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Complaint Investigation

O'neill Healthcare Lakewood

Inspection Date: August 27, 2025
Total Violations 1
Facility ID 365267
Location LAKEWOOD, OH
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Inspection Findings

F-Tag F0690

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, record review, and interview, the facility failed to ensure Resident #87 received appropriate incontinence care. This affected one resident (Resident #87) of three residents reviewed for incontinence care. The total census was 105.Findings include:

Record review of Resident #87 revealed she was admitted to the facility 06/05/20 and had diagnoses including dementia, diabetes, and encounter for palliative care.

Review of the minimum data set 3.0 assessment dated [DATE REDACTED] revealed she had significant cognitive impairment, was always incontinent, had no listed allergies and no orders or care plan indicating specific alterations to common incontinence care practices.

Observation of an incontinence care procedure for Resident #87 on 08/25/25 at 8:43 A.M. by Certified Nurse Aide (CNA) #501 revealed CNA #501 prepared for the procedure by wetting half of two towels with water. She wiped the resident’s front perineal area twice with one wetted towel, used the dry half of

the same towel to dry it, then repeated the process on the resident’s backside. No soap or other peri-care area approved cleaning product was used during the process.

Interview with CNA #501 on 08/25/25 at 8:56 A.M. confirmed the above observations. She said she believed Resident #87 had allergies and could not use soap. The surveyor brought up the resident’s chart on their laptop at this time and confirmed with CNA #501 the resident had no listed allergies and no orders against using soap for incontinence care.

Record review of the facility’s incontinence care policy dated 01/2024 revealed staff were to give appropriate care after each incontinence episode, including washing affected areas with body wash, cleanser, or soap and water.

This deficiency represents noncompliance investigated under Complaint Number 2577547.

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

Event ID:

📋 Inspection Summary

O'NEILL HEALTHCARE LAKEWOOD in LAKEWOOD, OH inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

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 LAKEWOOD, 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 LAKEWOOD or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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