Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Bay Village during CMS and state inspections, most recent first.
Surveyors found that the facility did not ensure meals were palatable, visually appealing, or served at appetizing temperatures. A family member reported ongoing concerns about food quality and temperature, and multiple residents stated that their food was cold, overcooked, hard, unappetizing, or had declined in quality, with one resident needing to ask CNAs to reheat meals. Observation of a test breakfast tray with the Dietary Manager showed an extremely hard biscuit, bland and lukewarm sausage gravy, and thick, unseasoned oatmeal without typical enhancers, contrary to the facility’s policy that meals be promptly distributed to maintain adequate temperature and appearance.
Surveyors found that the facility failed to maintain a clean, safe, and well-maintained environment, with multiple rooms showing loose or damaged flooring under beds, dislodged baseboard covers with exposed heating elements, broken or cracked walls and windowsills, and holes or peeling drywall near beds. Some residents’ bedding was stained or damaged, with one room having a strong urine odor, and another bed cover showing a brown stain. Environmental cleanliness issues included dirty air conditioner filters, a wall unit vent with only a thin cover, dead bugs in overhead hallway light fixtures, and a dented, discolored, and sticky hallway air filter unit. One resident reported that loose floor planking under the bed was related to how she is positioned in bed.
Surveyors found that two residents were exposed to cold drafts in their rooms due to a window leak and a gap above an AC unit, resulting in discomfort. One resident used a rolled towel at the base of a closed window next to the bed to block cold air, while another resident’s room had a visible gap above the AC unit where cold air entered. Both residents reported feeling cold and uncomfortable, and the Director of Ancillary Services confirmed these environmental issues during rounds.
A high-risk resident with multiple comorbidities and a low Braden score was admitted without pressure ulcers but later sustained an unwitnessed fall resulting in a coccyx skin tear and right buttock bruising. The wound was not comprehensively measured or assessed at the time of injury, and although general skin integrity interventions were care planned, no problem or interventions specific to the new coccyx/right buttock wound were added. Days later, a CNP evaluated the area and classified it as an unstageable pressure ulcer with 100% slough, and new wound treatments and an air mattress were ordered. The care plan, however, was not revised to include the pressure ulcer, its specific treatment, or the added pressure-relieving interventions, contrary to facility policy requiring care plan modification and ongoing wound assessment for residents who develop pressure ulcers.
A resident with COPD, chronic atrial fibrillation, lumbago with bilateral sciatica, and moderate cognitive impairment had a care plan and MD order requiring all transfers to be done with a Hoyer lift and specified sling with 2-person assist. The resident later reported to family and a police officer that an aide picked her up under the arms and placed her in a wheelchair, causing back pain, with no mention of a mechanical lift. One CNA stated she and another CNA twice transferred the resident between bed and chair without using a gait belt or knowing the resident required a Hoyer lift, while the assisting CNA claimed a Hoyer was used and accused the family of lying. The Administrator confirmed the facility determined the CNAs had body-lifted the resident instead of using the ordered Hoyer lift, constituting a failure to follow the resident’s transfer requirements.
A resident with Parkinson’s disease, muscle weakness, and intact cognition had physician-ordered podiatry appointments but repeatedly missed them because transportation was not properly arranged. Although the resident had Ohio managed Medicaid coverage that allowed multiple round-trip visits and required transport scheduling in advance, the insurer reported no transports were ever set up. The resident stated he missed two appointments due to the facility’s failure to arrange transportation, outside office staff reported multiple no-shows without cancellation or rescheduling, and an NP was not informed of any missed visits. An RN unit manager indicated transport confirmations were sent by text to the resident’s phone, while the resident reported his phone had been broken for two years, and the RN confirmed the resident was not transported to at least one scheduled appointment due to transportation issues.
