F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview the facility failed to ensure the appropriate state agency (The Ohio
Department of Mental Health and Addiction Services) was notified of a significant change in a resident's
Pre-admission Screen and Resident Review (PASRR). This affected one (Resident #88) of one resident
reviewed for PASRR status. The facility census was 117.
Findings include:
Clinical record review revealed Resident #88 was admitted to the facility on [DATE] with diagnoses that
included but were not limited to metabolic encephalopathy, unspecified dementia, type II diabetes mellitus,
schizoid personality disorder and major depressive disorder. Review of the most recent quarterly Minimum
Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #88 had severe cognitive impairment and
required extensive assistance for completion of activities of daily living.
Review of the PASRR form dated 08/01/23 for Resident #88 revealed no indications of serious mental
illness and/or developmental disability. Review of section E; Indications of Serious Mental Illness revealed
mood disorder and personality disorder were indicated.
Review of nursing progress note dated 11/07/23 timed at 11:49 P.M. revealed Resident #88 was sent out
and admitted to the hospital for diagnosis of jaundice and abnormal lab values.
Review of nursing progress note dated 11/14/23 timed at 9:00 P.M. revealed Resident #88 was readmitted
to the facility.
Review of medical diagnoses for Resident #88 dated 11/14/23 revealed new diagnoses of schizoaffective
disorder and bipolar disorder.
Review of current PASRR records on 03/11/24 for Resident #88 revealed no evidence the state PASRR
authority (The Ohio Department of Mental Health and Addiction Services) was made aware of Resident
#88's new mental health diagnoses following her readmission on [DATE] via the completion of a new
PASRR as required.
Interview on 03/11/24 at 2:40 P.M. with the Administrator confirmed a PASRR was not completed following
Resident #88's readmission on [DATE].
Interview on 03/11/23 at 3:55 P.M. with Social Worker #203 confirmed no new PASRR was submitted to the
state PASRR authority to address Resident #88's new mental health diagnoses of schizoaffective
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
365264
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365264
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
O'Neill Healthcare Bay Village
605 Bradley Rd
Bay Village, OH 44140
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0644
disorder and bipolar disorder following her readmission on [DATE].
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365264
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365264
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
O'Neill Healthcare Bay Village
605 Bradley Rd
Bay Village, OH 44140
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, staff interview and facility policy review, the facility failed to ensure food was served
in a sanitary manner and food was stored and dated properly. This had the potential to affect 114 residents
receiving meals from the facility. The facility identified three residents (#14, #113, and #168) who received
nothing by mouth. The facility census was 117.
Findings include:
A tour of the kitchen was conducted on 03/10/24 from 9:05 A.M. to 9:55 A.M. with Dietary Manager #200.
The following concerns were observed during the kitchen tour.
In the dry storage area, five packages of eight count Italian split sub buns were found with a use by date of
03/05/24, one package of 12 count hamburger buns with a use by date of 03/05/24.
In the walk in refrigerator, a Ziploc bag with ham slices was found with a date of 02/28/24, a plastic
container of egg salad dated 03/05/24, a plastic container of sliced peaches dated 03/05/24, a plastic
container of sliced cucumbers dated 03/05/24 which appeared to be slimy, an unlabeled, undated Ziploc
bag of cooked bacon slices, a Ziploc bag of four hot dogs with a date of 03/05/24, an undated container of
egg salad, two open packages of sliced American cheese that were undated, and one undated open
package of mozzarella wrapped in plastic wrap.
An observation of the convection oven revealed it was heavily soiled on the bottom of the oven and the two
ovens were also heavily soiled on the bottom.
Review of the facility document titled, Weekly cleaning assignments hanging of the kitchen wall revealed
incomplete daily cleaning assignments for all shifts dated 02/25/24 through 03/02/24.
Interview at the time of the observations with Dietary Manager #200 confirmed the above findings. Dietary
Manager #200 stated foods were to be labeled and dated when stored, leftovers were to be discarded after
three days and kitchen cleaning tasks were to be completed per the posted cleaning schedule.
Observation on 03/10/24 at 9:50 A.M. in the kitchen revealed Dietary Supervisor #201 with an uncovered
beard. Interview at the time of the observation with Dietary Supervisor #201 confirmed he was not wearing
a beard cover, he stated they were out of beard covers.
Observation on 03/11/24 at 11:43 A.M. during tray line observation revealed [NAME] #202 was wearing a
mask below his chin exposing his beard while preparing sandwiches. Dietary Manager #200 confirmed the
observation and stated facial hair was to be covered.
Review of the undated facility policy called Food Storage revealed leftover food was to be stored in covered
containers or wrapped carefully and securely. Each item was to be clearly labeled and dated before being
refrigerated. Leftover food was to be used within three days.
Review of the undated facility policy called General Sanitation of Kitchen revealed the staff would maintain
the sanitation of the kitchen through compliance with a comprehensive cleaning schedule. Tasks would be
assigned to the responsibility of specific positions. Cleaning schedule would be
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365264
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365264
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
O'Neill Healthcare Bay Village
605 Bradley Rd
Bay Village, OH 44140
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
posted, and employees were to initial and date tasks when completed.
Level of Harm - Minimal harm
or potential for actual harm
Review of the undated facility policy called Employee Sanitary Practices revealed all employees were to
wear hair restraints.
Residents Affected - Many
The facility identified three residents (#14, #113, and #168) who received nothing by mouth.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365264
If continuation sheet
Page 4 of 4
