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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at O'neill Healthcare North Olmsted during CMS and state inspections, most recent first.
The facility did not consistently update individualized care plans or implement new fall prevention interventions after multiple residents experienced falls, including incidents with injuries. Post-fall investigations were incomplete, lacking root cause analysis and witness statements, and immediate interventions were not always documented or added to care plans. Staff interviews confirmed inconsistent investigation practices and delays in updating care plans for residents at high risk for falls.
Several residents and their representatives were not given the federally required 30-day period to rescind binding arbitration agreements, instead being limited to 21 days as stated in the facility's documentation. This was confirmed through record review and staff interviews, affecting multiple residents who signed these agreements.
A resident with severe cognitive and physical impairments, dependent on staff for all ADLs and transfers, was not assisted out of bed as required by their care plan. Despite having a care plan specifying use of a mechanical lift and two staff for transfers to a wheelchair, the resident remained in bed for several days, with staff interviews confirming no medical reason for this inaction.
A resident with multiple medical conditions did not receive a timely referral or appointment for cataract surgery as recommended by an ophthalmologist. Despite documentation of the need for follow-up, the facility did not schedule the necessary appointment, and staff confirmed the delay during interviews.
A resident with limited mobility and multiple medical conditions did not receive pressure ulcer dressings as ordered on several occasions. Despite physician orders for specific wound care interventions, documentation and staff interviews confirmed that treatments were missed, and the resident developed a deep tissue injury in addition to an existing wound. Facility protocols for wound care and monitoring were not followed.
A resident with multiple chronic conditions was evaluated by a consultant dentist for mouth pain, who recommended a referral to an Oral Maxillofacial Surgeon. Despite this, staff did not schedule the necessary follow-up dental appointment in a timely manner after being made aware of the need.
Surveyors found that three residents requiring enhanced barrier precautions (EBP) due to intravenous access, Foley catheter, or wounds did not have appropriate PPE or signage in place as ordered. The DON confirmed EBP was not implemented at the time of observation, and EBP for one resident was only started after the survey began, despite facility policy and CDC guidance requiring these precautions.
Three residents with complex medical conditions were not assessed for or offered influenza and/or pneumococcal vaccines, and their records lacked required documentation of vaccine assessment, consent, or refusal, despite facility policy mandating these actions.
Three residents with complex medical conditions were not timely offered the COVID-19 vaccine, as required by facility policy. Documentation was incomplete or missing, with unsigned or absent consent forms and no evidence in the medical records that the vaccine was offered. These deficiencies were confirmed by a unit manager during interviews.
A resident with a history of falls and a right leg fracture was admitted to the facility. Despite being instructed on the use of the call light, the resident was not fully oriented and was frequently incontinent. Observations revealed the call light was out of reach, and there was no bedside table, compromising her safety. The resident was found attempting to get out of bed, unaware of the call light's location. A staff member confirmed these observations and provided a call pendant, acknowledging the need for a bedside tray table.
Failure to Update Care Plans and Conduct Thorough Fall Investigations
Penalty
Summary
The facility failed to ensure individualized care plan interventions were developed, updated, and implemented following falls for multiple residents, and did not conduct thorough post-fall investigations with root cause analysis. For one resident with a history of falls and moderate cognitive impairment, repeated falls occurred, including incidents resulting in wrist fractures, without evidence of new fall prevention interventions being added to the care plan or thorough investigations being completed. Staff interviews confirmed that witness statements were not consistently obtained, and care plans were not updated after each fall, despite the resident being identified as high risk for falls and requiring assistance with ambulation and toileting. Another resident with hemiplegia, diabetes, and mild cognitive impairment experienced multiple falls over the course of a year. The care plan and fall interventions were not consistently updated to reflect new interventions identified after each fall, and some interventions were delayed in being added to the care plan. Fall investigations lacked witness statements, and immediate interventions were not always documented or incorporated into the resident's care plan in a timely manner. Staff interviews confirmed that fall investigations were often verbal and not thoroughly documented. A third resident with severe cognitive impairment and multiple comorbidities experienced an unwitnessed fall resulting in a head injury. The post-fall assessment did not identify a root cause, and there were no witness statements or comprehensive investigation documented. The facility's policy required individualized interventions and thorough investigation after each fall, but these procedures were not consistently followed for the residents reviewed.
