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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eagle Pointe Skilled Nursing & Rehab during CMS and state inspections, most recent first.
A resident with multiple serious conditions and total dependence on staff for transfers and toileting repeatedly reported that two CNAs providing his care smelled strongly of marijuana and that he did not want them caring for him, while other residents and staff also reported ongoing strong marijuana odors on these CNAs and concerns about possible impairment. A unit manager and other staff acknowledged smelling marijuana on the CNAs, and the administrator was informed, but the facility’s grievance documentation lacked completed follow-up with the resident, and leadership confirmed that, beyond general staff education, no further action was taken to ensure the CNAs were not working while smelling of marijuana or possibly impaired, resulting in a failure to promptly and adequately resolve the grievance.
Multiple cognitively intact residents with orders for opioid and gabapentin pain medications were affected when an agency RN on a night shift misappropriated controlled drugs and other medications. Pharmacy records showed oxycodone deliveries for two residents, but the corresponding controlled substance administration records were missing. During shift change, the agency RN reported having dropped and reorganized controlled substance cards and completed a count that initially appeared correct. Shortly after she left, oncoming LPNs discovered that a full card and additional tablets of oxycodone, as well as several cards of gabapentin, were missing, and that some doses were documented as wasted with cosignature initials that did not match any staff on duty. A second agency nurse denied assisting with reorganizing or wasting medications, and facility staff later confirmed the missing medications and irregular documentation, establishing that residents were not protected from misappropriation of their medications.
A cognitively intact resident with emphysema, respiratory failure, and severe morbid obesity, who required moderate assistance with bathing, reported that a CNA applied vinegar to his leg during a shower after he said he did not want it used. The CNA stated she had used vinegar for other residents for odor and yeast issues and added it to a washcloth with soap and water, claiming the resident did not refuse until after the shower. There were no MD orders for vinegar, no documentation that vinegar was used during the resident’s showers, and no record that the resident was educated about or consented to its use or that he reported being upset. A grievance documented the resident’s complaint, and a social service staff member reported the resident said he had refused vinegar and that the CNA claimed she was instructed to use it, which the staff member denied, contrary to the facility’s Resident Rights policy requiring residents be informed of and participate in their treatment.
A cognitively intact resident with multiple chronic conditions who required assistance with bathing reported that a CNA applied vinegar to his body during a shower after he explicitly refused its use. Record review confirmed there was no physician order for vinegar for this resident, and both the NP and PCP/Medical Director stated they had never ordered vinegar or acetic acid baths for any resident. The CNA admitted using vinegar baths for some residents to minimize yeast and odors, despite facility policies requiring a physician’s order for medications and any skin or wound-related procedures.
A facility failed to conduct ordered lab tests for a resident with multiple diagnoses, including diabetes and seizures. Despite physician orders for regular lab tests such as Keppra and Ferritin levels, these were not completed since admission. The Vitamin D level was also overdue. The DON confirmed the oversight, which was against the facility's policy requiring staff to arrange for necessary tests.
A facility failed to provide trauma-informed care for a resident with PTSD, as there was no care plan addressing PTSD or associated triggers, and no psychosocial assessment was conducted. Despite the resident's request to avoid male caregivers and preference for bed baths due to PTSD triggers, staff were unaware of these needs. The facility's policy required universal screening and individualized care plans, which were not followed.
A resident with multiple sclerosis and muscle weakness did not receive ordered adaptive eating equipment, such as built-up utensils and a two-handled mug, during meals. Observations and staff interviews revealed a lack of communication and coordination between the kitchen and nursing staff, resulting in the resident using regular silverware and a plastic cup. The facility's policy on assistive devices was not followed, potentially affecting other residents with similar needs.
Failure to Promptly Resolve Grievances About Staff Smelling of Marijuana and Incomplete Grievance Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to promptly address and resolve a resident grievance regarding staff smelling of marijuana while providing care, and to properly document and follow up on that grievance. One resident with intact cognition and significant physical dependence on staff for activities of daily living reported that two CNAs providing his care smelled strongly of marijuana. This resident, who had multiple serious medical diagnoses including panlobular emphysema, COPD, dependence on a respirator, heart failure, type 2 diabetes, muscle wasting, insomnia, and anxiety, stated that the odor was so strong it upset him and caused him to feel he could not trust these CNAs to safely use a mechanical lift for his transfers. He reported his concerns to multiple facility staff, including the DON, ADON, scheduler, and social services designee, and indicated that this was not the first time he had raised the issue. Facility documentation showed that a unit manager completed a witness statement after the resident reported that two CNAs smelled like marijuana. The unit manager documented that she could smell a faint odor of marijuana on the CNAs, although she did not believe they appeared impaired, and she told them it was not appropriate to come to work smelling like marijuana. A resident concern/complaint form and a resident/family grievance form were completed, indicating that the administrator spoke with the evening supervisor and that the CNAs were told they were not to smell like marijuana. However, the grievance form’s follow-up section, which should document the name and date of the individual contacted, comments, and the staff member completing follow-up with the resident or family, was left blank. The DON later verified that the grievance documentation was incomplete. Multiple residents and staff corroborated ongoing concerns about staff smelling of marijuana. Another cognitively intact resident reported that one CNA always smelled of marijuana, that the odor was very strong, and that the CNA moved very slowly while providing care, causing concern that she might be impaired. This resident stated that both CNAs smelled of marijuana on more than one occasion and that the odor was noticeable even when they were behind the nurse’s station. A third resident reported that residents at council meetings had stated they smelled marijuana in the building and on staff, and that residents had informed administration of these concerns as an ongoing problem. Several CNAs and an LPN reported smelling marijuana odor on the same CNAs while they were working, with one CNA stating she believed they were working impaired based on incomplete work from the prior shift, and another CNA reporting she had seen them vaping a substance with a strong marijuana odor during breaks and had reported this to the night unit manager. The scheduler and social services designee confirmed that the primary resident had texted them about the CNAs smelling of marijuana and that they had notified the administrator and nursing leadership. The DON acknowledged that the facility was a drug-free workplace and that smelling of marijuana constituted reasonable suspicion for testing, and further acknowledged that, aside from general staff education, no additional corrective action was taken to ensure the CNAs were not working while smelling of marijuana or possibly impaired, and that grievance follow-up with the resident was not completed or documented.
