Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at O'neill Healthcare Middleburg Heights during CMS and state inspections, most recent first.
Undated Oxygen Tubing for Two Residents: The facility failed to ensure oxygen tubing was dated for two residents receiving O2 therapy. One resident had acute respiratory failure with hypoxia and hypertensive heart disease, and the other had CHF, hypoxemia, and COPD. During observation, staff confirmed the tubing for both residents was not dated, despite physician orders requiring weekly tubing changes and dating/initialing of new tubing.
A resident with a history of UTIs and heart disease experienced decreased urine output over three shifts, but the nursing staff failed to assess the condition or notify the physician. The resident was later diagnosed with a UTI and septic shock at the hospital, leading to their death. Interviews revealed a lack of protocol and failure to follow facility policy on monitoring and documenting urine output.
Undated Oxygen Tubing for Two Residents
Penalty
Summary
The facility failed to ensure oxygen tubing was dated for two residents receiving oxygen therapy. Resident #76 was admitted with acute respiratory failure with hypoxia and hypertensive heart disease and had a physician order for oxygen at 2 liters per minute via nasal cannula continuously, with the tubing to be changed weekly on Sunday. During observation, Resident #76’s oxygen tubing was not dated, and an LPN confirmed this at the time of the observation. The resident’s MDS showed a BIMS score of 06 out of 15, indicating impaired cognition, and the care plan identified altered respiratory status/difficulty with oxygen therapy included per physician order. Resident #36 was admitted with CHF, hypoxemia, and COPD and had a physician order for oxygen tubing to be changed weekly every Thursday, with the tubing dated and initialed when replaced. During observation, Resident #36’s oxygen tubing was not dated, and an RN confirmed this at the time of the observation. The resident’s MDS showed a BIMS score of 14 out of 15, indicating intact cognition, and the care plan identified altered respiratory status/difficulty with oxygen therapy included per physician order. The facility policy titled Respiratory Therapy Equipment stated oxygen cannula and tubing would be changed as necessary.
Failure to Monitor Urinary Catheter Leads to Resident's Decline
Penalty
Summary
The facility failed to ensure comprehensive monitoring and timely identification of a change in condition for a resident with an indwelling urinary catheter. The resident, who had a history of UTIs, low back pain, hematuria, urinary retention, and heart disease, experienced decreased urine output over three nursing shifts, totaling only 200 ml. Despite this significant decrease, the nursing staff did not conduct a comprehensive assessment or follow up with the STNA staff regarding the resident's urine output. Additionally, the nursing staff failed to notify the physician about the resident's low urine output. The resident's condition deteriorated, and the family requested a transfer to the emergency room. Upon arrival at the hospital, the resident was found to have a firm abdomen, abdominal distension, and pain, with the indwelling catheter draining dark, thick, purulent urine after being replaced. The resident was diagnosed with a UTI and septic shock, which led to hospitalization and subsequent discharge to an inpatient hospice center, where the resident later expired. The cause of death was noted as bacteremia due to septic shock and heart disease. Interviews with facility staff revealed a lack of protocol for handling low or no urinary output and a failure to take appropriate actions such as flushing the catheter or notifying the physician. The staff assumed the family had emptied the catheter bag, and there was no documentation of issues with the catheter or decreased urine output. The facility's policy required monitoring and documentation of urine output and characteristics, but these were not adequately followed, contributing to the resident's decline.
Removal Plan
- The facility identified two charge nurses, LPN #307 and LPN #308 who failed to identify the resident's condition and assess Resident #80 appropriately and timely. LPN #307 and LPN #308 received disciplinary action and education regarding urinary devices, output monitoring, resident assessments, interventions, notification to family and physician, and documentation.
- STNA #315 and STNA #312 were identified as the STNAs involved in Resident #80's care. STNA #315 and STNA #312 were educated on notification of change in resident urine output including amount, color, odor, or complaints of pain from resident.
- RDCS #325 provided education to the DON regarding urinary devices, output monitoring, resident assessments, interventions, notifications to family and physician/nurse practitioner (NP) and documentation. Education was completed to include monitoring of resident with urinary devices related to change in urinary output (decreased ml out, change in characteristics such as color/odor), completing focused urinary assessment (obtaining vital signs, checking abdomen for distention/tenderness, asking resident if any complaints of pain in abdomen, flank, or back, checking condition of catheter drainage for tubing for clot, kinks, sediment, and initiating interventions as needed. The DON educated the two Unit Managers (LPN #301 and #309) on the same above topics. The DON and Unit Managers educated all 26-nursing staff on the above topics.
- The facility identified seven residents (#17, #42, #45, #47, #55, #57, and #62) with urinary devices. The DON assessed the seven residents for signs and symptoms of dehydration, urine output outside of resident baseline parameters, and complaints related to urinary status, and reviewed their medical records. Residents #17, #42, #57, and #62 were stable and no interventions were indicated. Residents #45, #47, and #55 had no urine output documented, and a physician order was obtained to document urine output on each shift. Residents #45, #47, and #55 had sufficient urine output and no other interventions were indicated.
- The DON/Unit Managers educated all 31 STNAs on urinary devices, output monitoring, and notification to the charge nurse of any observed change in resident's baseline status.
- An ad hoc Quality Assurance and Performance Improvement (QAPI) was held to review the findings of Resident #80's change in condition and decreased urine output.
- The DON/designee would review all new physician orders and notes to ensure any change in condition or potential risk of infection were addressed appropriately and notifications were completed. Audits would be completed daily for four weeks and randomly thereafter for a total of four months to ensure appropriate assessment, documentation, and notification.
- The DON/designee would complete audits on all residents with an indwelling urinary catheter weekly for a period of four weeks and randomly thereafter for a total of four months to ensure appropriate assessment, documentation and notification. This audit would include physical assessment of catheter, documentation review of urine output, monitoring of signs and symptoms of infection including urine color being collected. All findings will be reviewed by the QAPI committee with the Medical Director weekly (if necessary) or on a monthly basis.
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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 Middleburg Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkside Villa | 0.3 mi | ★★★★★ | 0 | 0 |
| Hopkins Rehabilitation And Care Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Aristocrat Berea Healthcare And Rehabilitation | 1 mi | ★★★★★ | 5 | 0 |
| Northwestern Healthcare Center | 1.5 mi | ★★★★★ | 30 | 1 |
| Berea Center | 1.8 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.