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 Parkside Villa during CMS and state inspections, most recent first.
Temperature monitoring logs for unit and personal refrigerators and freezers used to store outside foods were not consistently completed as required by facility policy. This deficiency was confirmed by a Registered Dietitian during observation and review of records, potentially affecting all residents receiving food, including those who are NPO.
Multiple residents and staff reported insufficient nursing staff, resulting in long wait times for assistance, unanswered call lights, and delays in getting residents out of bed or providing necessary care. Observations confirmed that some residents were left without help due to lack of staff coverage, and care plans requiring timely assistance were not followed.
Surveyors found that multiple residents dependent on supplemental oxygen had undated oxygen tubing, and staff could not confirm when the tubing was last changed. Despite a facility policy requiring weekly changes and dating of oxygen tubing, this was not consistently followed, as confirmed by observations, interviews, and record reviews.
Staff failed to store medications securely, leaving at least 200 prescription and over-the-counter medications—including creams, injectables, and pills—unsecured in an unlocked staff development room. The room contained medications for discharged residents awaiting return to the pharmacy, and this lapse had the potential to affect 101 independently mobile residents. Facility policy required secure storage accessible only to authorized personnel, which was not followed.
A resident with multiple complex medical conditions did not receive a timely Hemoccult test as ordered by a provider. Documentation showed inconsistent recording of bowel movements and unclear evidence of test completion, with the only result documented more than two weeks after the order. Nursing staff and a nurse practitioner confirmed the delay and lack of timely communication of results, constituting a deficiency in timely laboratory services.
A resident with a history of respiratory and psychiatric conditions, who was dependent for all ADLs but had intact cognition, was repeatedly observed smoking on facility grounds and possessing smoking materials despite the facility's non-smoking policy. Staff interventions and re-education were not effective in ensuring compliance, and the resident continued to access and use smoking materials in violation of facility rules.
A resident with cognitive impairment and dependence on staff for ADLs was found unable to reach her call light, which was observed hanging on the floor while she called out for help. Staff were unaware of her need for assistance, and facility policy requiring call lights to be within reach was not followed.
A resident with significant medical needs and total dependence for ADLs did not receive restorative therapy as ordered, receiving therapy only five times in a month instead of the prescribed frequency. Staff interviews confirmed that restorative aides were frequently reassigned to other duties, resulting in missed therapy sessions.
A resident with dementia and a history of falls, who required staff assistance for transfers, was repeatedly found on the floor after attempting to self-transfer from bed to wheelchair. Staff interviews and observations confirmed that the resident's wheelchair was left within reach, contrary to care plan instructions, and that staff were unaware of the resident's fall until alerted by a surveyor. The facility did not document or implement specific fall prevention interventions as required by its policy.
A resident who was dependent on regular hemodialysis missed a scheduled treatment because there were not enough staff available to assist with getting her out of bed and transporting her to the in-house dialysis unit. Despite attempts by dialysis staff to coordinate with facility staff, the resident was not brought to her appointment, and documentation was later found to be inaccurate regarding her attendance. The facility was responsible for ensuring timely transport to dialysis, as outlined in their agreement with the dialysis provider.
A facility failed to provide a bed hold notice to a resident discharged to the hospital, who had a history of heart transplant and renal disease. The resident did not sign or receive a written copy of the notice, and the facility later claimed they could not meet his needs. The resident intended to return, leaving belongings at the facility, but was not informed in writing about the bed hold policy.
The facility failed to properly label and manage insulin vials, affecting five residents. Open vials were not dated or labeled with the resident's name, and vials for discharged or relocated residents were not removed from medication carts. LPNs confirmed these lapses, which violated the facility's medication storage policy.
The facility failed to test blood glucose levels appropriately for two residents with type two diabetes, leading to non-compliance with physician orders and CDC guidelines. Blood glucose levels were checked after meals instead of before, as required, resulting in incorrect insulin administration.
