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 Orrville Pointe during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, daily wandering, hallucinations, and delusions eloped after a smoke break when she exited a locked unit before the door fully reset. She walked barefoot down the street, refused redirection, and became physically combative with staff until police detained her and returned her for evaluation. The smoking headcount log had no documentation for the smoke break, and the facility policy required residents to be supervised and monitored during smoking times.
The facility failed to employ a full-time RN DON to provide direct oversight of nursing services for all residents. After the prior DON was terminated, an interim DON who also worked at another building was only present one to two days per week, while an ADON who was an LPN handled day-to-day issues and a clinical RN worked weekday shifts but did not function as DON. Staff interviews consistently confirmed the absence of a full-time DON and reliance on the LPN ADON for leadership. The administrator acknowledged there was no full-time DON and that there were no job descriptions for the DON or ADON, and the facility assessment did not list a DON among those completing it, despite identifying the DON as a required member of the IDT and necessary staff classification.
The facility failed to effectively administer operations when leadership did not thoroughly investigate or act on repeated concerns about the DON’s performance and possible alcohol use while on duty. Staff and a behavioral health provider reported the DON’s poor attendance, lack of communication, failure to address clinical issues such as falls and showers, and multiple instances of the DON smelling of alcohol and appearing impaired. CNAs and an LPN described fear of retaliation, difficulty reaching the DON for resident care issues, and unsafe staffing conditions when the DON left or arrived late. Although a performance improvement plan identified substantiated concerns including failure to meet RN coverage, unprofessional conduct, and allegations of working under the influence, there was no evidence that the Administrator or corporate HR monitored the DON’s behavior, audited staffing or documentation, or conducted a documented investigation into these allegations.
A resident with chronic kidney disease, dysphagia, and severe cognitive impairment experienced a fall from bed, after which bleeding from the right elbow was noted and initially cleansed with normal saline, with steri-strips and a dry dressing applied. Following this event, there were no documented treatment orders or ongoing wound care for the elbow skin tear on the TAR, and no further progress note entries describing the wound or its size or monitoring. The ADON confirmed the absence of ordered treatments, wound measurements, and ongoing assessment or documentation related to the skin tear.
A resident with severe cognitive impairment and multiple neuropsychiatric diagnoses was ordered clonazepam at different doses and times. An RN administered a 1 mg clonazepam dose by removing the medication from another resident’s controlled medication card instead of from the correct resident’s supply. The discrepancy was discovered at shift change when controlled drug counts did not reconcile. This occurred despite facility policy requiring verification of the resident’s identity and triple-checking the medication label to ensure the five rights of medication administration.
The facility failed to maintain RN coverage for at least eight consecutive hours a day, seven days a week, as required. A review of staff schedules and payroll records revealed that no RNs were present on specific dates, potentially affecting all 45 residents. This was confirmed through an HR interview.
The facility inaccurately reported RN and DON hours in the PBJ, failing to record any punches for three consecutive days. The BOM, responsible for data submission, was unaware of the discrepancy, which affected all 45 residents.
The facility's infection preventionist failed to ensure staff were fit tested for N95 masks, crucial for preventing disease spread. Two STNAs were observed providing care to a resident under COVID-19 precautions without fit testing or eye protection. The Clinical Manager, also the IP, was not fit tested, and the facility did not conduct annual fit testing, violating CDC and OSHA standards.
The facility failed to provide monthly spend-down letters to residents approaching or over the resource limit, affecting three residents with various medical conditions. Interviews revealed the BOM was unaware of the requirement, despite the facility's policy mandating notification to prevent loss of Medicaid or SSI eligibility.
A facility failed to ensure proper PPE use for a resident in COVID-19 isolation. Despite signage indicating the need for an N95 mask and gloves, two STNAs did not fully adhere to PPE protocols, omitting eye protection and initially not using an isolation gown. Interviews confirmed the staff's awareness of the required precautions, yet they did not comply, and the signage lacked complete PPE instructions.
A facility failed to address pharmacy recommendations in a timely manner for a resident prescribed Olanzapine without an allowable diagnosis. Despite repeated recommendations from the consultant pharmacist to verify the medication's necessity and update the diagnosis list, the issue was not resolved until months later, when the diagnosis was updated to schizoaffective disorder.
A facility failed to monitor a resident's use of the anticoagulant Eliquis, despite the resident's care plan indicating the need for monitoring due to high-risk medications. Interviews with staff confirmed the absence of monitoring orders and documentation, and the facility lacked an anticoagulation policy.