A resident with multiple comorbidities, cognitive impairment, a stage II pressure ulcer, MASD, and an MDRO-infected right foot wound was care planned for Enhanced Barrier Precautions (EBP). During observed wound care to the right fifth toe, an LPN entered the room marked for EBP without a gown, removed a soiled dressing, then cleansed the wound and applied calcium alginate using the same pair of gloves before changing gloves only to place the foam dressing. In interview, the LPN acknowledged both the EBP requirement for gown and gloves and that gloves should have been changed after removing the old dressing, which was inconsistent with the facility’s wound care policy requiring hand hygiene and new gloves between dressing removal and wound care.
PASARR screening was inaccurate for a resident with documented unspecified intellectual disabilities, schizoaffective disorder, major depressive disorder, and Alzheimer’s disease. The PASARR did not list the resident’s schizoaffective disorder or major depressive disorder and incorrectly answered No to the question about intellectual disability/mental retardation, despite the diagnoses being in the record. An LSW confirmed the PASARR did not match the resident’s diagnoses.
A resident with Parkinson's disease, diabetes, and muscle weakness had intact cognition, but the chart did not show an activity care plan reflecting the resident's choices and preferences. The AD confirmed the record lacked evidence of an implemented activity care plan, and the resident reported some activities were cancelled due to lack of participation.
A resident who was cognitively intact and needed assistance with ADLs was not involved in ongoing care planning. EMR review showed no care conference documentation for an extended period, and interviews with the resident, MDSC, and LSW confirmed the resident had not been invited to or attended care conferences and had not been updated on the plan of care. Facility policy required care plan meetings after admission and at least quarterly, with the resident invited to attend.
Medication administration errors resulted in a 6.9% error rate, exceeding the 5% threshold. One RN gave scheduled and sliding-scale insulin without priming the Humalog KwikPen per manufacturer directions, and an LPN gave an oral antineoplastic medication after breakfast instead of before breakfast for a resident with prostate cancer and cognitive impairment.
Inaccurate CNA Staffing Postings: The facility posted 12 CNAs on the daily staffing sheet for the day shift, but observation found only 10 CNAs present in the building. Review of the staffing schedule showed a different CNA count than the posted information, and the HR Director confirmed she could not explain the discrepancy between the posted staffing, the schedule, and the staff actually on site.
A resident with a history of stroke and other conditions did not receive prescribed wound care for a skin tear on the left hand. Despite physician orders for daily treatment, the wound was left open and untreated, as confirmed by observations and family interviews. An LPN admitted to not being aware of the wound care orders.
A resident with severe cognitive impairment and multiple medical conditions did not receive adequate nutritional and hydration care in a facility. The resident required a mechanically altered diet and staff assistance for feeding, but the facility failed to consistently document meal intake and did not have a clear plan for feeding assistance. This led to the resident being hospitalized for dehydration and high sodium levels, highlighting deficiencies in the facility's care practices.
The facility failed to ensure call lights were within reach for three residents, including one with a femur fracture and dementia, another with multiple sclerosis and vision impairment, and a third with dementia and mobility issues. Observations revealed call lights were out of reach, confirmed by staff, despite facility policy requiring accessibility.
A facility failed to timely report an abuse allegation involving a resident who was cognitively intact and had multiple medical conditions. The resident's granddaughter reported that a male CNA refused bathroom assistance and took away the resident's call light, TV remote, and cell phone. The incident was reported to the DON but not fully communicated to the Administrator until several days later, violating the facility's policy on timely reporting of abuse allegations.
The facility failed to provide fortified pudding to several residents during lunch, as required by physician orders or dietitian recommendations. These residents, who had specific dietary needs due to various medical conditions, did not receive the fortified pudding because the facility ran out halfway through meal service. This resulted in non-compliance with the dietary interventions outlined for these residents.
The facility did not provide pureed foods at a smooth consistency for safe swallowing for three residents on prescribed pureed diets. Observations and taste tests revealed that the pureed peas were lumpy and contained pea shell pieces, which was confirmed by a Speech Therapist. This was contrary to the facility's guidelines that required pureed foods to hold their shape on a spoon and have a smooth texture.
The facility failed to honor dietary needs for three residents, including allergies to chocolate and wheat, and a preference for almond milk. Errors were identified during a tray line observation, affecting the potential dietary safety of 110 residents.
