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Orrville Pointe

230 South Crown Hill Road, Orrville, OH 44667 · For profit - Limited Liability company · 47 certified beds · (330) 682-2273 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited Jun 2026Resident-funds citation (F0569)Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0569)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (71%) runs well above the national median (45%)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1020 W High St · (330) 960-2326 · Call to confirm hours
Pharmacy
1114 West High St · (330) 683-0765 · Call to confirm hours
Grocery
1448 W High St · (740) 485-1689 · Call to confirm hours
Park
Orr Park0.8 mi
440 N Elm St · (330) 684-5070 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.1%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight11.0%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.6%0.2%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms82.2%30.1%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.2%3.2%3.3%better
Long-stay residents whose ability to walk worsened7.9%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication52.9%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine97.9%94.5%95.3%typical
Long-stay residents with pressure ulcers0.5%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control13.6%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table17.4%8.8%17.1%typical

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

0.39U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.24hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.39 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 27% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.33
RN hours/ resident / day
1.19
LPN hours/ resident / day
2.36
Aide hours/ resident / day
3.89
Total nurse hours/ resident / day
0.21
RN hoursweekends
70.9%
Total nursing turnover
85.7%
RN turnover

How full it usually is: this home is certified for 47 beds and averages 45.3 residents a day — about 96% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.89 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.19 hrs/resident/day on weekends vs 4.17 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.38 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 71% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

10
deficiencies at the latest standard inspection (2024-09-05)
6
at the previous standard inspection (2022-04-28)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.