The facility failed to administer influenza and pneumococcal vaccines to two residents as required. One resident, with severe cognitive impairment, did not receive the influenza vaccine for 2023 or the pneumococcal vaccine during admission, despite consent. Another resident, with moderate cognitive impairment, did not receive the influenza vaccine for 2023, with the last recorded vaccination in 2022. The RN Clinical Manager confirmed these deficiencies.
The facility failed to post daily nursing staff information, potentially affecting all 45 residents. An observation revealed no posted information, and an HR interview confirmed the absence of such postings.
The facility's assessment failed to include the infection preventionist role, omitting necessary hours for infection control management. This oversight was confirmed during an interview with the Assistant Administrator, highlighting a gap in planning for resident care and safety.
Resident Eloped During Supervised Smoke Break
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and a documented history of wandering was adequately supervised to prevent elopement and exposure to accident hazards. The resident had diagnoses including schizoaffective disorder, delusional disorder, obsessive compulsive disorder, auditory hallucinations, unspecified dementia with behavioral disturbance, generalized anxiety disorder, homicidal ideations, and ADHD. Her care plan identified that she wandered with no discernable, rational purpose and stated staff were to be aware of her whereabouts at all times and that she would not wander from the unit. The resident’s record showed she was severely cognitively impaired, had hallucinations and delusions, exhibited daily behavioral symptoms, wandered daily, and was independently mobile. On one occasion, while out in the courtyard smoking, she pushed open a gate and ran toward the sidewalk by the street before being stopped and returned to the building. On another occasion, she left the facility property after a scheduled smoke break. The incident record and SRI described that after the smoke break, the resident exited the locked unit during the brief period before the door fully reset, and no alarm sounded. After leaving the unit, the resident walked down the street barefoot and refused attempts by staff to redirect her. She became physically combative with staff, including hitting, biting, punching, and attempting to use a pen as a weapon. Police were called, and the resident was detained and returned to the facility for evaluation. Review of the smoking headcount log showed no documentation for the smoke breaks that day, including the break during which the resident eloped, and the facility policy required residents to be supervised and monitored by staff while smoking during designated smoking times.
Lack of Full-Time RN Director of Nursing and Inadequate Nursing Leadership Structure
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time Director of Nursing (DON) who is a registered nurse and to ensure that this position provided direct oversight of nursing services, as required. Review of staff schedules for a specified week showed that the interim DON, a registered nurse, was present in the facility for only 11 hours on one day and otherwise was only in the building one to two days per week since the prior DON was terminated in February. Interviews with the interim DON confirmed she was serving as DON at another building and only came to this facility intermittently, with a plan for the current Assistant DON, an LPN, to assume the DON role after completing RN school the following year. The facility census at the time was 44 residents. Multiple staff interviews corroborated that the facility did not have a full-time DON. The ADON, an LPN, reported that the previous DON had been terminated and that the interim DON only assisted once or twice a week, while a clinical RN was present in the building eight hours a day Monday through Friday but did not function as DON. Other LPNs and an RN confirmed that the interim DON was only in the facility one to two times a week and that staff brought issues to the ADON, who was not an RN. The Licensed Nursing Home Administrator verified there was no full-time DON and also stated there were no company job descriptions for the DON or ADON positions. Review of the facility assessment showed no DON listed among those completing the assessment, despite the document describing the DON as part of the interdisciplinary team and as a necessary staff classification to meet resident care and operational needs.
