Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Accord Care Community Orrville Llc during CMS and state inspections, most recent first.
The facility failed to ensure timely wound care interventions for two residents. One resident did not receive a wound clinic referral or ordered lab tests as directed by a practitioner, resulting in unmanaged pressure ulcers. Another resident, dependent on staff for ADLs and at risk for skin breakdown, was found in bed without required heel protector boots, a lapse confirmed by both the resident and an LPN.
A resident with quadriplegia and hand contractures did not receive prescribed rolled washcloths or splints to both hands as ordered, and staff confirmed the absence of a restorative program to maintain or improve range of motion after therapy services ended. Observations and staff interviews verified that the resident's contracture interventions were not in place, and no system existed to prevent further decline in functional abilities.
Surveyors found that several residents had dirty bedding, missing thermostat covers, and detached bathroom sink molding in their rooms. These issues were confirmed by an LPN and the housekeeping supervisor, while the regional facilities manager was unaware of the problems due to the recent resignation of the maintenance director. The deficiency had the potential to impact all residents.
A resident's personal funds were not refunded to their spouse within the required 30-day period following the resident's death. Despite multiple contacts and assistance from the Ombudsman, the refund check was delayed for several months, and facility staff confirmed the delay without providing a reason. The resident had multiple serious medical conditions at the time of death.
A resident with multiple vascular wounds on her lower extremities did not receive adequate pain management in a timely manner. Despite having a care plan, the facility failed to assess and treat the resident's pain effectively, particularly during dressing changes. The resident frequently reported high levels of pain, but pain assessments and timely administration of pain relief were lacking, as confirmed by staff interviews and observations.
The facility failed to administer the COVID-19 vaccine to residents who had consented, leading to several residents contracting the virus during an outbreak. Despite consent, the facility did not schedule a vaccine clinic or order vaccines, leaving residents unprotected. One resident required hospital treatment for COVID-19 and pneumonia, while another experienced symptoms after testing positive.
A staffing shortage at a facility left only one LPN, one RN in training, and one CNA to care for 53 residents, including those in a memory care unit. The CNA, new to the facility, was unable to access care plans or clean linens, resulting in inadequate care. The facility's policy requiring shift-to-shift reports was not followed, and the Administrator acknowledged the staffing issues.
A facility failed to ensure staff wore the correct PPE when entering a COVID-19 positive resident's room. An Agency CNA and the Maintenance Director entered the room without the required PPE, despite the resident being on droplet isolation precautions. The facility's Director of Nursing confirmed the PPE requirements, which were not followed. Education records showed the staff had not received recent PPE training.
A facility failed to ensure comprehensive and routine assessment of a resident's non-pressure related skin issues, leading to a deficiency. The resident, with a history of COPD and diabetes, had an abrasion on the right lower extremity that was initially assessed and treated, but subsequent monitoring was not consistently documented. The wound later progressed to a non-pressure chronic ulcer with fat layer exposure, as classified by an outside wound healing center. Despite being prescribed antibiotics and scheduled for follow-up, the resident was unable to attend due to an acute illness, and the facility did not ensure continued wound monitoring.
A facility failed to implement fall prevention interventions and update care plans for a resident at high risk for falls. The resident, with severe cognitive impairment, experienced two falls. The first fall investigation lacked documentation of witness statements and whether interventions like elbow protectors were used. The care plan was not updated with new interventions. The second fall resulted in visible bruising and a head injury, again lacking documentation of interventions. Staff confirmed the deficiencies in documentation and care plan updates.
The facility did not maintain food at palatable temperatures, affecting 54 residents. Several residents complained about cold and unpalatable food. Observations showed that while food was initially hot, it cooled significantly by the time it was served. A test tray confirmed the food was too cold, and the facility lacked a policy on required food temperatures at service.
A facility failed to maintain a medication error rate below five percent, resulting in a 6.67% error rate. An LPN did not prime insulin pens before administering doses to a resident with diabetes, contrary to manufacturer's guidelines. This oversight had the potential to affect additional residents receiving insulin injections, as confirmed by the DON.