Failure to Provide Palatable, Appealing Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were palatable, visually appealing, and served at safe and appetizing temperatures for multiple residents. A family member of one resident reported multiple concerns about food quality and temperature. Several residents reported that the food was always cold, had declined in quality, or was gross. One resident stated they frequently had to ask CNAs to reheat their food, and that the CNAs did so reluctantly. During the annual survey’s resident council portion, numerous residents reported that the food was overcooked, hard, and did not taste good. Direct observation of a test tray for a breakfast meal with the Dietary Manager showed biscuits with sausage gravy, oatmeal, and orange juice that did not meet the facility’s own standards for meal service and distribution. The biscuit was extremely hard and required significant force with a spoon to cut. The sausage gravy was bland, lacked seasoning, and was only lukewarm at 145 degrees. The oatmeal had a thick paste-like texture and was served without milk, brown sugar, or other flavor enhancers. The Dietary Manager confirmed these findings at the time of observation. Review of the facility’s undated meal service and distribution policy showed that residents’ meals were supposed to be distributed promptly to maintain adequate temperature and appearance, which was not achieved in these instances.
Failure to Maintain Clean, Safe, and Well-Maintained Environment
Penalty
Summary
Surveyors identified a deficiency in maintaining a clean, safe, and sanitary environment based on observations during environmental rounds and resident and staff interviews. Multiple resident rooms had physical plant issues, including loose flooring or floorboards under bed legs or footers, dislodged floor baseboard covers with exposed heating elements, broken or damaged walls and windowsills, and an indented hole on a bathroom door. Specific examples included loose flooring under beds in several rooms, a broken windowsill ledge with dislodged triangular pieces and an 18-inch wall crack extending toward the floor, semi-plastered wall holes behind beds, peeling paint and drywall near beds, and exposed drywall in another room. One resident reported that the floor planking had been loose under her bed due to the way she is positioned in bed. Additional environmental concerns involved unclean or stained items and equipment. One resident’s bottom bed sheet had a small hole and two small yellow stains, and there was a strong urine odor in the room without visible urine. Another resident’s bed cover had a brown stain. An air conditioner filter in one room had visible dirt and debris, and a wall unit air conditioner vent had only a thin cover that was cold to the touch. Dead bugs were observed in overhead hallway lighting lids throughout the building. An air filter unit in the hallway had a dent, visible yellow/light brown discoloration on its exterior, and was sticky to the touch. These conditions were verified at the time of discovery by the Director of Ancillary Services and were associated with multiple complaint investigations.
Failure to Maintain Comfortable Room Temperatures Due to Drafty Windows and AC Gaps
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment when two residents experienced cold air infiltration in their rooms. For one resident, surveyors observed a rolled towel placed at the base of the closed window next to the bed, with cold air felt coming through the window; the resident reported that cold air entered through the window, caused discomfort, and that the towel was placed there for that reason. For another resident, surveyors observed a gap above the air conditioner unit below the window, with cold air felt through the gap; this resident stated he was cold in his room and was uncomfortable. During environmental rounds, the Director of Ancillary Services confirmed these findings. This deficiency represents non-compliance investigated under Complaint Numbers 2642470, 1266873 (OH00165876), and 1266871 (OH00165428).