Failure to Investigate DON Misconduct and Alleged Impairment
Penalty
Summary
The deficiency involves the facility’s failure to effectively and efficiently administer operations so that residents could attain or maintain their highest level of well-being, specifically related to the performance and conduct of the Director of Nursing (DON) and the Administrator’s failure to investigate and implement protective measures. The DON’s personnel file showed she was hired and later terminated without any reference checks, a written job description, or termination documents explaining the reason for her discharge. A three‑month performance appraisal listed several goals for the DON, including proper scheduling, use of support systems, staying current with state survey regulations, and working on staffing and retention, but there was no indication of how these goals would be monitored after the evaluation period. Multiple written statements and interviews documented ongoing concerns about the DON’s attendance, communication, and possible impairment while on duty. A typed statement from the Social Service Designee (SSD) described months of poor communication, lack of support, and lack of attendance by the DON, resulting in the SSD having to manage residents’ medical questions and concerns. The SSD reported that there had been no fall reports for months, that the DON arrived late one day with a strong odor of alcohol, and that the DON ignored issues related to orders, advance directives, and family concerns. The SSD also reported that residents complained about not receiving showers, that she personally provided showers to reduce residents’ stress, and that residents stated they did not know who the DON was. There was no documentation of an investigation into these specific concerns, including the reported alcohol odor on the DON or the missed fall reports. Additional statements from a contracted behavioral health provider and the Assistant Director of Nursing (ADON) further detailed concerns about the DON’s reliability and conduct. The behavioral health provider reported a consistent lack of attendance and communication from the DON, noted smelling alcohol on the DON’s breath on multiple occasions, and stated that staff had been instructed by the DON not to speak with the provider about residents. The ADON reported that the DON frequently did not show up, especially when the Administrator was on vacation, took frequent smoke breaks, failed to follow up on concerns, left the building when staffing was inadequate, and was difficult to reach when staff had resident care issues. Staff interviews with CNAs and an LPN corroborated repeated observations of the DON smelling of alcohol, slurred speech, late arrivals, and erratic attendance, as well as staff fear of retaliation if they reported concerns. A performance improvement/reset plan was eventually developed that listed numerous substantiated concerns about the DON, including failure to meet RN coverage requirements, unreliable presence in the building, removal from on‑call duties without approval, unprofessional conduct toward staff, creating unsafe staffing conditions, allegations of reporting to work smelling of alcohol, dishonesty, retaliation against employees who raised concerns, undermining the chain of command, and a breakdown in communication with leadership and staff. However, there was no evidence that the Administrator or corporate human resources implemented or documented any monitoring of the DON’s performance or behavior after these issues were identified. The Administrator acknowledged that no audits of time punches, schedules, staffing, documentation, or interviews with staff and residents were conducted regarding the DON’s attendance, conduct, or possible impairment. The corporate human resources director confirmed receiving reports that the DON smelled strongly of alcohol and gave verbal instructions about testing, but there was no documented investigation or protective measures. Overall, the record showed that despite multiple reports and statements about the DON’s conduct and possible impairment, the Administrator did not complete a thorough investigation or implement timely and necessary protective actions to safeguard residents.
Failure to Assess, Monitor, and Treat Skin Tear After Resident Fall
Penalty
Summary
The facility failed to comprehensively assess, monitor, and treat a skin alteration that occurred after a fall for one resident. The resident, who had chronic kidney disease, dysphagia, and severe cognitive impairment per a recent MDS, was found lying on the floor in front of her bed after stating she had rolled out of bed. At that time, her right elbow was noted to be bleeding, was cleansed with normal saline, and steri-strips and a dry clean dressing were applied. However, review of the treatment administration records for the following months showed no evidence that any ongoing treatments were ordered or completed for the right elbow skin tear, and progress notes contained no further documentation regarding this wound. The ADON confirmed there were no treatment orders, no documentation of the size of the skin tear, and no monitoring of the skin tear after the initial incident. This deficiency represents non-compliance investigated under Complaint Numbers 2572467 and 1399215.
Medication Taken from Another Resident’s Controlled Supply
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received medication labeled with their own name, as required by facility policy and pharmaceutical service standards. A resident with severe cognitive impairment and diagnoses including dementia with behavioral disturbance, metabolic encephalopathy, mood disorder, history of traumatic brain injury, and catatonic disorder was admitted with physician orders for clonazepam 1 mg at 6:00 P.M. and 12:00 A.M., and clonazepam 0.5 mg at 12:00 P.M. A nursing progress note documented that on 03/24/26 at 9:24 P.M., the resident received clonazepam 1 mg instead of the ordered 0.5 mg dose. The facility’s investigation of a medication error for wrong dose confirmed that the resident received a 1 mg dose instead of the ordered 0.5 mg dose. During interviews, the ADON confirmed that an RN administered clonazepam 1 mg to the resident as ordered for the 6:00 P.M. dose but obtained the medication from another resident’s controlled medication card. The RN stated he did not believe he made a medication error because the resident ultimately received the correct 1 mg dose for that time, although he initially thought it was an error due to the separate 0.5 mg order at 12:00 P.M. The error was discovered at shift change when the controlled medication counts for the two residents did not match. The RN acknowledged that the five rights of medication administration include the right resident and right medication. The facility’s “Administering Medications” policy requires staff to verify the resident’s identity before administration and to check the medication label three times to ensure the right resident, medication, dosage, time, and method, which did not occur in this instance.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to maintain registered nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of the nursing staff punch detail, nursing staff schedule, and payroll-based journal (PBJ) submission for specific dates, which revealed that no registered nurses were present and working in the facility on 12/22/23, 12/23/23, and 12/25/24. This lapse in RN coverage had the potential to affect all 45 residents residing in the facility. The findings were verified through an interview with a Human Resources representative.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to accurately report staff hours worked in the Payroll Based Journal (PBJ), which had the potential to affect all 45 residents residing in the facility. Upon reviewing the facility's time punches, it was found that no Registered Nurse (RN) and no Director of Nursing (DON) punches were recorded on three consecutive days: 12/23/23, 12/24/23, and 12/25/23. Despite this, the PBJ data submitted for 12/23/23 and 12/24/23 inaccurately reflected eight RN hours and eight DON hours each day, while no hours were submitted for 12/25/23. An interview with the Business Office Manager (BOM) revealed that she was responsible for submitting the PBJ data, which was checked over by the Administrator. However, she was unaware that the PBJ reporting did not match the staffing records for the specified dates. This discrepancy in reporting was identified during the survey, indicating a lapse in the facility's internal processes for ensuring accurate and verifiable staffing data submission.