Misappropriation of Controlled Medications by Agency RN During Night Shift
Penalty
Summary
The deficiency involves the facility’s failure to protect several residents from misappropriation of their medications, specifically controlled substances and other drugs. Multiple residents with intact cognition and orders for pain medications, including opioids and gabapentin, were affected. One resident with rheumatoid arthritis, chronic pain, and COPD had an order for scheduled oxycodone; another resident with COPD, diabetes, and morbid obesity had an as-needed oxycodone order; a third resident with schizophrenia and phantom limb pain had an order for gabapentin; a fourth resident with arthritis and muscle wasting also had an order for gabapentin; and a fifth resident with osteomyelitis and rheumatoid arthritis had an as-needed oxycodone order. At the time of later interviews, the cognitively intact residents reported they were unaware of any misappropriation and felt their pain was well managed, but records showed that their medications had been misappropriated. The events leading to the deficiency centered on a night shift during which an agency RN was the only nurse assigned to one side of the building, with an agency LPN assigned to the other side. Pharmacy delivery records showed that oxycodone tablets had been delivered for two residents, but the corresponding Individual Patient Controlled Substance Administration Records for those medications were missing. During the 7:00 p.m. to 7:00 a.m. shift, the agency RN documented wasting oxycodone tablets for two former residents, with cosignature initials that the facility later determined did not match any staff on duty. The next morning, during shift-to-shift controlled substance counts, the agency RN reported that she had dropped all the controlled substance cards and that another nurse had helped her reorganize them. Witness statements from oncoming LPNs described that the agency RN attempted to have them clock her out on the agency app before report, stated that the cards had been dropped and reorganized, and then completed a count that initially appeared correct. Within minutes after the agency RN left, the oncoming LPNs recounted the controlled substances and discovered discrepancies. A full card of oxycodone for one resident and four oxycodone tablets for another resident were missing, along with the associated count sheets. Additional review showed that a card of oxycodone signed into the cart two days earlier was no longer present and not documented as removed, and that some controlled substances were documented as wasted with unrecognizable cosignature initials. Further investigation revealed that two cards of gabapentin for one resident and one card of gabapentin for another resident were also missing. The agency LPN who was alleged to have assisted with reorganizing the cards denied ever going to the other side or wasting medications with the agency RN. Facility staff, including the MDS nurse and DON, confirmed that multiple oxycodone tablets and gabapentin cards for the identified residents were missing and that the documentation of wasting and cosigning did not match any staff who had worked during the relevant shift. The facility’s abuse, neglect, exploitation, or misappropriation policy addressed reporting requirements but did not contain language stating that residents were to remain free from misappropriation, and the misappropriation of medications was determined to have occurred prior to the survey.
Failure to Honor Resident’s Right to Refuse Treatment and Maintain Dignity During Bathing
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to be informed of and refuse treatment, and to provide care in a manner that maintained the resident’s dignity. The resident, admitted with panlobular emphysema, acute and chronic respiratory failure, and severe morbid obesity, required moderate assistance with bathing and personal hygiene. During a shower, a CNA applied vinegar to the resident’s leg. The resident reported that the CNA told him she needed to pour vinegar on him, that he told her no, and that she proceeded anyway. The CNA stated she had previously used vinegar at the request of other residents for odor and yeast issues, and that she added vinegar to a washcloth with soap and water while assisting this resident. According to the CNA, the resident asked what she was using and why, but she stated he did not tell her no until after the shower, when he began yelling "no means no." Record review showed no physician orders for the use or application of vinegar as a treatment for this resident and no documentation in the nurse’s notes that vinegar had been used during his showers. There was also no documentation that the resident had been educated on the use of vinegar during bathing or personal hygiene, or that he had reported being upset that vinegar was used without his prior knowledge or consent. A grievance form documented that the resident reported the CNA used vinegar on him during his shower. The social service designee reported that the resident told her he had refused the use of vinegar and that the CNA claimed the social service designee had instructed her to use it, which the social service designee denied. The facility’s Resident Rights policy stated that residents have the right to be informed of and participate in their care planning and treatment, which was not followed in this instance.