The facility failed to meet the dietary preferences of four residents, including serving orange juice to a resident who disliked it and not providing milk to two residents who requested it. These actions were contrary to the facility's policy on therapeutic diets.
A resident with dementia had conflicting advanced directives in their medical records, with one indicating Full Measures and another indicating DNR-CC. The facility's policy required consistent documentation, but the directives in the hard chart and electronic record were not aligned. An LPN and the Administrator confirmed the inconsistency, which could lead to confusion in emergency situations.
A resident with significant cognitive and physical impairments was found with a bruise on the forehead, but the facility failed to promptly notify the resident's POA, who discovered the injury herself. The facility's policy required immediate notification of changes in a resident's condition, which was not followed in this instance.
A resident with dementia and muscle weakness sustained a forehead bruise of unknown origin, which was not reported to the State agency as required. The injury was discovered by an LPN during breakfast, and the resident's Power of Attorney was informed but not given an explanation. Observations suggested the bruise might have been caused by contact with the bed's side rail, contrary to initial suggestions of a mechanical lift incident.
A resident with multiple dependencies was found with a forehead bruise, but the LTC facility failed to conduct a thorough investigation. Initial observations suggested the injury might have been caused by a Hoyer lift, but further examination indicated it could have been from a bed rail. The facility did not follow its policy for reporting and investigating such injuries, leading to a deficiency.
A facility failed to provide appropriate treatment for a resident's moisture-associated dermatitis (MASD), leading to inadequate healing. The resident, with Alzheimer's and diabetes, had an intervention for incontinence care, but the zinc cream treatment was not consistently ordered or documented. Staff interviews revealed the resident sometimes refused care, and a 4-N-1 Skin Protectant was used instead, which was not a treatment for MASD. Observations confirmed MASD presence, and the physician's order was not initially in the electronic health record.
A resident with severe cognitive impairment and incontinence was left sitting in a common area with a strong odor of urine and a stained chux pad, indicating a lack of timely care. Despite the resident's care plan requiring regular incontinence care, staff failed to address the issue promptly, resulting in the resident's brief, pants, chux pad, and wheelchair cushion being saturated with urine.
A facility failed to investigate an allegation of verbal abuse involving a resident with intact cognition who required substantial assistance for ADLs. The resident reported an inappropriate comment made by an STNA during care, but the facility did not document or investigate the incident as required by their policy. The DON was aware but did not conduct a thorough investigation, and the interim administrator was not informed of the incident.
The facility failed to honor food preferences for three residents, serving them items they disliked despite clear documentation on their diet tray tickets. The Dietary Manager acknowledged the errors and mentioned plans to update preferences and audit diet tickets.
The facility did not complete required 90-day and annual performance evaluations for several STNAs, potentially affecting all 58 residents. This issue was confirmed by the Business Office Manager during a complaint investigation.
Failure to Provide Timely Wound Care and Maintain Preventative Devices
Penalty
Summary
The facility failed to maintain proper wound care for two residents. For one resident with multiple complex diagnoses, including a sacral pressure ulcer, a Certified Nurse Practitioner ordered a referral to a wound clinic and laboratory tests for a comprehensive metabolic panel. However, the facility did not follow through with these orders, as the referral was not made and the laboratory tests were not obtained. This was confirmed by both the practitioner and the Regional Director of Clinical Operations, and wound documentation later showed the presence of an unstageable pressure ulcer. For another resident with diabetes, chronic kidney disease, and polyneuropathy, the care plan required the use of heel protector boots while in bed to prevent skin breakdown. Despite this, the resident was observed in bed without the boots, which were found lying against the wall. The resident stated the boots should have been on, and this was verified by an LPN present at the time, who acknowledged the boots should have been in use.