Failure to Fit Test Staff for N95 Masks
Penalty
Summary
The facility's infection preventionist (IP) failed to ensure that staff were appropriately fit tested for N95 respirator masks, which is crucial to prevent cross-contamination and the spread of infectious diseases within the facility. This deficiency was observed when two State Tested Nursing Assistants (STNAs) were seen wearing N95 respirator masks without having been fit tested. The STNAs were involved in providing care to a resident under COVID-19 precautions, yet neither was observed wearing eye protection as required by the signage on the resident's door. Interviews with the STNAs confirmed that they had not been fit tested since their hire, despite being involved in the care of residents on COVID-19 precautions. Further investigation revealed that the Clinical Manager, who assumed the role of the infection preventionist, was also not fit tested for an N95 respirator mask since her hire. The facility did not ensure that nursing staff were fit tested annually, which is a requirement to ensure that each staff member has an approved respirator mask when providing care to COVID-19 positive residents. This oversight is contrary to the Centers for Disease Control and Prevention (CDC) guidance, which mandates that N95 respirators be used within a comprehensive respiratory protection program, including medical evaluations, fit testing, and training as per the Occupational Safety and Health Administration's (OSHA) Respiratory Protection Standard.
Failure to Provide Monthly Spend-Down Letters
Penalty
Summary
The facility failed to provide monthly spend-down letters to residents who were approaching or over the resource limit, affecting three residents. Resident #13, diagnosed with cerebral infarction, dementia, adjustment disorder, and schizoaffective disorder, had financial balances exceeding the resource limit from April to June 2024, but only received a spend-down letter in July 2024. Similarly, Resident #32, with diagnoses including psychotic disorder, dementia, and schizoaffective disorder, had balances over the limit during the same period and received letters only in January, March, and July 2024. Resident #33, diagnosed with osteoarthritis, anemia, and other conditions, also had balances over the limit in May and June 2024, but only received a letter in July 2024. Interviews with the Business Office Manager (BOM) and Sister Facility Business Office Manager (SFBOM) revealed that the BOM was unaware of the requirement to send monthly spend-down letters when residents were approaching or over the resource limit. The facility's policy, revised in April 2018, mandates that residents be informed when their personal funds account reaches $200 less than the SSI resource limit to prevent loss of Medicaid or SSI eligibility. The BOM confirmed the absence of spend-down letters for the affected months during the interview.
Inadequate PPE Use During COVID-19 Isolation
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was maintained while providing care for Resident #41, who was under isolation precautions due to a COVID-19 diagnosis. Resident #41, who has spastic quadriplegic cerebral palsy and moderate cognitive impairment, tested positive for COVID-19 and was placed under strict isolation precautions. Despite the presence of signage indicating the need for an N95 respirator mask and gloves, staff members did not fully adhere to the required PPE protocols. Specifically, State tested Nursing Assistant (STNA) #134 initially entered the resident's room without donning an isolation gown and did not use eye protection at any point during the interaction. Further observations revealed that STNA #149, who assisted STNA #134, also failed to use appropriate PPE, including eye protection, while providing care for the COVID-19 positive resident. Interviews with the staff confirmed the lack of adherence to PPE protocols, despite being educated on the necessary precautions. Additionally, the signage at the entrance of Resident #41's room did not include instructions for staff or visitors to don an isolation gown and eye protection, which are required according to the facility's policy and CDC guidelines.
