Cycle 1
Health 2024-03-13 · Fire 2024-03-13
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Bay Village, OH
O'neill Healthcare Bay Village
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
605 Bradley Rd, Bay Village, OH
(440) 871-3474
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
138
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
O'neill Healthcare
Operator or chain grouping
Approved since
1971-01-28
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
0.81
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.66
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
2.91
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.69
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.32
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
0.41
CMS adjusted RN staffing hours
Adjusted total hours
2.66
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,530
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.49% · Performance 24.66% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.11% · Performance 8.17% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.60
Baseline 41.89% · Performance 57.14% · Measure score 1.60 · Achievement 1.60 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.16 hours · Performance 3.20 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.98% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 143 · Observed rate 11.89% · Lower 95% interval 8.1% |
| Discharge to community | 36.19% |
50.57%
14.4 pts worse
|
Worse than the National Rate · Eligible stays 143 · Observed rate 29.37% · Lower 95% interval 28.88% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 87.38% |
95.27%
7.9 pts worse
|
Numerator 90 · Denominator 103 |
| Falls with major injury | 0.97% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 103 |
| Discharge self-care score | 59.42% |
53.69%
5.7 pts better
|
Numerator 41 · Denominator 69 |
| Discharge mobility score | 52.17% |
50.94%
1.2 pts better
|
Numerator 36 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 0.97% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 103 · Adjusted rate 0.89% |
| Healthcare-associated infections requiring hospitalization | 8.17% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 101 · Observed rate 9.9% · Lower 95% interval 4.72% |
| Staff COVID-19 vaccination coverage | 6.49% |
8.2%
1.7 pts worse
|
Numerator 10 · Denominator 154 |
| Staff flu vaccination coverage | 13.65% |
42%
28.4 pts worse
|
Numerator 37 · Denominator 271 |
| Discharge function score | 73.91% |
56.45%
17.5 pts better
|
Numerator 51 · Denominator 69 |
| Transfer of health information to provider | 97.3% |
95.95%
1.3 pts better
|
Numerator 36 · Denominator 37 |
| Transfer of health information to patient | 98% |
96.28%
1.7 pts better
|
Numerator 49 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 4.44% |
25.2%
20.8 pts worse
|
Numerator 2 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.8
1.5 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
92.4%
4.7 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.4% · Q2 98.9% · Q3 98.9% · Q4 98.8% · 4Q avg 97.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.6% |
94.5%
2.9 pts worse
|
95.5%
3.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.3%
1 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 3.4% · Q4 3.7% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.3% |
26.1%
6.8 pts better
|
11.4%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 1.2% · Q3 33.8% · Q4 37.5% · 4Q avg 19.3% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
6.2%
1 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 5.6% · Q3 6.7% · Q4 7.2% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
25.4%
8.3 pts better
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 13.5% · Q3 20.0% · Q4 26.1% · 4Q avg 17.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.4% |
11.5%
4.1 pts better
|
16.7%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 2.0% · Q3 12.0% · Q4 8.7% · 4Q avg 7.4% · 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 | 5.9% |
7.7%
1.8 pts better
|
16.3%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.8% · Q3 7.5% · Q4 0.0% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.0% |
6.2%
2.2 pts better
|
14.9%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 2.8% · Q3 4.0% · Q4 2.9% · 4Q avg 4.0% · 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 | 17.2% |
21.7%
4.5 pts better
|
19.8%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 10.9% · Q3 26.1% · Q4 17.0% · 4Q avg 17.2% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
3.7%
0.6 pts worse
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 5.8% · Q3 1.8% · Q4 3.8% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.3% |
78.1%
2.8 pts worse
|
81.7%
6.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 53.7% · Q2 82.4% · Q3 92.3% · Q4 74.3% · 4Q avg 75.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
12.5%
4.9 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 7.4% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.9% |
75.6%
6.3 pts better
|
79.7%
2.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.1% |
25.1%
1 pts worse
|
23.9%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.1% · Observed 26.5% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-03 · Fire 2022-03-03
7 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-08-15 · Fire 2019-08-15
3 health deficiencies
Top issue: Environmental (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-13
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-03-13
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-03-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-03-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-03-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-03-13
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-03-13
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-03-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-03-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-05
F · Potential for more than minimal harm
2022-03-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-03-29
E · Potential for more than minimal harm
2022-03-03
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-03-29
E · Potential for more than minimal harm
2022-03-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-03-29
E · Potential for more than minimal harm
2022-03-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-29
E · Potential for more than minimal harm
2022-03-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-03-29
E · Potential for more than minimal harm
2022-03-03
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 2022-03-29
E · Potential for more than minimal harm
2022-03-03
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-03-29
F · Potential for more than minimal harm
2019-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-02
F · Potential for more than minimal harm
2019-08-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-10-02
F · Potential for more than minimal harm
2019-08-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-10-02
E · Potential for more than minimal harm
2019-08-15
K227 · Egress Deficiencies
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2019-10-02
E · Potential for more than minimal harm
2019-08-15
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 2019-10-02
E · Potential for more than minimal harm
2019-08-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-10-02
E · Potential for more than minimal harm
2019-08-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-10-02
E · Potential for more than minimal harm
2019-08-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-10-02
C · Minimal harm
2019-08-15
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-10-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2026-02-10
E · Potential for more than minimal harm
2026-01-21
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 2026-02-10
D · Potential for more than minimal harm
2026-01-21
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-02-10
D · Potential for more than minimal harm
2026-01-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-10
D · Potential for more than minimal harm
2026-01-21
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 2025-04-10
D · Potential for more than minimal harm
2026-01-21
F774 · Administration Deficiencies
Health
Help the resident with transportation to and from laboratory services outside of the facility.
Corrected 2026-02-10
D · Potential for more than minimal harm
2026-01-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-10
D · Potential for more than minimal harm
2025-03-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-28
D · Potential for more than minimal harm
2024-12-31
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-31
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-06
E · Potential for more than minimal harm
2024-06-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-06-12
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-06-12
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-06-20
F · Potential for more than minimal harm
2024-03-13
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 2024-04-05
D · Potential for more than minimal harm
2024-03-13
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-02-15
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-13
F · Potential for more than minimal harm
2022-03-03
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 2022-03-29
D · Potential for more than minimal harm
2022-03-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-03-29
E · Potential for more than minimal harm
2019-08-15
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 2019-10-02
B · Minimal harm
2019-08-15
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2019-10-02
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
Ziska, Doreen
5% Or Greater Indirect Ownership Interest · Individual
O'neill Management, LLC
Operational/Managerial Control · Organization
Oneill, Deborah
Corporate Director · Individual
Oneill, Deborah
Corporate Officer · Individual
Oneill, John
Corporate Director · Individual
Oneill, John
Corporate Officer · Individual
Trockley, Kevin
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
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Rae Ann Suburban
Westlake, OH
2-star overall rating with 1-star inspections with $10,065 in total fines with 11 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Huntington Woods Care & Rehab Center
Westlake, OH
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
#3
Rae-Ann Westlake
Westlake, OH
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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