Failure to Maintain Restorative Program and Hand Contracture Interventions
Penalty
Summary
The facility failed to implement a restorative program to prevent the decline of residents' functional abilities, specifically for a resident with contractures of both hands. The resident had multiple diagnoses, including quadriplegia and contractures, and physician orders directed that rolled washcloths be applied to both hands twice daily. The care plan also included this intervention. However, observations revealed that the resident's hands were clenched in a tight-fisted position without the prescribed splints or washcloths in place. This absence was verified by nursing staff during the survey. Interviews with facility staff, including LPNs and the Therapy Director, confirmed that there was no restorative program in place to address range of motion exercises or to implement therapy recommendations after therapy services were discontinued. The Therapy Director acknowledged that residents who had received therapy services were at risk for functional decline due to the lack of restorative follow-up. The Assistant Director of Nursing also verified the absence of a restorative program and the failure to maintain the resident's hand splints as ordered.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, sanitary, and safe environment for its residents. During observations, three residents were found with dirty bedding, and multiple rooms had missing thermostat covers. Additionally, strips of molding that should have been attached to bathroom sinks were found detached and leaning against the wall in some resident bathrooms. These conditions were verified by both nursing and housekeeping staff at the time of observation. Interviews revealed that the Regional Facilities Manager was unaware of the missing thermostat covers and detached molding, attributing the oversight to the recent resignation of the maintenance director without notice. The deficiency was identified during investigations under two complaint numbers and had the potential to affect all residents in the facility.
Failure to Timely Refund Resident Personal Funds After Death
Penalty
Summary
The facility failed to convey a resident's personal funds and provide a final accounting to the resident's representative within 30 days of the resident's death, as required by facility policy. Record review showed that the resident, who had diagnoses including Alzheimer's Disease, dementia, severe protein-calorie malnutrition, congestive heart failure, and type 2 diabetes mellitus with diabetic neuropathy, expired in the facility. The resident's spouse reported not receiving the refund check for the resident's personal funds until several months after the resident's death, despite contacting the Ombudsman for assistance. Interviews with the Business Office Manager and the Administrator confirmed that the refund check was not issued within the required 30-day timeframe, and no explanation was provided for the delay. The Ombudsman also confirmed being contacted by the resident's spouse and subsequently speaking with the Administrator, who stated they were working on the issue. Documentation showed that the refund check for $759.00 was eventually issued to the resident's spouse, but not in a timely manner as stipulated by facility policy.
Inadequate Pain Management for Resident with Vascular Wounds
Penalty
Summary
The facility failed to implement an effective pain management program for a resident with multiple vascular wounds on her lower extremities. The resident, who was cognitively intact, had a history of peripheral vascular disease, major depressive disorder, type two diabetes, and heart failure. Despite having a care plan that included administering analgesia and monitoring pain, the facility did not adequately assess or treat the resident's pain prior to wound care treatments. The resident's medical records revealed multiple instances where pain assessments were not conducted, and pain medication was not administered in a timely manner. The resident frequently reported pain, especially during dressing changes, but there was no documented evidence of pain assessments or administration of pain relief prior to these procedures. The resident's pain was often rated high on a scale of zero to ten, yet the facility failed to provide consistent pain management. Interviews with staff and observations confirmed that the resident experienced significant pain, particularly during wound care. Staff members acknowledged the resident's complaints of pain and the ineffectiveness of the current pain management approach. The facility's policy on administering pain medications emphasized the importance of assessing pain and recognizing non-verbal signs, but these guidelines were not followed, leading to inadequate pain management for the resident.