Failure to Assess and Care Plan Newly Developed Coccyx/Buttock Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess a newly identified skin alteration on a resident’s sacral/buttock area and to timely revise the resident’s care plan for pressure ulcer prevention and treatment. The resident was admitted with multiple medical diagnoses, including senile degeneration of the brain, emphysema, heart block, obstructive and reflux uropathy, hyperlipidemia, heart failure, and atrial fibrillation. On admission, the resident had no pressure areas but did have scattered bruising, abrasions, scabs, and a surgical incision. A Braden Scale assessment completed on the day of admission showed a score of 12, indicating high risk for skin breakdown, with findings of very limited sensory perception, very moist skin, chairfast status, very limited mobility, probably inadequate nutrition, and a potential problem with friction and shear. A nutrition assessment documented that the diet was adequate and that the resident was at risk for skin breakdown but had no identified pressure ulcers. An MDS assessment confirmed no pressure ulcers and total dependence on staff for ADLs, with an indwelling urinary catheter and bowel incontinence. On a later date, the resident sustained an unwitnessed fall. An LPN found the resident on the floor sitting on his bottom, and the resident reported pain in that area. The LPN documented an injury on the coccyx described as a skin tear and redness, and the facility’s fall report listed a bruise to the coccyx, a bruise to the right cheek, and a skin tear to the coccyx. Weekly wound documentation for the right buttock and coccyx on the date of the fall recorded bruising measuring 4.5 cm by 2.6 cm with a wound bed described as 100% purple, and a skin tear to the coccyx without measurements or further description of the periwound area. There was no evidence in the medical record that the skin tear was fully measured and assessed or that a specific treatment was implemented immediately following the fall. A care plan initiated that same day addressed the resident’s potential for alteration in skin integrity with general preventive interventions such as turning and repositioning, heel offloading, pressure-reducing surfaces, and incontinence care, but it did not include a problem or interventions specific to the right buttock bruise and coccyx skin tear sustained from the fall. Subsequently, a treatment order for the right buttock/coccyx area was entered the day after the fall to cleanse with normal saline, pat dry, and apply Triad cream every shift and as needed for a skin tear related to the fall. Several days later, the wound team CNP evaluated the right buttock wound and classified it as a pressure ulcer with 100% yellow, soft slough and moderate serous drainage, measuring 4.5 cm by 2.5 cm with depth unable to be determined. Weekly wound documentation on that date described the wound as an unstageable pressure ulcer with intact periwound skin, and the treatment was changed to Medihoney, calcium alginate, and a dressing. An air mattress was also ordered at that time. Despite the reclassification of the wound as an unstageable pressure ulcer and the addition of new pressure-relieving interventions, the resident’s care plan was not updated to include the identified pressure ulcer, the new wound treatment, or the air mattress. Interviews with the DON, Regional Director of Clinical Services, MDS coordinator, and CNP confirmed that the initial skin tear and bruising were not comprehensively assessed and that the care plan was not revised to reflect the development and treatment of the pressure ulcer, contrary to the facility’s pressure ulcer prevention and treatment policy, which requires care plan modification to reflect changes in condition and weekly wound evaluation and discussion by the IDT. The facility’s policy on Pressure Ulcer Prevention and Treatment Protocol states that residents with a Braden score of 12 or less are considered high risk for pressure ulcer development and that residents who develop a pressure ulcer must have appropriate nutritional evaluation, wound care interventions per protocol or MD orders, referrals as needed, and care plan modifications to reflect changes in condition. The policy also requires daily monitoring of periwound skin, weekly wound measurements, and weekly IDT discussion of wound status, with adjustments to treatment as needed. In this case, the resident, who was identified as high risk on admission, developed a wound to the coccyx/right buttock area following a fall that was initially documented as a bruise and skin tear but not fully measured or assessed, and the care plan was not updated when the wound was later classified as an unstageable pressure ulcer and new interventions were ordered. These omissions constitute the failure to provide appropriate pressure ulcer care and to prevent new ulcers from developing as cited in the deficiency.
Failure to Follow Hoyer Lift Transfer Requirements for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was transferred in accordance with physician orders and the resident’s care plan, which required use of a Hoyer mechanical lift with a medium purple sling and assistance of two staff for all transfers. The resident had multiple diagnoses, including COPD, lumbago with sciatica on both sides, and chronic atrial fibrillation, and had a care plan intervention in place specifying mechanical lift transfers. A physician order also directed that a Hoyer lift be used for all transfers on all shifts. The resident’s MDS reflected moderate cognitive impairment. The incident came to light when the resident’s daughter reported that the resident complained of back pain after being gotten out of bed the previous evening and expressed concern that the pain was related to how staff had transferred the resident. The daughter contacted the local police department, and an officer subsequently interviewed the resident. The resident reported that an aide, described as a black female in her late 20s, picked her up under both armpits and placed her in a wheelchair, and that she experienced pain during the move from bed to chair. This description did not include the use of a Hoyer mechanical lift as required by the care plan and physician order. During the facility’s investigation, one CNA stated in a witness statement that she had cared for the resident on the relevant day shift and had transferred the resident twice, from bed to chair and later from chair back to bed, with assistance from another CNA. She acknowledged having a gait belt but not using it and stated she did not know the resident required a Hoyer lift, and that the resident appeared comfortable and voiced no concerns at the time. The assisting CNA, in a later telephone interview, claimed that a Hoyer lift had been used and alleged the family was lying. The Administrator, however, confirmed that the facility determined the two CNAs had not used a Hoyer mechanical lift and had instead body-lifted the resident from bed to chair and back, contrary to the resident’s care plan and physician orders.
