Cycle 1
Health 2023-08-31 · Fire 2023-08-31
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Lakewood, OH
O'neill Healthcare Lakewood
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
13900 Detroit Ave, Lakewood, OH
(216) 228-7650
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
102
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
O'neill Healthcare
Operator or chain grouping
Approved since
1971-08-06
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
0.45
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.55
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.24
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,296
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.96% · Performance 22.02% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.82% · Performance 8.02% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.17
Baseline 41.33% · Performance 54.81% · Measure score 2.17 · Achievement 2.17 · Improvement 0
Adjusted total nurse staffing
0.56
Baseline 3.48 hours · Performance 3.24 hours · Measure score 0.56 · Achievement 0.56 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.63% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 157 · Observed rate 10.83% · Lower 95% interval 8.02% |
| Discharge to community | 49.93% |
50.57%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 158 · Observed rate 44.94% · Lower 95% interval 43.11% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 59.49% |
95.27%
35.8 pts worse
|
Numerator 47 · Denominator 79 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 79 |
| Discharge self-care score | 75.93% |
53.69%
22.2 pts better
|
Numerator 41 · Denominator 54 |
| Discharge mobility score | 77.78% |
50.94%
26.8 pts better
|
Numerator 42 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 79 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.02% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 101 · Observed rate 8.91% · Lower 95% interval 4.97% |
| Staff COVID-19 vaccination coverage | 11.25% |
8.2%
3.1 pts better
|
Numerator 18 · Denominator 160 |
| Staff flu vaccination coverage | 8.15% |
42%
33.9 pts worse
|
Numerator 19 · Denominator 233 |
| Discharge function score | 85.19% |
56.45%
28.7 pts better
|
Numerator 46 · Denominator 54 |
| Transfer of health information to provider | 96% |
95.95%
About the same
|
Numerator 48 · Denominator 50 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.64% |
25.2%
11.6 pts worse
|
Numerator 3 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
92.4%
0.7 pts better
|
93.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 90.8% · Q3 94.3% · Q4 94.8% · 4Q avg 93.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.1% |
94.5%
1.4 pts worse
|
95.5%
2.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.8% |
3.3%
2.5 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 4.6% · Q3 7.1% · Q4 9.1% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 41.1% |
26.1%
15 pts worse
|
11.4%
29.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 64.2% · Q2 37.9% · Q3 30.6% · Q4 35.3% · 4Q avg 41.1% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
6.2%
1.3 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 3.9% · Q3 3.6% · Q4 6.5% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.0% |
25.4%
3.6 pts worse
|
19.6%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 23.1% · Q3 34.5% · Q4 30.6% · 4Q avg 29.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.2% |
11.5%
8.3 pts better
|
16.7%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 0.0% · Q3 2.6% · Q4 2.4% · 4Q avg 3.2% · 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 | 4.5% |
7.7%
3.2 pts better
|
16.3%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 4.1% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
6.2%
1.2 pts better
|
14.9%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 6.5% · Q3 4.1% · Q4 1.8% · 4Q avg 5.0% · 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 20.7% · Q2 21.6% · Q3 36.4% · Q4 23.2% · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
3.7%
1.4 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.6% · Q3 4.0% · Q4 3.7% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.8% |
78.1%
5.7 pts better
|
81.7%
2.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.6% · Q2 75.6% · Q3 81.9% · Q4 90.1% · 4Q avg 83.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
12.5%
0.4 pts better
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 12.8% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.6% |
75.6%
6 pts worse
|
79.7%
10.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
25.1%
0.2 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 27.7% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-30 · Fire 2020-01-30
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2018-11-08 · Fire 2018-11-08
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-08-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-24
F · Potential for more than minimal harm
2023-08-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-24
F · Potential for more than minimal harm
2023-08-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-24
F · Potential for more than minimal harm
2023-08-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-24
F · Potential for more than minimal harm
2023-08-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-24
F · Potential for more than minimal harm
2023-08-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-08-31
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-08-31
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-08-31
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 2023-10-24
E · Potential for more than minimal harm
2023-08-31
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-08-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-08-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-08-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-08-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-24
F · Potential for more than minimal harm
2020-01-30
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2020-03-10
F · Potential for more than minimal harm
2020-01-30
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 2020-03-10
F · Potential for more than minimal harm
2020-01-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-03-10
F · Potential for more than minimal harm
2018-11-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2018-12-21
F · Potential for more than minimal harm
2018-11-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-12-21
E · Potential for more than minimal harm
2018-11-08
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2018-12-21
E · Potential for more than minimal harm
2018-11-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-12-21
D · Potential for more than minimal harm
2018-11-08
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 2018-12-21
C · Minimal harm
2018-11-08
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2018-12-21
C · Minimal harm
2018-11-08
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2018-12-21
C · Minimal harm
2018-11-08
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2018-12-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-08-27
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-05-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-05-26
D · Potential for more than minimal harm
2024-05-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-29
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-29
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-02-02
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-02-27
D · Potential for more than minimal harm
2023-09-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-24
F · Potential for more than minimal harm
2023-08-31
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 2023-10-24
F · Potential for more than minimal harm
2023-08-31
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 2023-10-24
D · Potential for more than minimal harm
2023-08-31
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-08-31
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-03-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-04
D · Potential for more than minimal harm
2020-01-30
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2020-03-10
D · Potential for more than minimal harm
2020-01-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-10
D · Potential for more than minimal harm
2020-01-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-03-10
E · Potential for more than minimal harm
2018-11-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2018-12-21
D · Potential for more than minimal harm
2018-11-08
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2018-12-21
D · Potential for more than minimal harm
2018-11-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-12-21
D · Potential for more than minimal harm
2018-11-08
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2018-12-21
D · Potential for more than minimal harm
2018-11-08
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2018-12-21
D · Potential for more than minimal harm
2018-11-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-12-21
C · Minimal harm
2018-11-08
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2018-12-21
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
Ziska, Doreen
5% Or Greater Indirect Ownership Interest · Individual
Oneill, Deborah
5% Or Greater Indirect Ownership Interest · Individual
Chuma, Kimberly
Contracted Managing Employee · Individual
O'neill Management, LLC
Operational/Managerial Control · Organization
Oneill, Deborah
Corporate Officer · Individual
Oneill, John
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Crestmont North Nursing Home
Lakewood, OH
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Enniscourt Nursing Care
Lakewood, OH
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Rocky River Gardens Rehab And Nursing Ctr
Cleveland, OH
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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