Failure to Administer COVID-19 Vaccine to Consenting Residents
Penalty
Summary
The facility failed to ensure that residents who had consented to receive the COVID-19 vaccination were administered the vaccine. This deficiency affected several residents, including four specific individuals who had consented to the vaccine but did not receive it. The failure to administer the vaccine was due to the facility's inability to schedule a COVID-19 clinic or order the vaccines from the pharmacy in a timely manner. As a result, these residents were left unprotected during a COVID-19 outbreak within the facility. One resident, who had consented to the vaccine upon admission, tested positive for COVID-19 and was transferred to the emergency room with symptoms of shortness of breath, low oxygen saturation, and chest pain. The resident was diagnosed with COVID-19 and pneumonia and required ongoing hospital treatment. Another resident, who also consented to the vaccine, tested positive for COVID-19 and experienced symptoms such as congestion and malaise. This resident had not been provided the vaccine prior to contracting the virus. The facility's infection control log revealed that multiple residents tested positive for COVID-19 during the outbreak. Interviews with facility staff, including the Administrator, confirmed that the residents who had consented to the vaccine were not administered it due to a failure to schedule a clinic and order the vaccines. The facility's COVID-19 policy emphasized the importance of vaccination, but the lack of timely action resulted in residents being exposed to and contracting the virus.
Staffing Shortage Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to provide timely care to all 53 residents, including those in a locked memory care unit. On the morning of 02/03/25, the facility was left with only one LPN, one RN in training, and one CNA after multiple staff members called off. This left the memory care unit unattended for a period, and the remaining staff were unable to provide adequate care, including timely incontinence care and repositioning of residents. Agency CNA #208, who was new to the facility, was the only CNA present and was directed to the memory care unit without receiving a proper report or access to care plans. She found residents in need of care, including one covered in bowel movement, and was unable to access clean linens due to a locked laundry area. The CNA expressed concerns about resident safety and her ability to provide adequate care under these conditions. Interviews with staff confirmed the lack of coverage and the absence of a shift-to-shift report. The facility's policy requires CNAs to complete a walkthrough and provide a detailed report to the oncoming shift, which did not occur. The Administrator acknowledged the staffing shortage and the failure to ensure proper coverage, noting that the facility's memory care unit should be staffed 24 hours a day.
Failure to Adhere to PPE Protocols for COVID-19 Positive Resident
Penalty
Summary
The facility failed to ensure that staff donned and doffed the correct personal protective equipment (PPE) when entering and exiting the room of a resident who was COVID-19 positive. This deficiency was observed when an Agency Certified Nursing Assistant (CNA) and the Maintenance Director entered the room of a COVID-19 positive resident without wearing the required PPE, which included gloves, an N95 respirator mask, gowns, and face shields. The resident was on droplet isolation precautions, and a sign indicating this was posted outside the room. Despite this, the staff members only wore surgical masks and did not adhere to the facility's infection control protocols. The incident occurred during a COVID-19 outbreak in the facility, where 20 residents had tested positive. The facility's Director of Nursing confirmed the PPE requirements for entering a COVID-19 positive room, which the staff failed to follow. A review of the facility's recent education records revealed that the CNA and Maintenance Director had not signed off on receiving education related to PPE and droplet precautions. The facility's policy on transmission-based precautions was also reviewed, which outlined the necessary protective measures for staff entering rooms of residents with infections transmitted by droplets.
Failure to Monitor Non-Pressure Related Skin Issues
Penalty
Summary
The facility failed to ensure comprehensive and routine assessment of non-pressure related skin issues for a resident, leading to a deficiency. Resident #10, who had a medical history including chronic obstructive pulmonary disease, type two diabetes mellitus with diabetic neuropathy, and peripheral vascular disease, was admitted with an abrasion on the right lower extremity. The wound was initially assessed and treated, but subsequent monitoring was not consistently documented. The wound was described as an abrasion on 01/03/25 and 01/16/25, but no further wound monitoring was recorded after the latter date. The resident's wound was later classified as a non-pressure chronic ulcer with fat layer exposure by an outside wound healing center, indicating a progression in the wound's severity. Despite being prescribed antibiotics for a wound infection and being scheduled for follow-up at the wound center, the resident was unable to attend due to an acute illness. The facility's failure to ensure continued wound monitoring after the resident's visit to the wound center on 01/16/25 was confirmed by Compliance Specialist #206. This deficiency was investigated under Complaint Numbers OH00161733 and OH00161732.