Failure to Provide Required 30-Day Rescission Period for Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed of their right to rescind a binding arbitration agreement within the federally required 30 calendar days after signing. Instead, the arbitration agreements provided to residents specified only a 21-day period for rescission. This deficiency was identified through a review of the arbitration agreements for four residents, all of whom had signed agreements that did not comply with the 30-day rescission requirement. The facility had a total of 33 residents who had agreed to binding arbitration upon admission, and the census at the time was 57. Interviews with the Admissions Director confirmed that the arbitration agreement in use was last revised in 2021 and that the agreements for the affected residents all stated a 21-day rescission period. Upon review of the relevant regulation, the Admissions Director acknowledged that the agreements should have allowed for a 30-day rescission period, as required. The deficiency was based on direct review of resident records and facility documentation, as well as staff interviews.
Failure to Assist Dependent Resident with Out-of-Bed Transfers
Penalty
Summary
Staff failed to provide necessary assistance to a resident with severe physical and cognitive impairments, resulting in the resident not being assisted out of bed as required by their care plan. The resident, who had a history of cerebral infarction with hemiplegia/hemiparesis, diabetes, intracardiac thrombosis, peripheral vascular disease, hypertensive heart disease, chronic atrial fibrillation, vitreous degeneration, and aphasia, was assessed as being dependent on staff for all activities of daily living, including transfers and mobility. The care plan specified that the resident should be encouraged to be out of bed using a mechanical lift and with the assistance of two staff members for transfers to a tilt-in-space wheelchair. Despite these documented needs and interventions, multiple observations over several days revealed that the resident remained in bed and was not assisted into their wheelchair. Interviews with nursing and therapy staff confirmed that the resident had not been assisted out of bed since discharge from skilled therapy services, and there was no medical reason preventing the resident from being mobilized. The facility's policy required staff to provide assistance with activities of daily living, including transfers, for residents unable to perform these tasks independently, but this was not followed in the resident's case.
Failure to Schedule Cataract Surgery Referral for Resident
Penalty
Summary
The facility failed to ensure that a resident received timely follow-up for vision care as recommended by a specialist. The resident, who had multiple diagnoses including acute kidney injury, type 2 diabetes mellitus, major depressive disorder, anxiety, insomnia, muscle weakness, and cervicalgia, was seen by an ophthalmologist who recommended a cataract evaluation and possible surgery. Documentation in the medical record showed an order for referral to an ophthalmologist for cataract surgery, but there was no evidence that the referral was sent or an appointment scheduled. Interviews with the resident and the unit manager confirmed that the surgery had not been scheduled, despite the facility being aware of the need for follow-up since February.
Failure to Complete Pressure Ulcer Dressings as Ordered
Penalty
Summary
The facility failed to ensure that pressure ulcer dressings were completed as ordered for a resident with multiple medical conditions, including limited mobility, obesity, and a history of falls and transient ischemic attacks. The resident was assessed as having moderately impaired cognition and was at low risk for pressure ulcer development according to the Braden scale, but required frequent repositioning and maximum assistance due to spending most of each shift in bed or a chair. Physician orders were in place for wound care, including cleansing and application of triad ointment to wounds on the buttocks and sacral area, with specific instructions for frequency and additional interventions such as use of a low-air loss mattress and regular turning. Despite these orders, review of the Treatment Administration Record (TAR) revealed that wound care treatments were not documented as completed on three separate night shifts. Staff interviews confirmed that the treatments were not applied as ordered on those dates. Observations and medical record reviews further indicated that the resident developed a deep tissue injury (DTI) on the left buttock, classified as a pressure ulcer, in addition to a moisture-associated skin damage (MASD) wound. Facility policy required adherence to physician orders and regular monitoring of wound care, but these protocols were not followed, resulting in a deficiency related to pressure ulcer care.