A resident with type two diabetes received insulin incorrectly when an LPN used a syringe to extract insulin from a KwikPen, contrary to manufacturer guidelines. Despite the facility having a sufficient supply of needles for the KwikPens, the LPN was unaware and used an improper method, risking severe health complications for the resident.
The facility failed to maintain appropriate infection control standards during medication administration. An LPN was observed popping medications into a bare hand instead of a medication cup or gloved hand. The facility did not provide a policy on hand hygiene during medication administration when requested.
Failure to Maintain Required Refrigerator Temperature Logs
Penalty
Summary
The facility failed to ensure that temperature monitoring logs for unit refrigerators and freezers, which are used to store outside foods brought in for residents, were completed as required. Observations and interviews with the Registered Dietitian revealed that temperature logs were missing or incomplete for several units, including Cypress, Juniper, Woods, and Redwood, as well as for personal refrigerators and freezers in specific resident rooms. The logs were only sporadically completed during the month, with some units having no recorded temperatures for extended periods. The facility's policy, revised in February 2023, requires a written record of daily temperatures for cold food storage. At the time of the survey, the Registered Dietitian confirmed that the required temperature monitoring logs were not maintained as stipulated by facility policy. This deficiency had the potential to affect all 115 residents receiving food from the facility kitchen, including twelve residents identified as receiving nothing by mouth (NPO), out of a total census of 142.
Failure to Provide Adequate Nursing Staff for Resident Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple resident and staff interviews, observations, and record reviews. Several residents reported that there were not enough staff, particularly aides, resulting in long wait times for assistance and unanswered call lights. Staff interviews corroborated these concerns, with both CNAs and LPNs stating that staffing levels were insufficient to manage the census and acuity of the residents, especially in units with higher care needs. Specific incidents highlighted the impact of inadequate staffing on resident care. One resident with chronic respiratory failure, diabetes, and impaired mobility was observed calling out for help and unable to reach her call light, which was found out of her reach. The assigned CNA had left, and there was no coverage, leaving the resident without assistance. Another resident with impaired mobility and requiring a mechanical lift reported not being able to get out of bed at her preferred time due to staff shortages. A third resident, who required maximum assistance for ADLs, remained in bed throughout the day despite repeated requests for help, as confirmed by both the resident and a CNA. These findings were based on direct observations, interviews, and review of care plans and MDS assessments, demonstrating that the facility did not ensure sufficient staffing to meet residents' needs for timely assistance with activities of daily living, mobility, and safety. The deficiency was identified during the investigation of multiple complaints and had the potential to affect all residents in the facility.
Failure to Change and Date Oxygen Tubing for Residents Receiving Respiratory Care
Penalty
Summary
The facility failed to ensure that oxygen tubing for residents requiring respiratory care was properly labeled and changed according to facility policy. Observations and interviews revealed that six residents who were dependent on supplemental oxygen had undated oxygen tubing, and staff were unable to confirm when the tubing was last changed. The facility's policy required that oxygen tubing be changed and dated weekly, but this was not consistently implemented. Residents affected had significant medical histories, including chronic obstructive pulmonary disease, respiratory failure, dependence on supplemental oxygen, and other serious respiratory conditions. During observations, residents were found using oxygen tubing that was not dated, and both residents and staff were unable to verify when the tubing had last been replaced. Staff interviews indicated confusion regarding responsibility for changing and dating the tubing, with some staff stating it was the responsibility of nurses, while others indicated the respiratory department was responsible. Review of facility documentation confirmed the existence of a policy mandating weekly changes and dating of oxygen tubing, but this policy was not followed in practice. The deficiency was identified through direct observation, resident and staff interviews, and review of medical records and facility policies, affecting all residents reviewed for respiratory services during the survey.
