end stage kidney disease, and diabetes mellitus showed inconsistencies regarding code status. The hospital paperwork indicated the resident was to be Full code, while the advance directive form in the facility's records had DNRCCA selected and was signed by a physician but not dated. Additionally, the form had a hospital sticker, further complicating the clarity of the resident's code status. Interviews with staff and the resident's family confirmed the confusion, as the Corporate Registered Nurse acknowledged the presence of both a Full code hospital document and an undated DNRCCA form. The facility's policy required staff to check the chart for code status, but the lack of a dated, clearly documented directive led to uncertainty. This deficiency was identified during a complaint investigation and affected one resident out of three reviewed for advance directives.
Failure to Maintain Resident Privacy During Blood Draw
Penalty
Summary
The facility failed to ensure Resident #9 had her blood drawn in a private area, compromising infection control and resident dignity. Resident #9, who has diagnoses including Parkinsonism, low back pain, cognitive communication disorder, and bipolar disorder, was observed having her blood drawn in the hallway in front of the nurse's station. This action was contrary to the facility's protocol, which mandates that blood draws occur in the resident's room. The phlebotomist involved misunderstood the instructions given by the RN, leading to the blood draw being conducted in an inappropriate location. Resident #9, who has moderate cognitive impairment and requires extensive assistance for daily activities, confirmed the blood draw occurred in the hallway but was unsure why. The RN clarified that she only helped the phlebotomist identify the resident and did not authorize the blood draw in the hallway. This incident was identified during a complaint investigation and highlights a lapse in maintaining resident privacy and infection control protocols.
Incomplete Admission Assessment for Resident
Penalty
Summary
The facility failed to complete an accurate admission assessment for Resident #97. Upon review of the closed medical record, it was found that the admission assessment did not document the resident's abdominal wound, colostomy site, or a skin assessment despite complaints of pain in the buttocks/coccyx area. Additionally, no height or weight was obtained or documented. The interim care plan noted risks for falls and skin impairment but lacked further details. The admission Minimum Data Set (MDS) assessment also failed to assess the resident's cognition and detailed the resident's extensive assistance needs for bed mobility, eating, and toileting, as well as incontinence and ostomy for bowel elimination. The nurse responsible for the incomplete assessment was no longer employed by the facility at the time of the interview with Corporate RN #623, who confirmed the deficiencies in the admission assessments. The facility's policy on admitting residents required all observed assessment data to be documented, including the resident's height and weight. The failure to adhere to this policy resulted in incomplete and inaccurate documentation for Resident #97, who had significant medical conditions including an unspecified open wound of the abdominal wall, chronic obstructive pulmonary disorder, type two diabetes mellitus, and hypertensive chronic kidney disease with stage five end stage renal disease. This deficiency was identified during an investigation under Complaint Number OH00153495.
Failure to Provide Diet Order and Baseline Measurements for Resident
Penalty
Summary
The facility failed to provide a diet order or baseline height and weight for Resident #97 during his stay. Resident #97, who had multiple diagnoses including an unspecified open wound of the abdominal wall, chronic obstructive pulmonary disorder, type two diabetes mellitus, and hypertensive chronic kidney disease in stage five end stage renal disease, was admitted without a diet order from the hospital. The physician's orders for January 2024 also did not include any diet orders, and the admission assessment lacked height and weight measurements. The interim care plan and dietary communication form listed a regular diet with regular texture and thin liquids, but these were not based on a physician's order. The resident required extensive one-person assistance for eating, as noted in the admission Minimum Data Set (MDS) assessment. Interviews with the Administrator, Corporate Registered Nurse (RN) #623, and Dietary Manager #531 confirmed the absence of an official diet order and baseline height and weight for Resident #97. The facility's policy required the charge nurse to notify the dietary manager of any new admissions and their diet type, but this was not followed. The nurse who authored the dietary communication form without a physician's order was no longer employed by the facility. The deficiency was investigated under Complaint Number OH00153495.
Failure to Provide Wound Physician Follow-Up
Penalty
Summary
The facility failed to provide wound physician follow-up for a complicated abdominal wall wound for Resident #97 as ordered on admission. Resident #97 had a history of an unspecified open wound of the abdominal wall, chronic obstructive pulmonary disorder, type two diabetes mellitus, and hypertensive chronic kidney disease in stage five end stage renal disease. The resident was admitted to the facility with a wound vac to his abdominal wall surgical site, which was later found to be infected and treated with antibiotics. Despite the discharge orders including oral antibiotics and no incision care orders, the facility did not arrange for follow-up appointments with a wound care physician as required. The admission assessment initially indicated no wound issues, but a subsequent skin assessment revealed an abdominal surgical incision that required evaluation by the wound care team. An order was placed for the wound care physician to assess the resident on 01/15/24, but this order was canceled on 01/16/24 without explanation. The facility's policy on wound care was not followed, as the resident did not receive the necessary wound care interventions or referrals to a wound care specialist. The deficiency was confirmed through interviews with the Administrator and Corporate RN, who acknowledged the lack of follow-up and the cancellation of the wound care order prior to the resident's discharge on 01/16/24.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestmont North Nursing Home | 0.3 mi | ★★★★★ | 5 | 0 |
| Enniscourt Nursing Care | 0.3 mi | ★★★★★ | 2 | 1 |
| Rocky River Gardens Rehab And Nursing Ctr | 3.4 mi | ★★★★★ | 7 | 0 |
| Larchwood Care | 3.4 mi | ★★★★★ | 16 | 0 |
| Westpark Healthcare Campus | 3.6 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.