  • Immediate jeopardy · J2026-06-24 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of an emergency medical services (EMS) run report, review of hospital records, staff and family interviews, and facility policy review, the facility failed to ensure medications were appropriately secured and inaccessible to residents. This resulted in Immediate Jeopardy and serious life-threatening harm and negative health outcomes on 06/05/26 at approximately 9:00 A.M. when Resident #46 was observed to have multiple empty medication cards (packaged by pharmacy and provided specific labeling including the resident's name, medication name and dosage, and administration times) of Keppra (an anticonvulsant medication used to treat seizures) and Baclofen (a skeletal muscle relaxant and antispasmodic) each which had an original quantity of 30 and belonged Resident #11. Facility staff notified the physician who instructed staff to monitor the resident throughout the day. At approximately 7:45 P.M., while outside at a smoke break, Resident #46 experienced a change in condition…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to protect Resident #31 from abuse and mistreatment on 06/11/26 at approximately 10:00 P.M. when Registered Nurse (RN) #107 forced a spoonful of applesauce and medications into Resident #31's mouth as she was unresponsive. This affected one Resident (#31) of three residents reviewed for abuse. The facility census was 45. Findings include: Review of the medical record for Resident #31 revealed an admission date of 11/30/24. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, and chronic respiratory failure with hypoxia. Resident #31 passed away at the facility on 06/13/26. Review of the care plan dated 04/20/26 revealed Resident #31 was experiencing a significant decline in health status related to terminal illness. Interventions included to administer all medications as ordered and provide a supportive, private environment for resident and family.Review of the five-day Minimum Data Set (MDS)…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-24 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of the Ohio Department of Health's Certification and Licensure System, and facility policy review, the facility failed to ensure an allegation of staff to resident abuse was reported to the State Agency as required. This affected one resident (#31) of three residents reviewed for abuse. The facility census was 45. Findings include: Review of the medical record for Resident #31 revealed an admission date of 11/30/24. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, and chronic respiratory failure with hypoxia. Resident #31 passed away at the facility on 06/13/26. Review of the care plan dated 04/20/26 revealed Resident #31 was experiencing a significant decline in health status related to terminal illness. Interventions included to administer all medications as ordered and provide a supportive, private environment for resident and family.Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-24 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of the Ohio Department of Health's Certification and Licensure System, and facility policy review, the facility failed to ensure an investigation into alleged of staff to resident abuse was timely and thoroughly investigated. This affected one Resident (#31) of three residents reviewed for abuse. The facility census was 45. Findings include: Review of the medical record for Resident #31 revealed an admission date of 11/30/24. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, and chronic respiratory failure with hypoxia. Resident #31 passed away at the facility on 06/13/26. Review of the care plan dated 04/20/26 revealed Resident #31 was experiencing a significant decline in health status related to terminal illness. Interventions included to administer all medications as ordered and provide a supportive, private environment for resident and family.Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-24 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were administered per physician orders. This affected one Resident (#25) of three residents observed and reviewed for medication administration. The facility census was 45.Findings include: Review of Resident #25's medical record revealed an admission date of 01/04/23. Diagnoses included paranoid schizophrenia, dementia, depression, Alzheimer's disease, impulse disorder, and delusions.Review of a care plan dated 02/24/26 revealed Resident #25 required Clozaril (antipsychotic medication) therapy due to severe schizophrenia. Interventions included to monitor and document the resident's response to Clozaril therapy and monitor the resident during medication administration to assure they are not pocketing medication.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had impaired cognition. Resident #25 was dependent with toileting, transfers, and mobility.Review of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-24 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to prevent a significant medication error for Resident #31, when routine and as-needed medications for end-of-life comfort were unavailable for administration. This affected one Resident (#31) of five residents reviewed for medication administration. The facility census was 45.Findings include: Review of the medical record for Resident #31 revealed an admission date of 11/30/24. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, and chronic respiratory failure with hypoxia. Resident #31 passed away at the facility on 06/13/26. Review of the care plan dated 04/20/26 revealed Resident #31 was experiencing a significant decline in health status related to terminal illness. Interventions included to administer all medications as ordered and provide a supportive, private environment for resident and family. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-24 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain an accurate and complete medical records which included documentation of resident to resident altercations. This affected two residents (#6 and #47) of three residents reviewed for abuse. The facility census was 45. Findings include: 1.Review of Resident #6's medical record revealed an admission date of 12/22/25. Diagnoses included depression, bipolar disorder, and mood disorder.Review of a care plan dated 01/16/26 revealed Resident #6 was prone to anger and aggression and had poor coping skins and due to serious mental illness and underdeveloped coping skills, anger is often misplaced on others. Interventions included be attentive to angry and aggressive behaviors, use appropriate word choices and tone of voice, set limits on specific behavior, document all behaviors and their responses to interventions. Resident #6 was at risk for behaviors that can be physically or emotionally harmful to self or others that included physical altercations…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Self-Reported Incident (SRI), interviews and review of facility policy, the facility failed to ensure that Resident #41 was adequately supervised to prevent elopement and risk of accident hazards. This affected one resident (#41) out of three residents reviewed for accident hazards. The facility census was 44.Findings include:Review of the medical record for Resident #41 revealed an admission date of 09/01/25 with pertinent diagnoses including schizoaffective disorder bipolar type, delusional disorder, obsessive compulsive