Failure to Implement Fall Prevention and Update Care Plans
Penalty
Summary
The facility failed to implement documented fall prevention interventions and did not update care plans in a timely manner to prevent repeat falls for a resident. The resident, who was severely cognitively impaired and at high risk for falls, experienced two falls within a short period. The first fall occurred when the resident was found on the floor between beds, likely rushing to the bathroom. The investigation lacked documentation of witness statements, the resident's last toileting, and whether the resident was wearing elbow protectors and non-skid socks. The care plan was not updated to include new interventions after this fall. The second fall happened two days later, with the resident found on the floor with visible bruising and a closed head injury. Again, there was no documentation regarding the use of elbow protectors or the resident's last toileting. The facility's policy required monitoring and documentation of residents' responses to interventions, which was not followed. Interviews with staff confirmed the lack of documentation and timely updates to the care plan, contributing to the deficiency.
Food Temperature Deficiency
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures, affecting 54 residents who received meals. During the annual survey, several residents reported that their food was cold and not palatable. Observations of the tray line revealed that while food was initially above 165 degrees Fahrenheit, by the time it was served, the temperature had dropped significantly. A test tray showed that the chicken thigh was at 108 degrees Fahrenheit and the peas at 115 degrees Fahrenheit, which the Dietary Manager acknowledged as too cold. The facility did not have a policy specifying the required food temperatures at the point of service.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.67% due to two errors in 30 opportunities. This deficiency was identified during a review of medication administration for a resident with type two diabetes mellitus and diabetic chronic kidney disease. The resident required insulin administration as part of their care plan. However, the Licensed Practical Nurse (LPN) responsible for administering the insulin did not follow the manufacturer's guidelines for priming the insulin pen before injection. This oversight occurred during the administration of both insulin lispro and insulin glargine, leading to potential inaccuracies in the insulin dosage administered. The LPN admitted to not priming the insulin pen and was unaware of the correct procedure, as evidenced by their question, "How do you do that?" This lack of knowledge and adherence to proper medication administration protocols had the potential to affect not only the resident in question but also an additional 13 residents who received insulin injections. The Director of Nursing confirmed that the LPN worked with residents throughout the facility, further highlighting the potential widespread impact of this deficiency.
Failure to Accommodate Resident Dietary Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the preferences of four residents, as observed during a survey. Resident #3, who has severe cognitive impairment due to dementia and Alzheimer's disease, was served orange juice despite a documented dislike for it. Similarly, Resident #8, who has intact cognition and is on a no added salt diet, was served cake instead of the prescribed fruit for dessert. These discrepancies were confirmed by staff during the survey. Additionally, Resident #16, who has moderately impaired cognition and requires a consistent carbohydrate diet, was not provided with the requested eight ounces of milk with their meal. Resident #34, who also has moderately impaired cognition and is on a regular diet with double portions, was similarly not given milk as per their preference. These failures to adhere to dietary preferences and orders were verified by staff and are in violation of the facility's policy on therapeutic diets, which mandates that diets be prescribed in accordance with residents' goals and preferences.
Inconsistent Advanced Directives for a Resident
Penalty
Summary
The facility failed to ensure that the advanced directives for a resident were accurate and consistent across different records. Resident #108, who was not cognitively intact due to conditions such as dementia, insomnia, and hypertension, had conflicting advanced directives in their medical records. The hard copy chart contained two different directives: one indicating Full Measures, requiring all life-saving measures, and another indicating Do Not Resuscitate - Comfort Care (DNR-CC), which specified that CPR should not be initiated in case of cardiac or respiratory arrest. Both forms were dated the same day, and the electronic medical record indicated the resident's directive as DNR-CC. During an interview, an LPN and the Administrator confirmed the presence of two different advance directives in the hard chart and stated that in the event of a cardiac or respiratory arrest, staff would follow the directive in the hard chart. They acknowledged that the directives in the electronic record and the hard copy chart should be consistent, but they were not for Resident #108. The facility's policy required that information about advance directives be prominently displayed in the medical record and reviewed annually with the resident or their representative, but this was not adhered to in this case.