Unsecured Storage of Medications in Unlocked Room
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were stored in a safe, secure, and proper manner. During an observation, it was found that the staff development room contained seven large boxes and a table full of prescription medication cards for residents who had been discharged, as well as additional medications stacked on the floor. There were also three large bags of medications ready to be returned, and a variety of creams, injectables, breathing treatments, and unused pills, tablets, and capsules. In total, at least 200 separate medications were found unsecured in the room. The Maintenance Supervisor confirmed that the staff development room was unlocked and contained a significant quantity of medications. The DON acknowledged that the room should have been locked and that the medications were awaiting return to the pharmacy for resident credit. Facility policy required that medications be stored safely, securely, and only accessible to authorized personnel, which was not followed in this instance. The unsecured storage of medications had the potential to affect 101 independently mobile residents out of a census of 142.
Failure to Timely Complete and Communicate Physician-Ordered Lab Test
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory testing was completed in a timely manner for a resident with multiple complex medical conditions, including anoxic brain damage, type II diabetes mellitus with chronic kidney disease, dependence on renal dialysis, anemia, malnutrition, and a gastrostomy. The resident was admitted and later discharged during the review period, and required total assistance for toileting, with interventions in place to monitor and report bowel movements. On a specific date, a nurse practitioner ordered a Hemoccult test to be performed with the next bowel movement and for the physician to be notified upon completion, with the order to be carried out every shift until discontinued. Review of the resident's medical record and medication administration records revealed inconsistent documentation regarding the collection and completion of the Hemoccult test. Over the course of several days, nursing notes frequently indicated either no bowel movement or failed to specify whether a sample was obtained. There were multiple shifts where no response was recorded, and the majority of entries either marked the test as not applicable or provided no clear indication of test completion. The only documented result was a negative Hemoccult test recorded more than two weeks after the initial order, with no evidence that the physician was notified of the result in a timely manner. Interviews with nursing staff and the nurse practitioner confirmed that there was no evidence of a Hemoccult test being obtained or resulted until well after the order was placed, and that the result was not timely according to the expectations for such testing. The nurse practitioner specifically stated that a timely result would be within 24 hours of obtaining a sample, and acknowledged that the result obtained was not within this timeframe. This failure to complete and communicate the ordered laboratory test in a timely manner constituted a deficiency in meeting the needs of the resident and potentially affected all residents in the facility.
Failure to Enforce Non-Smoking Policy for Resident
Penalty
Summary
The facility failed to effectively implement its non-smoking policy for a resident with a history of respiratory failure, metabolic encephalopathy, delusional disorder, and visual hallucinations. The resident was assessed as having intact cognition but was dependent for all activities of daily living. Despite being informed of the facility's non-smoking policy prior to admission and during periodic assessments, the resident was observed smoking on facility grounds and in possession of smoking materials, which was against the facility's stated policy. The resident had previously demonstrated non-compliance with the smoking policy, including not smoking only in designated areas and not adhering to correct smoking times. On one occasion, the resident was observed outside the facility in a wheelchair, removing cigarettes and a lighter from her purse and lighting a cigarette. Staff were notified and intervened to educate the resident. Later, the resident was asked by an RN to remove smoking materials from her purse, but she attempted to avoid compliance by leaving the area and denying possession of the materials when approached by a social worker. The facility's policy required informing residents and responsible parties of the non-smoking policy prior to admission and posting the policy within the facility, but these measures were not effectively enforced in this case.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach and accessible, as required by facility policy and the resident's care plan. The resident, who had chronic respiratory failure, type 2 diabetes, cellulitis, cognitive impairment, and was dependent on staff for ADLs, was observed in bed unable to locate or reach her call light. The call light was found hanging on the floor, out of the resident's reach, while she was calling out for help to get out of bed and get dressed. The resident reported she had been trying to find help for a while and was unaware of the call light's location. Staff present at the nursing station were not aware of the resident's need for assistance, and the LPN on duty stated she had just arrived and did not know who was assigned to the resident. Upon entering the room, the LPN confirmed the call light was out of reach and acknowledged it should have been attached to the resident's clothes. Review of facility policy confirmed that call lights are to always be placed within reach of residents, but this policy was not implemented in this instance.