Failure to Schedule Follow-Up Dental Appointment
Penalty
Summary
The facility failed to ensure that a follow-up dental appointment was scheduled for a resident who required further evaluation. The resident, who had multiple diagnoses including heart failure, morbid obesity, hemiplegia, neuropathy, and other chronic conditions, was seen by a consultant dentist for mouth pain. The dentist recommended a referral to an Oral Maxillofacial Surgeon. Despite this recommendation, the follow-up appointment was not scheduled in a timely manner. The resident reported needing the appointment since January, and staff confirmed that they were aware of the need for the appointment but had not scheduled it promptly.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices and Wounds
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for three residents who were identified as requiring them, as observed during a survey. For one resident with an intravenous midline for antibiotic administration, there was no evidence of EBP, such as signage or personal protective equipment (PPE), at the bedside despite a physician's order for EBP related to intravenous access. The DON confirmed that EBP was not in place at the time of observation and stated that PPE was kept in resident bathrooms and signs were posted on name cards by the doorway, but these measures were not observed in practice. Another resident with a Foley catheter, ordered to have EBP due to the indwelling device, was also observed without appropriate signage or PPE in place. The DON confirmed the absence of EBP for this resident as well. A third resident with wounds, including a deep tissue injury and moisture-associated skin damage, had a care plan and physician order for EBP due to increased risk of multidrug-resistant organism (MDRO) acquisition, but EBP was not initiated until after the survey process began. Facility policy and CDC guidance require EBP for residents with wounds or indwelling devices, but these were not consistently implemented as required.
Failure to Assess and Offer Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that residents were properly assessed for their vaccination status and were offered influenza and pneumococcal vaccines as required. Specifically, three residents with multiple chronic conditions and complex medical histories did not have documentation in their medical records indicating that they were assessed for or offered the influenza and/or pneumococcal vaccines. For one resident, there was no evidence of an influenza vaccination assessment or consent form, nor any documentation that the influenza vaccine was offered for the current season. Another resident's record lacked a completed pneumococcal vaccination assessment and consent form, with no documentation that the vaccine was offered. A third resident's record was missing both pneumococcal and influenza vaccination assessment and consent forms, as well as any documentation that these vaccines were offered. Interviews with the unit manager confirmed the absence of required documentation and the failure to offer the vaccines. Review of facility policies indicated that it is the facility's protocol to offer these vaccines to all residents, provide educational materials, and document consent or refusal in the resident's chart. However, these procedures were not followed for the affected residents, resulting in the identified deficiency.
Failure to Timely Offer and Document COVID-19 Vaccination to Residents
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccine was timely offered to three residents, as required by policy and regulatory guidance. For one resident, the medical record showed that the COVID-19 vaccine consent form was left unsigned, undated, and incomplete, with no evidence that the vaccine was offered. For a second resident, there was no documentation in the medical record that the COVID-19 vaccination assessment or consent form was completed, nor any indication that the vaccine was offered. For a third resident, both the physical and electronic medical records lacked any COVID-19 vaccination assessment, consent form, or documentation that the vaccine was offered. These findings were confirmed through interviews with a unit manager, who acknowledged the absence of required documentation and the failure to offer the vaccine as per facility policy. The residents involved had complex medical histories, including conditions such as diabetes, heart failure, kidney disease, stroke, dementia, and other chronic illnesses. The facility's infection control policy referenced adherence to CDC and APIC guidelines but was not followed in these cases.
Failure to Accommodate Resident Needs and Ensure Safety
Penalty
Summary
The facility failed to provide appropriate and reasonable accommodations for Resident #63, which compromised her safety. Resident #63 was admitted with a history of falling, a nondisplaced fracture of the right leg, polyarthritis, and COPD. Upon admission, she was oriented to her room and instructed on the use of the call light. However, she was not fully oriented to her surroundings and was frequently incontinent. She was also instructed not to bear weight on her right leg. Despite these conditions, the resident's call light was found on the floor behind her bed, out of her reach, and there was no bedside table available in her room. Additionally, a pitcher of water was also on the floor, further indicating a lack of proper accommodations. During an observation, Resident #63 was seen attempting to get out of bed with her left foot on the floor, while her right leg, which was in a brace, remained in bed. She expressed that she needed help but was unaware of the call light's location. A staffing coordinator confirmed these observations and subsequently placed a call pendant around the resident's neck, acknowledging that the resident was a new admission and needed a bedside tray table. This situation highlights the facility's failure to ensure the resident's needs were reasonably accommodated, as evidenced by the lack of accessible call light and necessary bedside equipment.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,053 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near North Olmsted
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gardens Of North Olmsted | 1.1 mi | ★★★★★ | 27 | 0 |
| Berea Center | 2.3 mi | ★★★★★ | 0 | 0 |
| O'neill Healthcare Fairview Park | 2.4 mi | ★★★★★ | 0 | 0 |
| Joshua Tree Care Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Health Center At The Renaissance | 2.7 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for O'neill Healthcare North Olmsted.
100% money-back within 48 hours.
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.