Failure to Arrange Transportation for Outside Podiatry Appointments
Penalty
Summary
The deficiency involves the facility’s failure to ensure transportation was adequately arranged for an insured resident’s outside podiatry appointments. The resident was admitted with Parkinson’s disease, muscle weakness, and a cognitive communication deficit, but the admission MDS showed intact cognition. Physician orders documented podiatry appointments on 12/04/25 at 11:15 A.M. and 01/08/26 at 2:15 P.M., and the resident was covered by an Ohio managed Medicaid plan that, per facility transportation guidelines, required transportation to be scheduled at least two days in advance and allowed up to 30 round trips per year. Despite these provisions, the insurance transportation representative reported that no transportation had been set up for any past or future appointments for this resident. The resident reported missing two appointments because the facility did not set up transportation in a timely manner. Outside office staff stated the resident was a no-show to multiple appointments due to transportation issues and that facility staff did not call to cancel or reschedule. The NP reported she was not notified of any missed appointments and confirmed transportation was a problem. The RN unit manager stated that confirmation for transport had been sent to the resident’s phone, but the resident reported his phone had been broken for two years and he could not receive texts. The RN unit manager confirmed the resident was not transported to the 01/08/26 appointment due to transportation issues. Facility transportation guidelines also indicated that routine or unrelated appointments should be canceled or rescheduled during a skilled stay, and that certain Medicare transports without secondary insurance would be billed to the resident at booking, but there was no evidence these guidelines were effectively implemented to ensure the resident’s ordered podiatry appointments were supported with appropriate transportation.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control measures during wound care for one resident on Enhanced Barrier Precautions (EBP). The resident was admitted with multiple diagnoses including hemiplegia, hemiparesis, type II diabetes, dysphagia, cerebral infarction (stroke), depression, anxiety, right knee contracture, hypertension, and heart failure. A quarterly MDS documented that the resident was cognitively impaired, dependent on staff for hygiene and transfers, and had a stage II pressure ulcer and moisture associated skin damage. The care plan indicated the resident required EBP due to a multidrug resistant organism (MDRO) infection in a right foot wound, and physician orders directed cleansing the right fifth toe with normal saline, patting dry, applying calcium alginate, and covering with a foam dressing. During an observation of wound care, an LPN gathered supplies and entered the resident’s room, which had signage indicating EBP and the requirement for staff to wear gloves and a gown when providing wound care to any skin opening requiring a dressing. The LPN did not don a gown, washed her hands, put on gloves, and removed the old dressing from the right fifth toe. Using the same gloves that had been used to remove the soiled dressing, she then cleansed the wound and applied calcium alginate before changing gloves to apply the foam dressing. In a subsequent interview, the LPN confirmed she did not change gloves after removing the dressing and before cleansing the wound, and acknowledged that the resident required EBP and that she was required to wear gloves and a gown while providing wound care. Review of the facility’s wound care policy showed it required handwashing, glove use to remove the dressing, handwashing again, and then new gloves to complete the dressing change. This deficiency was investigated under Complaint Numbers 2703441 and 2642470.