Failure to Notify POA of Resident Injury
Penalty
Summary
The facility failed to timely notify the Power of Attorney (POA) of Resident #25 about an injury of unknown origin. Resident #25, who was readmitted with diagnoses including age-related physical debility, dementia, and Parkinson's disease, was found with a bruise on the forehead. The resident was dependent on staff for various activities and was rarely or never understood, indicating significant cognitive and physical impairments. On the morning of the incident, a Licensed Practical Nurse (LPN) noticed the bruise while feeding the resident in the dining room, but the POA was not informed until later, despite being present at the facility. Interviews revealed that the POA, who worked as a receptionist at the facility, discovered the injury herself when she visited her mother. The POA was not notified by the staff and had to inquire about the injury upon noticing it. The facility's policy required prompt notification of changes in a resident's condition to the resident, their physician, and their representative, which was not adhered to in this case. This deficiency was identified during an investigation under Complaint Number OH00158226.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State agency, affecting a resident who was reviewed for abuse. The resident, who was readmitted with diagnoses including dementia and muscle weakness, was dependent on staff for all activities of daily living. A bruise was discovered on the resident's forehead, which was not reported as required by the facility's policy on abuse, neglect, and injuries of unknown origin. The injury was first noted by an LPN during breakfast, who observed a bruise with an open area on the resident's forehead. The resident's Power of Attorney, who also worked at the facility, noticed the injury later that morning and was informed by the nurse that the cause was unknown. Despite the facility's policy requiring immediate reporting of such injuries, no Facility Reported Incident (FRI) was completed for this case. Interviews and observations revealed inconsistencies in the explanation of how the injury occurred. While the Director of Nursing suggested the injury might have been caused by a mechanical lift, observations indicated that the bruise's location and shape were consistent with contact with the bed's side rail. The facility's policy mandates that all injuries of unknown origin be reported to the appropriate authorities, but this was not done in this instance.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, identified as Resident #25, who was dependent on staff for all activities of daily living due to multiple diagnoses including dementia and Parkinson's disease. The resident was found with a bruise on the forehead, which was not present the previous day. The bruise was initially noted by an LPN during breakfast, but no immediate investigation was initiated to determine the cause of the injury. Interviews with staff revealed inconsistencies in the accounts of how the injury might have occurred. The Director of Nursing (DON) and other staff speculated that the injury could have been caused by contact with a Hoyer lift bar during a transfer, but observations and further interviews suggested that the injury's location was more consistent with contact with the bed's side rail. Despite these observations, the facility did not conduct a comprehensive investigation, as required by their policy, which mandates interviewing all staff who had contact with the resident during the period of the alleged incident. The facility's policy on reporting and investigating injuries of unknown origin was not followed, as the injury was not reported to the necessary authorities, and the investigation was not documented thoroughly. The DON confirmed that only two staff members and the resident's Power of Attorney were interviewed, and no other staff or residents were questioned. This lack of thorough investigation and documentation represents a deficiency in the facility's compliance with its own policies and regulatory requirements.
