Cycle 1
Health 2024-04-12 · Fire 2024-04-12
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fairview Park, OH
O'neill Healthcare Fairview Park
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
20770 Lorain Road, Fairview Park, OH
(440) 331-0300
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
118
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
O'neill Healthcare
Operator or chain grouping
Approved since
2015-08-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.59
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.46
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.01
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,894
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.12
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.56% · Performance 21.23% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.89
Baseline 5.05% · Performance 5.78% · Measure score 6.89 · Achievement 6.89 · Improvement 0
Total nurse turnover
1.96
Baseline 61.29% · Performance 55.67% · Measure score 1.96 · Achievement 1.96 · Improvement 1.04
Adjusted total nurse staffing
0
Baseline 3.73 hours · Performance 3.12 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.59% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 239 · Observed rate 14.64% · Lower 95% interval 8.71% |
| Discharge to community | 50.35% |
50.57%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 244 · Observed rate 41.39% · Lower 95% interval 44.27% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.98% |
95.27%
2.7 pts better
|
Numerator 194 · Denominator 198 |
| Falls with major injury | 1.01% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 198 |
| Discharge self-care score | 66.13% |
53.69%
12.4 pts better
|
Numerator 82 · Denominator 124 |
| Discharge mobility score | 59.68% |
50.94%
8.7 pts better
|
Numerator 74 · Denominator 124 |
| Pressure ulcers or injuries, new or worsened | 1.01% |
2.29%
1.3 pts better
|
Numerator 2 · Denominator 198 · Adjusted rate 1.01% |
| Healthcare-associated infections requiring hospitalization | 5.78% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 143 · Observed rate 4.9% · Lower 95% interval 3.72% |
| Staff COVID-19 vaccination coverage | 16.15% |
8.2%
7.9 pts better
|
Numerator 21 · Denominator 130 |
| Staff flu vaccination coverage | 20.09% |
42%
21.9 pts worse
|
Numerator 45 · Denominator 224 |
| Discharge function score | 65.32% |
56.45%
8.9 pts better
|
Numerator 81 · Denominator 124 |
| Transfer of health information to provider | 98.28% |
95.95%
2.3 pts better
|
Numerator 114 · Denominator 116 |
| Transfer of health information to patient | 96.77% |
96.28%
0.5 pts better
|
Numerator 60 · Denominator 62 |
| Resident COVID-19 vaccinations up to date | 43.56% |
25.2%
18.4 pts better
|
Numerator 44 · Denominator 101 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.3%
1.1 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 3.1% · Q4 4.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 38.1% |
26.1%
12 pts worse
|
11.4%
26.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 27.3% · Q3 47.5% · Q4 58.3% · 4Q avg 38.1% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
6.2%
2.7 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.1% · Q3 1.9% · Q4 0.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.1% |
25.4%
12.7 pts worse
|
19.6%
18.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.1% · Q2 38.6% · Q3 38.2% · Q4 38.6% · 4Q avg 38.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.4% |
11.5%
8.1 pts better
|
16.7%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 4.5% · Q4 4.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.4% |
7.7%
2.7 pts worse
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 4.2% · Q3 4.3% · Q4 13.6% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.1% |
6.2%
1.1 pts better
|
14.9%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 7.3% · Q3 3.8% · Q4 1.9% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.3% |
21.7%
3.6 pts worse
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 22.4% · Q3 32.3% · Q4 27.5% · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 9.6% |
3.7%
5.9 pts worse
|
5.1%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 14.6% · Q3 7.4% · Q4 4.1% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
78.1%
18.4 pts better
|
81.7%
14.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 97.5% · Q3 98.0% · Q4 94.0% · 4Q avg 96.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
12.5%
1.7 pts better
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 11.6% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.2%
0.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.6% |
75.6%
18 pts better
|
79.7%
13.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
25.1%
1.2 pts better
|
23.9%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 28.6% · Expected 28.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-01-12 · Fire 2022-01-12
5 health deficiencies
Top issue: Environmental (1 deficiency)
14 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2019-03-21 · Fire 2019-03-21
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-12
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-12
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-17
F · Potential for more than minimal harm
2022-01-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-03-30
F · Potential for more than minimal harm
2022-01-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-03-30
F · Potential for more than minimal harm
2022-01-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-05-12
F · Potential for more than minimal harm
2022-01-12
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-03-30
F · Potential for more than minimal harm
2022-01-12
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-03-30
E · Potential for more than minimal harm
2022-01-12
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2022-03-30
E · Potential for more than minimal harm
2022-01-12
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-03-30
E · Potential for more than minimal harm
2022-01-12
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-03-30
E · Potential for more than minimal harm
2022-01-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-03-30
E · Potential for more than minimal harm
2022-01-12
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2022-03-30
E · Potential for more than minimal harm
2022-01-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-03-30
E · Potential for more than minimal harm
2022-01-12
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2022-03-30
E · Potential for more than minimal harm
2022-01-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-03-30
E · Potential for more than minimal harm
2022-01-12
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-03-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-26
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-07-17
E · Potential for more than minimal harm
2024-10-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-09-24
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-10-28
E · Potential for more than minimal harm
2023-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-27
E · Potential for more than minimal harm
2022-01-12
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-03-30
D · Potential for more than minimal harm
2022-01-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-03-30
C · Minimal harm
2022-01-12
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-02-15
F · Potential for more than minimal harm
2019-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-17
E · Potential for more than minimal harm
2019-03-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-04-17
D · Potential for more than minimal harm
2019-03-21
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2019-04-17
D · Potential for more than minimal harm
2019-03-21
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2019-04-17
Penalties and ownership
What sits behind the stars
Ownership
Carlow LLC
5% Or Greater Direct Ownership Interest · Organization
Oneill, John
5% Or Greater Indirect Ownership Interest · Individual
Oneill, Deborah
5% Or Greater Indirect Ownership Interest · Individual
Elliott, Jenna
Contracted Managing Employee · Individual
O'neill Management, LLC
Operational/Managerial Control · Organization
Oneill, Deborah
Corporate Officer · Individual
Oneill, John
Corporate Officer · Individual
Nearby options
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#2
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2-star overall rating with 1-star inspections with 27 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
#3
Rocky River Gardens Rehab And Nursing Ctr
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2-star overall rating with 1-star inspections with $104,742 in total fines with 16 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
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