PASARR Did Not Accurately Reflect Mental Health and Intellectual Disability Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not accurately completed for one resident. The resident was admitted with diagnoses that included unspecified intellectual disabilities, schizoaffective disorder, major depressive disorder, and Alzheimer's disease. The most recent MDS showed the resident was moderately cognitively impaired and required hands-on assistance from one staff person for activities of daily living. Review of the PASARR assessment showed the facility did not identify the resident's schizoaffective disorder or major depressive disorder in Section D, and answered No to the question asking whether the individual had a diagnosis of mental retardation in Section E despite documented unspecified intellectual disabilities. No additional PASARR assessments were found in the medical record. In interview, the LSW confirmed the PASARR did not accurately reflect the resident's diagnoses, and later reported that a new PASARR had been completed identifying a possible Level II intellectual disability.
Missing Activity Care Plan for Resident Preferences
Penalty
Summary
The facility failed to ensure Resident #31 had an activities care plan that reflected the resident's choices and preferences for activities. Resident #31 was admitted with diagnoses including Parkinson's Disease without dyskinesia, diabetes, and muscle weakness, and the admission MDS 3.0 assessment documented intact cognition. Review of the resident's care plans did not show evidence of an implemented activity care plan addressing the resident's choices or preferences. During interview, Resident #31 stated that some activities were cancelled due to lack of resident participation. The Activity Director confirmed that the resident's medical record did not contain evidence of an activity care plan indicating the resident's choices and preferences for activities. The facility policy reviewed stated that residents admitted to the facility were to be assessed upon admission and periodically thereafter.
Resident Not Included in Care Conferences
Penalty
Summary
The facility failed to ensure residents were involved in their ongoing plan of care for one resident, who was cognitively intact and required set up to partial/moderate assistance with ADLs. The resident was admitted with diagnoses including hemiplegia and hemiparesis, hypertension, osteoarthritis, major depressive disorder, vertigo, and anxiety disorder. Review of the electronic medical record showed the last social service assessment progress note was on 10/31/23 and the last social service progress note was on 05/01/24, with no documentation of a care conference from 10/31/23 through 01/13/26. Interviews confirmed the resident did not recall attending any care conferences or being updated on the plan of care, and later stated he had not seen a social worker or been invited to or attended a care conference since admission. The MDS Coordinator stated the social worker arranged care conference dates and that the MDS Coordinator did not attend care conferences, and verified there were no sign-in sheets or care conference progress notes in the electronic chart. The LSW stated the resident had not had a care conference since her employment began in October 2025 and verified there were no care conference notes or attendance sheets in either the electronic or physical chart. Facility policy required care plan meetings after admission and at least quarterly, with the resident, responsible party, and outside consulting agencies invited when applicable.
Medication Error Rate Exceeded 5% Due to Two Administration Errors
Penalty
Summary
The facility failed to ensure medication error rates did not exceed 5%, with surveyors identifying 2 medication errors out of 29 opportunities for a 6.9% error rate. This affected two residents observed during medication administration. Review of the facility policy showed medications were to be administered in a safe manner, but the observed administration events did not meet the ordered directions or manufacturer guidance. Resident #40 had diagnoses including schizophrenia, type 2 diabetes mellitus with diabetic neuropathy, and generalized anxiety disorder, and was ordered Humalog KwikPen both as scheduled mealtime insulin and as sliding scale insulin. During observation, an RN administered 15 units of Humalog based on the resident's blood glucose result of 157, but did not prime the insulin pen according to the manufacturer's directions. Resident #97 had diagnoses including malignant neoplasm of the prostate, obstructive and reflex uropathy, and cognitive communication deficit, and was ordered Abiraterone Acetate 250 mg, four tablets by mouth every morning before breakfast. During observation, an LPN administered the medication after breakfast instead of before breakfast.