Delayed Response to Pharmacy Recommendations for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed in a timely manner for a resident who was receiving Olanzapine, an antipsychotic medication. The resident, who had diagnoses including anxiety disorder, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, depression, and schizoaffective disorder, was prescribed Olanzapine without an allowable diagnosis to support its use. The consultant pharmacist had made repeated recommendations on four separate occasions, from April to August, to verify the reason for the medication and update the diagnosis list or consider alternative therapy. Despite these recommendations, the facility did not address the issue until September, when the order was finally changed to reflect the use of Olanzapine for schizoaffective disorder. The delay in addressing the pharmacy's recommendations was confirmed by the MDS Nurse, who acknowledged that the recommendations were communicated to the physician but were not acted upon in a timely manner. The facility's policy required the consultant pharmacist to contact the Medical Director or Administrator if no action was taken, but this step was not mentioned in the report.
Failure to Monitor Anticoagulant Use in Resident
Penalty
Summary
The facility failed to monitor a resident's use of anticoagulant medications, specifically Eliquis, which was prescribed for cardiovascular disease. The resident, who had multiple diagnoses including bipolar disorder, hypertension, and dementia, was receiving several high-risk medications such as antipsychotics, antidepressants, and anticoagulants. Despite the care plan indicating the need to monitor for adverse effects of these medications, there was no documentation or orders in place to monitor the resident for side effects related to the anticoagulant. Interviews with facility staff, including an LPN and the DON, confirmed the absence of monitoring orders and documentation for the resident's anticoagulant use. The facility also lacked an anticoagulation policy to guide staff in monitoring for potential side effects, such as abnormal bleeding or bruising, which are critical for residents on such high-risk medications.
Failure to Administer Required Vaccinations
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal vaccines were administered to residents as required, affecting two residents. Resident #6, who was admitted with diagnoses including unspecified dementia, bipolar disorder, and diffuse traumatic brain injury, had consented to receive both the influenza and pneumococcal vaccines. However, the medical record did not show evidence of the resident receiving the influenza vaccine for 2023 or the pneumococcal vaccine during their admission. This was confirmed by an interview with the RN Clinical Manager, who acknowledged the oversight. Similarly, Resident #30, admitted with diagnoses including diffuse traumatic brain injury, unspecified dementia, and late-onset Alzheimer's disease, had consented to receive the influenza vaccine annually. Despite this, the resident's medical record indicated that the last influenza vaccine was administered in 2022, with no record of the 2023 vaccine being given. The RN Clinical Manager confirmed this deficiency as well. The facility's policies on influenza and pneumonia prevention did not appear to be effectively implemented, as evidenced by the lack of timely vaccinations for these residents.
Failure to Post Daily Nursing Staff Information
Penalty
Summary
The facility failed to ensure the daily nursing staff information was posted, which had the potential to affect all 45 residents residing in the facility. During an observation conducted on September 5, 2024, between 11:32 A.M. and 2:05 P.M., it was noted that no nursing staff information was posted throughout the facility. An interview conducted on the same day at 2:34 P.M. with a Human Resources representative confirmed that the nursing staff information was not posted in a prominent area within the facility.
Incomplete Facility Assessment Lacks Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that its facility-wide assessment was complete and accurate, which had the potential to affect all 45 residents residing in the facility. The assessment, dated August 2024, was intended to determine the necessary resources for competent care during both daily operations and emergencies. However, upon review, it was found that the assessment did not include the infection preventionist role in the list of staff types or in the staff plan. This omission meant that the facility did not determine the required hours for the infection preventionist to effectively manage the infection control program. The facility assessment form outlined various staff types and the required hours for each, including licensed nurses, nursing assistants, administrative staff, and others. Despite this detailed listing, the absence of the infection preventionist role was confirmed during an interview with the Assistant Administrator. This oversight in the facility's assessment process indicates a gap in planning for infection control, which is a critical component of resident care and safety.
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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) |
|---|---|---|---|---|
| Accord Care Community Orrville Llc | 0.8 mi | ★★★★★ | 3 | 0 |
| Glendora Health Care Center | 5 mi | ★★★★★ | 3 | 0 |
| Shady Lawn Nursing Home | 5.8 mi | ★★★★★ | 0 | 0 |
| Smithville Western Care Center | 6 mi | ★★★★★ | 0 | 0 |
| Apostolic Christian Home Inc | 6.5 mi | ★★★★★ | 0 | 0 |
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