Unauthorized Use of Vinegar Bath Without Physician Order or Resident Consent
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders, professional standards, and the resident’s expressed preferences. A cognitively intact resident with multiple chronic conditions, including COPD, CHF, OSA, GERD, DVT, Lupus anticoagulant syndrome, anemia, muscle wasting, difficulty walking, pain, major depressive disorder, anxiety, iron deficiency, bilateral hip OA, acute and chronic respiratory failure, and morbid obesity, required moderate assistance with bathing and personal hygiene. During a shower, a CNA applied vinegar topically to the resident after telling him she had to pour vinegar on him. The resident stated he refused the use of vinegar, but the CNA applied it anyway. Record review showed no physician order for the use or application of vinegar for this resident, and the NP confirmed he had not ordered vinegar and would not order acetic acid for bathing. The PCP/Medical Director stated she had only discussed vinegar conceptually with staff and had never written an order for its use for any resident. The CNA acknowledged using vinegar baths for some residents to minimize yeast and odors. Facility policies on Medication and Treatment Orders and Wound Care required a physician’s order for medications and any procedure involving skin and wound management, but vinegar was used on the resident without such an order and in direct opposition to the resident’s stated refusal.
Failure to Conduct Ordered Lab Tests for a Resident
Penalty
Summary
The facility failed to ensure that laboratory tests were obtained as ordered for a resident, which was identified during a review of medical records and interviews. The resident, who was admitted with diagnoses including diabetes, dementia, hypertension, and seizures, had physician orders for several lab tests to be conducted every six months, including a Complete Blood Count (CBC), Hemoglobin A1c (HbA1c), Liver Function Test, Lipid Panel, Thyroid-Stimulating Hormone (TSH), Keppra level, Vitamin D level, and Ferritin level. However, there was no documented evidence that the Keppra and Ferritin levels were completed since the resident's admission, and the Vitamin D level, which was last completed on 07/15/24, was overdue for a repeat test by 01/15/25. The Director of Nursing confirmed during an interview that the required lab tests had not been completed as ordered. The facility's policy, last revised in November 2018, stated that the physician would identify and order diagnostic and lab testing based on the resident's needs, and staff were responsible for processing test requisitions and arranging for tests. Despite these protocols, the necessary lab tests were not conducted, leading to a deficiency in providing appropriate treatment and care according to the resident's orders, preferences, and goals.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for a resident diagnosed with PTSD, morbid obesity, and anxiety disorder. The resident, who was cognitively intact, had a history of PTSD from past sexual abuse and a sexual assault in a previous nursing facility. Despite the resident's request to avoid male caregivers and preference for bed baths due to triggers associated with the shower room, the facility did not have a care plan addressing PTSD or associated triggers. Additionally, there was no psychosocial assessment conducted for the resident, which was contrary to the facility's policy. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's PTSD triggers. The Social Service Designee did not complete psychosocial assessments unless instructed by the MDS nurse, who assumed that contracted Psychological Services would handle these assessments. The MDS/LPN confirmed the absence of a care plan for PTSD and was unsure about staff education on PTSD. Furthermore, a CNA was unaware of the resident's PTSD triggers and had not been educated about the resident's history. The facility's policy required universal screening for traumatic events and the development of individualized care plans to address past trauma, which was not adhered to in this case.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment as ordered for Resident #43, who had diagnoses including multiple sclerosis, muscle weakness, and schizoaffective disorder. The resident had a physician's order for built-up utensils and a two-handled mug for all meals, which was not provided. Observations on two separate occasions revealed that the resident's meal tray lacked the necessary adaptive equipment, and the resident was using regular silverware and a plastic cup without handles. Interviews with staff, including a CNA, LPN, and the Dietary Manager, confirmed the absence of adaptive equipment and highlighted a lack of communication and coordination between the kitchen and nursing staff regarding the resident's needs. The Dietary Manager admitted to discrepancies between the kitchen's records and nursing orders for adaptive equipment, acknowledging that an audit to reconcile these differences had not been conducted. The Dietician was unaware of the resident's need for adaptive equipment, indicating a breakdown in communication and oversight. The facility's policy on assistive devices and equipment, which mandates the provision and supervision of such equipment based on comprehensive assessments, was not adhered to in this case. This deficiency had the potential to affect other residents with similar orders for adaptive equipment.
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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 Orwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ohman Family Living At Blossom | 12.7 mi | ★★★★★ | 0 | 0 |
| Ohman Family Living At Briar | 12.9 mi | ★★★★★ | 2 | 0 |
| Andover Village Retirement Community | 14.7 mi | ★★★★★ | 3 | 0 |
| Jefferson Healthcare Center | 15 mi | ★★★★★ | 0 | 0 |
| Ohio Living Lake Vista | 15.2 mi | ★★★★★ | 8 | 0 |
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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 June 2026) and official state health department websites.