Inaccurate CNA Staffing Postings
Penalty
Summary
The facility failed to ensure that the posted daily staffing information included an accurate count of CNAs working in the facility. Record review of the daily staffing posting for 01/13/26 showed 12 CNAs listed as working from 7:00 A.M. to 7:00 P.M., but observation at 9:34 A.M. found only 10 CNAs actually working in the facility. Review of the staffing schedule for that day showed eight CNAs scheduled from 7:00 A.M. to 7:00 P.M., one aide scheduled from 7:00 A.M. to 3:00 P.M., one aide scheduled from 3:00 P.M. to 7:00 P.M., and one aide scheduled from 9:30 A.M. to 5:00 P.M., with six additional CNAs scheduled to start at 7:00 P.M. and two scheduled to start at 11:00 P.M. The Human Resources Director confirmed the discrepancy and stated she was covering for the usual scheduler and could not account for why the daily posting differed from the scheduled staffing and the staff actually present.
Failure to Provide Wound Care as Ordered
Penalty
Summary
The facility failed to provide appropriate wound care for a resident, identified as Resident #109, according to the physician's orders. Resident #109, who has a medical history including stroke, diabetes mellitus, kidney disease, anxiety, post-traumatic stress disorder, and cognitive impairment, experienced a fall and was transferred for evaluation. Following the fall, a physician's order was issued on 02/25/25 for the treatment of a skin tear on the resident's left hand. The order specified that the wound should be cleansed with normal saline, patted dry, treated with triple antibiotic ointment, covered with a non-adherent dressing, and wrapped with gauze once daily until healed. However, observations and interviews revealed that the prescribed wound care was not performed. On 02/26/25, the resident was observed with an open laceration on the left hand, covered only by steri-strips, some of which were peeling, and a moderate amount of dried blood was noted. Interviews with the resident's wife and son confirmed that no dressing was applied on 02/25/25 after the resident returned from the emergency department, nor was there a dressing in place the following morning. An LPN, who was responsible for the resident's care on 02/25/25, admitted to not performing the wound care, stating she was unaware of the wound orders. This deficiency was investigated under Complaint Number OH00161145.
Failure to Provide Adequate Nutritional and Hydration Care
Penalty
Summary
The facility failed to provide adequate nutritional and hydration care for a resident, identified as Resident #108, who was dependent on staff for feeding assistance. The resident had multiple medical conditions, including encephalopathy, dysphagia, and Alzheimer's disease, and required a mechanically altered diet with honey thickened liquids. Despite these needs, the facility did not consistently document the resident's meal intake on several occasions, and there was no clear plan addressing the extent of feeding assistance required. Resident #108 was admitted with a weight of 130.6 pounds and had a nutritional assessment indicating a need for 1800 calories and 1800 milliliters of fluid daily. However, the resident's meal intake records showed significant gaps, with no documentation on several days and instances of meal refusal. The resident was eventually admitted to the emergency department with dehydration and high blood sodium levels, conditions that had led to multiple hospitalizations in the past. Interviews with facility staff, including a registered dietician and the administrator, confirmed that the care plan did not adequately address the resident's feeding assistance needs. The facility's policies on activities of daily living and weight recording were not effectively implemented, contributing to the resident's nutritional and hydration deficiencies. This deficiency was investigated under two complaint numbers, indicating ongoing issues with the facility's care practices.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that residents had their call lights within reach while unattended in their rooms, affecting three residents. Resident #39, who had a history of falls and was at high risk for falls due to a femur fracture, weakness, and dementia, was observed lying in bed with the call light on the opposite side of the room, out of reach. Despite being alert and responsive, the resident was unable to access the call light due to the bed's position against the wall. This was confirmed by an LPN who noted that the call light could reach the resident if stretched across the room. Resident #36, diagnosed with multiple sclerosis, paraplegia, and vision impairment, was also affected. The resident was observed sitting in a tilt chair with the call light connected to the bed and out of reach. Despite requiring assistance for mobility and being at high risk for falls, the resident confirmed the inability to reach the call light. A CNA verified the situation, acknowledging that the resident used the call light for assistance when it was accessible. Similarly, Resident #43, who had dementia and was at high risk for falls, was found in a wheelchair with the call light located behind the bed and out of reach. The resident, who required assistance for mobility and was dependent on staff for transfers, confirmed the inability to reach the call light. A CNA corroborated this, noting that the resident could normally use the call light but was unable to do so due to its placement. The facility's policy required call lights to be within reach, but this was not adhered to, as confirmed by the Administrator and DON.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident, which was identified during a review of records, interviews, and the facility's self-reported incident (SRI). The incident involved a resident who was cognitively intact and had multiple medical conditions, including metabolic encephalopathy and cirrhosis of the liver. The resident's granddaughter reported that a male CNA refused to assist the resident to the bathroom, took away her call light, TV remote, and personal cell phone, and instructed her not to call anyone. This incident was initially reported to the DON on November 30th, but the SRI was not initiated until December 4th, indicating a delay in reporting. The facility's policy requires that all alleged violations involving abuse, neglect, or mistreatment be reported immediately, or within two hours if they involve abuse or result in serious bodily injury. However, the facility did not adhere to this policy, as the Administrator was not informed of the full extent of the allegations until December 4th. The investigation into the allegations was completed on December 11th and was found to be unsubstantiated. This deficiency was identified under Complaint Number OH00160465, highlighting non-compliance with timely reporting requirements.