Failure to Provide Ordered Restorative Therapy Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that a resident received restorative therapy as ordered by the physician. The resident, who had diagnoses including chronic respiratory failure with hypoxia, acute kidney failure, tracheostomy care, and malnutrition, was dependent for all activities of daily living and had impaired cognition. The care plan required passive range of motion exercises to be provided six to seven days a week, and the physician order specified passive range of motion to upper and lower extremities three to six times a week. However, documentation showed that the resident only received restorative therapy five times in a 30-day period. Interviews with facility staff confirmed that restorative therapy was not provided as scheduled due to staffing shortages, with restorative aides being reassigned to other duties. The facility's policy required regular screening and supervision of restorative nursing programs, but these were not followed as intended for the resident in question. This deficiency was identified during an investigation under a specific complaint number.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate fall prevention interventions for a resident with dementia, a pressure ulcer, and type 2 diabetes, who was identified as a high fall risk. The resident required staff assistance for activities of daily living and transfers, and her care plan specified that her wheelchair should not be within reach to prevent unsupervised transfers. Despite these documented needs, the resident's wheelchair was repeatedly found at her bedside, enabling her to attempt self-transfers without supervision. On two separate occasions, the resident was found on the floor in her room, having attempted to transfer herself from bed to wheelchair. Staff interviews confirmed that the resident was known to attempt unsupervised transfers and that her wheelchair should have been kept out of reach, but this intervention was not consistently implemented. Observations revealed that staff were unaware of the resident's fall and did not respond until prompted by a state surveyor. Additionally, the facility's fall prevention policy required assessment and documentation of fall risk and implementation of interventions, but there was no documentation of specific interventions related to wheelchair placement in the resident's medical record. The facility failed to follow its own policy and did not ensure adequate supervision or environmental controls to prevent accidents for this high-risk resident.
Missed Dialysis Appointment Due to Insufficient Staffing
Penalty
Summary
A deficiency occurred when a resident who was dependent on dialysis did not receive a scheduled dialysis treatment due to insufficient staffing. The resident, who was alert, oriented, and dependent on staff for activities of daily living, required hemodialysis three times a week as ordered by her physician and documented in her care plan. On the date in question, there was no documentation in the resident's medical record or pre- and post-dialysis treatment forms indicating that dialysis was provided. Interviews with facility and dialysis staff confirmed that the resident missed her dialysis appointment because there were not enough staff available to get her out of bed and transport her to the in-house dialysis unit. The dialysis nurse reported that the CNA assigned to the resident was unable to assist due to a migraine, and no other staff were available to provide the necessary transport. Despite attempts by dialysis staff to coordinate with facility staff, the resident was not brought to her appointment, and the dialysis treatment was missed. Further review revealed discrepancies in documentation, as the Medication and Treatment Administration Record indicated the resident attended dialysis, but this was later confirmed to be inaccurate by the Director of Nursing and dialysis staff. The facility's agreement with the dialysis provider specified that the facility was solely responsible for transporting residents to and from dialysis at scheduled times, and missing or late arrivals could result in missed treatments. The deficiency was substantiated by interviews, record reviews, and facility policy.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice to Resident #170 when he was discharged to the hospital. Resident #170, who had a history of heart transplant, end-stage renal disease, and congestive heart failure, was initially admitted and then readmitted to the facility before being discharged to the hospital, where he later expired. A progress note indicated that a transfer and bed hold notice was signed by a nurse, but there was no evidence that Resident #170 signed the notice or received a written copy. Interviews with facility staff and hospital social workers revealed that the facility did not have Resident #170 sign the bed hold notice, nor did they provide him with a written copy. The hospital social worker reported that the facility initially stated they could not meet his needs and later claimed that the resident chose not to hold the bed, although the resident had left his belongings at the facility and intended to return. The facility's policy on bed hold notices was reviewed, indicating potential situations where a resident may not be eligible for readmission, but it was not followed in this case.
