O'neill Healthcare North Ridgeville
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
stand lift and thought it could be pressure causing edema to open. The DON stated Resident #69 had edema and the laceration could have been caused by the pressure against the equipment. The facility did training with all staff members on sit-to-stand lifts and the staff started using a Hoyer mechanical lift instead of a sit-to-stand and put pool noodles on the bedrails after the incident. The DON stated they did teach-back competency training with the CNAs and then did audits on other units for residents who used
the sit-to-stand and found no issues. Interview on 09/11/25 at 2:11 P.M. with Licensed Practical Nurse (LPN) #220, revealed two CNAs were transferring Resident #69 from her wheelchair to the bed via a sit-to-stand mechanical lift. LPN #220 stated the CNAs took the leg rests off the wheelchair prior to transfer.
LPN #220 stated when she assessed the resident the blood was still wet. LPN #220 stated after the resident went to the ER, they determined the resident's leg got scraped along the top of where the leg rest fits onto the wheelchair. LPN #220 did not recall any edema but stated the resident did not have her legs wrapped because that would have prevented the injury. LPN #220 stated she discussed this with RDCO #600 at the time of the incident.Interview on 09/15/25 at 12:32 P.M. with RDCO #600, revealed he investigated the incident involving Resident #69 then met with the family to discuss it. RDCO #600 stated
he believed the laceration occurred while Resident #69 was in the sit-to-stand and described it as more of a crushing injury than any issues with edema or swelling.The deficient practice was corrected by 02/22/25 when the facility implemented the following corrective actions: On 01/18/25, the resident was sent to the ER for evaluation and returned with 14 sutures in her right lower leg. On 01/18/25, the facility conducted a comprehensive investigation of the incident causing the laceration to Resident #69. The investigation included collecting witness statements and interviewing staff and facility determined it was caused by an unsafe transfer using a sit-to-stand lift. On 01/19/25, Resident #69's transfer orders were reviewed and changed from a sit-to-stand to a Hoyer mechanical lift. On 01/20/25, Resident #69's bed and wheelchair were inspected for sharp edges. The bed rails were padded for safety, tubi grips on the resident were to be
in place and the wheelchair legs were to be removed prior to transfers. On 01/20/25, CNA #700 and CNA #750 were educated on transfer and returned a competency demonstrating on how to properly use a sit-to-stand. On 01/20/25 started education and training all nursing staff on proper usage of the sit-to-stand mechanical lift. On 01/22/25, Resident #69 was assessed by wound nurse On 01/23/25, the facility conducted audits of all residents being transferred by a sit to-stand lift. The audits continued through 04/02/25 and no additional issues were discovered. On 02/04/25, the resident was assessed by the Therapy Department due to new onset of decrease in strength, range of motion, balance, and increased need for assistance which placed the resident at risk for falls and further decline in function. The resident was assessed with strength, balance, activity intolerance and functional mobility deficits. The resident was unsteady with weight bearing activities in the stand-up lift, and it was painful. The resident has a decreased quality of life and recommended a Hoyer lift for all transfers. On 02/22/25, the facility reviewed the incident log, and no current issues were identified with sit-to-stand.This deficiency represents non-compliance investigated under Complaint Number OH001357840.
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O'NEILL HEALTHCARE NORTH RIDGEVILLE in NORTH RIDGEVILLE, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in NORTH RIDGEVILLE, OH, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from O'NEILL HEALTHCARE NORTH RIDGEVILLE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.