Inadequate Treatment for Moisture-Associated Dermatitis
Penalty
Summary
The facility failed to ensure appropriate treatment for moisture-associated dermatitis (MASD) for a resident, leading to inadequate healing. The resident, who had Alzheimer's disease, dementia, and diabetes, was admitted to the secured memory care unit. An intervention was in place to provide incontinence care and apply barrier cream after each episode. However, the zinc cream treatment for MASD was discontinued on a specific date, and there was no evidence of the treatment being ordered or provided for a period thereafter. The resident's skin condition was documented as improving, but the treatment was not consistently documented in the medical records. Interviews with staff revealed that the resident sometimes refused care, which contributed to the inconsistency in treatment. The Director of Nursing indicated that a 4-N-1 Skin Protectant barrier cream was used during the period when the zinc cream was not ordered, but a manufacturer representative clarified that this product was not a treatment for MASD. Observations confirmed the presence of MASD on the resident's buttocks, and it was noted that the physician's order for treatment was not initially entered into the electronic health record. This deficiency was investigated under a specific complaint number.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as Resident #15, who was admitted with diagnoses including diffuse traumatic brain injury, lack of coordination, and schizoaffective disorder. The resident's care plan indicated they were incontinent of bowel and bladder, requiring regular assessment and incontinence care, including the application of barrier cream after each episode. Observations revealed that the resident was left sitting in a common lounge area in a wheelchair with a strong odor of urine and a visibly stained chux pad, indicating a lack of timely care. Further observations showed that the resident remained in this condition for an extended period, as staff members, including the Medical Records/Activity Director, did not address the issue. An interview with a State tested Nurse Aide (STNA) revealed that the resident was last changed after breakfast and before lunch, but the STNA could not specify the exact time. Eventually, another STNA confirmed that the resident's incontinence brief, pants, chux pad, and wheelchair cushion were saturated with urine, highlighting the facility's failure to adhere to its Perineal Care policy, which aims to ensure cleanliness, comfort, and infection prevention.
Failure to Investigate Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to complete an investigation of an allegation of potential staff-to-resident verbal abuse involving Resident #51. The resident, who had intact cognition and required substantial assistance for activities of daily living, reported an incident where a State tested Nursing Assistant (STNA) made an inappropriate comment during care. Despite the resident stating that they did not feel it was abuse and felt safe, the facility did not document or investigate the incident as required by their Abuse Prevention Policy. Interviews revealed that the Director of Nursing (DON) was aware of the incident but did not conduct a thorough investigation or document any findings. Additionally, the Regional Director of Operations, who was the interim administrator at the time, was not informed of the incident and stated that she would have investigated it. The facility's failure to investigate and document the incident represents noncompliance with their policy to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food preferences for three residents, which was identified through observation, interview, and record review. Resident #15, who had intact cognition and required setup for eating, was served peas despite having a documented dislike for them on her diet tray ticket. Similarly, Resident #18, who also had intact cognition and required setup for eating, was served an egg bake for breakfast, although her diet tray ticket indicated a dislike for eggs. The Dietary Manager acknowledged the error, stating that the ticket was not updated. Resident #44, with intact cognition and requiring substantial assistance for eating, was also served an egg bake despite her diet tray ticket indicating a dislike for eggs. The resident confirmed that she frequently received eggs and had to request alternatives if she was still hungry. The Dietary Manager, who was recently employed, admitted to the kitchen being disorganized and mentioned plans to update residents' preferences and audit diet tickets. This deficiency was investigated under Complaint Number OH00155428.
Failure to Conduct Required STNA Evaluations
Penalty
Summary
The facility failed to conduct required 90-day and annual performance evaluations for state tested nursing assistants (STNAs), affecting five out of six STNAs whose personnel files were reviewed. This deficiency was identified during a complaint investigation and had the potential to impact all 58 residents in the facility. Specifically, STNAs hired on various dates in 2024 and earlier did not have their 90-day or annual evaluations completed as required. The Business Office Manager confirmed the absence of these evaluations for the identified STNAs.
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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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Nursing homes near Orrville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orrville Pointe | 0.8 mi | ★★★★★ | 5 | 0 |
| Glendora Health Care Center | 4.9 mi | ★★★★★ | 3 | 0 |
| Smithville Western Care Center | 5.5 mi | ★★★★★ | 0 | 0 |
| Apostolic Christian Home Inc | 5.7 mi | ★★★★★ | 0 | 0 |
| Shady Lawn Nursing Home | 6.5 mi | ★★★★★ | 0 | 0 |
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