Failure to Properly Label and Manage Insulin Vials
Penalty
Summary
The facility failed to properly label and manage insulin vials in accordance with accepted professional principles. During observations of multiple medication carts, surveyors found open vials of insulin that were not dated as to when they were opened and vials that were not labeled with the resident's name. Additionally, there were several instances where insulin vials for residents who had been discharged or moved to another unit were not removed from the medication carts. This affected five residents who required insulin, specifically residents #18, #27, #85, #105, and #115. Interviews with various Licensed Practical Nurses (LPNs) during the observations confirmed that staff were expected to write the resident's name and the date the insulin vial was opened, and to remove all insulin vials no longer in use from the carts. The facility's policy on medication storage, dated 2018, also required staff to place a date opened sticker on the vial when initially opened. The deficiency was identified under Complaint Number OH00152893.
Failure to Test Blood Glucose Levels Appropriately
Penalty
Summary
The facility failed to test blood glucose levels appropriately for two residents, leading to non-compliance with physician orders and CDC guidelines. Resident #12, who has type two diabetes, joint replacement surgery, and peripheral vascular disease, had a physician order to administer insulin based on blood glucose levels before meals. However, an LPN checked Resident #12's blood glucose level after breakfast, resulting in a reading of 206 and the administration of four units of insulin. The LPN admitted to being late and confirmed that blood glucose levels should be obtained before meals. The facility's policy did not specify the timing for blood glucose testing, which contributed to the deficiency. The Director of Nursing confirmed the correct procedure was to test before meals, aligning with CDC guidance that recommends checking blood glucose before meals and at other specified times. Similarly, Resident #23, who also has type two diabetes, had a physician order to administer insulin before meals and at bedtime. An LPN checked Resident #23's blood glucose level after breakfast, resulting in a reading of 100, which did not require additional insulin. The LPN acknowledged that blood glucose levels should be tested before meals. The Director of Nursing confirmed this procedure, and the facility's policy again lacked specific instructions on the timing of blood glucose testing. The CDC guidance supports testing blood glucose before meals, which was not followed in these instances, leading to the identified deficiency.
Significant Medication Error in Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. Resident #12, who had diagnoses including type two diabetes and required maximal assistance for personal care, was observed receiving insulin incorrectly. The LPN used a syringe to extract insulin from a KwikPen, despite the manufacturer's guidelines explicitly stating that a syringe should not be used as it could lead to an overdose of insulin. This practice was observed even though the facility had a sufficient supply of needles for the KwikPens in the general supply room, indicating a failure in proper medication administration procedures and communication among staff. The deficiency was identified during a medication administration observation where the LPN checked Resident #12's blood glucose level, which was 206, and administered four units of insulin using an incorrect method. The LPN stated that there were no needles for the KwikPens, but an inspection of the supply room revealed that needles were available. The supply clerk confirmed that staff needed to ask or retrieve the needles when they ran out. This incident highlights a significant lapse in following proper medication administration protocols, potentially putting the resident at risk for severe low blood sugar, seizures, or death.
Infection Control Deficiency During Medication Administration
Penalty
Summary
The facility failed to ensure appropriate infection control standards during medication administration. An LPN was observed sanitizing hands, opening the medication cart drawers, and removing bubble packs of medications. The LPN then popped seven medications for a resident into a bare hand. An interview with the LPN immediately after the observation revealed that the pills should have been popped into a medication cup or a gloved hand. The facility did not provide a policy regarding hand hygiene during medication administration when requested.
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 1,235 citations issued within 25 miles in the last 12 months — including the 12 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 Middleburg Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| O'neill Healthcare Middleburg Heights | 0.3 mi | ★★★★★ | 7 | 0 |
| Hopkins Rehabilitation And Care Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Aristocrat Berea Healthcare And Rehabilitation | 1.1 mi | ★★★★★ | 5 | 0 |
| Northwestern Healthcare Center | 1.4 mi | ★★★★★ | 30 | 1 |
| Berea Center | 1.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.