Failure to Provide Fortified Pudding as Ordered
Penalty
Summary
The facility failed to provide fortified pudding to five residents during lunch, as required by physician orders or dietitian recommendations. These residents were identified as being at risk for altered nutrition or hydration due to various medical conditions, including dementia, diabetes mellitus, chronic obstructive pulmonary disease, depression, anxiety disorder, malignant neoplasm, chronic kidney disease, and dysphagia. The deficiency was observed when the facility ran out of fortified pudding halfway through the meal service, affecting residents who were supposed to receive it as part of their dietary interventions. The affected residents had specific dietary needs documented in their care plans and physician orders, which included fortified pudding to help maintain weight, support wound care, or prevent weight loss. Despite these documented needs, the facility's failure to provide the fortified pudding as ordered resulted in non-compliance with the dietary interventions outlined for these residents. The deficiency was noted during an observation of the tray line, where it was confirmed that the fortified pudding was unavailable for the residents in question.
Failure to Provide Smooth Pureed Foods for Residents
Penalty
Summary
The facility failed to provide pureed foods at a smooth consistency for safe swallowing for three residents who were prescribed pureed diets. During an observation of the tray line, it was noted that the pureed peas appeared lumpy, and a taste test confirmed the presence of pea shell pieces, indicating the food was not smooth in consistency. This was verified by a Speech Therapist who confirmed the inconsistency of the pureed food. The facility's guidelines stated that pureed foods should hold their shape on a spoon and have a smooth texture, which was not adhered to in this instance.
Failure to Honor Resident Dietary Needs
Penalty
Summary
The facility failed to honor food allergies and preferences for three residents, which was identified during an observation of the tray line. Resident #43, who has a diagnosis of hemiplegia, anxiety disorder, and depression, was noted to have a chocolate allergy. Despite this, their lunch tray included chocolate chip cookies, which were only replaced with fruit after the error was pointed out. Similarly, Resident #111, diagnosed with dementia, osteoarthritis, and atherosclerotic heart disease, was allergic to wheat but also received chocolate chip cookies on their tray. This mistake was corrected only after it was brought to the attention of the dietary aide. Additionally, Resident #69, who has quadriplegia, chronic obstructive pulmonary disease, anxiety disorder, and major depressive disorder, was supposed to receive almond milk as part of their dietary plan to address nutritional risks. However, the dietary aide confirmed that almond milk was not available for this resident. These deficiencies were noted to have the potential to affect 110 out of 111 residents who received meals from the facility kitchen, indicating a systemic issue in the dietary service's ability to accommodate resident-specific dietary needs.
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.
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What surveyors actually found near you
We read the 895 citations issued within 25 miles in the last 12 months — including the 7 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bay Village
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rae Ann Suburban | 1.3 mi | ★★★★★ | 0 | 0 |
| Huntington Woods Care & Rehab Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Rae-ann Westlake | 1.6 mi | ★★★★★ | 0 | 0 |
| Avon Place Healthcare Center | 2.1 mi | ★★★★★ | 11 | 0 |
| Lutheran Home | 2.5 mi | ★★★★★ | 1 | 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.