disorder, auditory hallucinations, unspecified dementia moderate with other behavioral disturbance, generalized anxiety disorder, homicidal ideations, and attention deficit hyperactivity disorder.Review of Resident #41's care plan, initiated on 09/09/25, revealed Resident #41 exhibited symptoms that were not easily altered and potentially harmful to the resident or others and wandered with no discernable, rational purpose. Goals included staff will be…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-04-15 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, review of the facility assessment, and staff schedule review the facility failed to ensure a full time Director of Nursing (DON) was employed by the facility and involved in direct oversight of nursing services. This had the potential to affect all residents in the facility. The facility census was 44.Findings include: Review of the staff schedule from 04/06/26 through 04/12/26 revealed the interim DON, Registered Nurse/DON #450, was in the facility for 11 hours on 04/07/26.An interview on 04/13/26 at 8:34 A.M. with the Assistant Director of Nursing (ADON) (a Licensed Practical Nurse) revealed DON #500 was terminated in February for a bunch of different reasons. DON #450 was the DON at another building but came to the facility once or twice a week to assist the ADON. Clinical Registered Nurse (RN) #104 was the RN in the building for eight hours Monday through Friday. There were RNs that were weekend workers to ensure there were RNs seven days a week, but none were the facility DON. Interview on 04/14/26 at 10:25 A.M. with DON #450 revealed she was in the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-04-15 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on personnel record review, and interview, the facility failed to be effectively and efficiently administered in a manner that allowed all residents to attain or maintain their highest level of well-being when the administrator failed to ensure concerns regarding Director of Nursing (DON) #500's (who was part of the facility administration) performance and allegations of DON #500 working under the influence of alcohol were thoroughly investigated and timely and necessary protective measures were implemented to safeguard the residents. This had the potential to affect all 44 residents who resided in the facility.Findings include: Review of the personnel file for Director of Nursing (DON) #500 revealed she was hired on 04/30/25 and terminated on 02/09/26. The personnel file revealed no evidence of reference checks being completed. In addition, there was no written job description for the Director of Nursing (DON) in the employee's file nor was a job description available to review during the onsite survey. Record review revealed there were no termination documents located in the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a skin alteration was comprehensively assessed, monitored and a treatment was ordered after a fall. This affected one (Resident #45) of three residents reviewed for falls. Facility census was 44.Findings include: Review of the medical record revealed former Resident #45 was admitted on [DATE] with diagnoses that included chronic kidney disease, dysphagia, disorders. Resident #45 expired on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 had severe cognitive impairment.A nursing progress note dated [DATE] at 4:46 P.M. revealed Resident #45 was observed lying on the floor in front of her bed. The resident stated she rolled out of bed. Resident #45's right elbow was bleeding. The resident's elbow was cleansed with normal saline and steri-strips were applied and covered with dry clean dressing. Review of the treatment administration record (TAR) for June and July revealed no evidence of treatments being completed to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · Dcited before2026-04-15 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, incident report review, and policy review, the facility failed to ensure Resident #37 received medication labeled with Resident #37's name. This affected one (Resident #37) of three residents reviewed for medication administration. The facility census was 44.Findings include: Review of the medical record revealed Resident #37 was admitted on [DATE] with diagnoses that included dementia with behavioral disturbance, metabolic encephalopathy, mood disorder, history of traumatic brain injury, and catatonic disorder. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #37 had severe cognitive impairment. Review of physician orders revealed Resident #37 was ordered clonazepam (benzodiazepine) one milligram (mg) at 6:00 P.M. and 12:00 A.M. Resident #37 was also ordered clonazepam 0.5 mg at 12:00 P.M. A nursing progress note dated 03/24/26 at 9:24 P.M. revealed Resident #37 received clonazepam one mg instead of 0.5 mg as ordered. Review of the facility…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-09-05 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and staff interview, the facility failed to maintain registered nurse (RN) coverage in the facility at least eight consecutive hours a day seven days a week as required. This had the potential to affect all 45 residents who reside in the facility. Findings include: Review of the nursing staff punch detail, nursing staff schedule, and payroll based journal (PBJ) submission for 12/22/23, 12/23/23, and 12/25/24 revealed no registered nurses were present working in the facility. Interview on 09/05/24 at 10:39 A.M. with Human Resources (HR) #105 verified the identified findings. The deficient practice was corrected on 04/01/24 when the facility implemented the following corrective actions: • Beginning 03/01/24 Director of Nursing (DON)/Designee reviewed the current number of RN's employed by the facility and update the roster intermittently. • Beginning 03/01/24 the facility would advertise for RN's on job recruitment sites and review daily.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Past Non-Compliance
  • Potential for harm · F2024-09-05 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to completely and accurately report staff hours worked in Payroll Based Journal (PBJ). This had the potential to affect all 45 residents residing in the facility. Findings include: Review of facility time punches revealed no Registered Nurse (RN) and no Director of Nursing (DON) punches were recorded on 12/23/23, 12/24/23 and 12/25/23. Review of PBJ data revealed on 12/23/23, eight RN hours and eight DON hours were submitted; on 12/24/23, eight RN hours and eight DON hours were submitted and on 12/25/23, no RN hours or DON hours were submitted. Interview on 09/05/24 at 10:39 A.M. with Business Office Manager (BOM) #105 revealed she was responsible for submitting PBJ data and while it was checked over by the Administrator, she was the only one who input the staffing data for submission. BOM #105 was unaware the PBJ reporting did not reflect the staffing as recorded on 12/23/23 and 12/24/24 as of the time…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Past Non-Compliance
  • Potential for harm · F2024-09-05 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, Employee Phone List review and interview, the facility infection preventionist (IP) failed to ensure staff were appropriately fit tested for N95 respirator masks to prevent the potential for cross contamination and spread of infectious diseases in the facility. This finding had the potential to affect all 45 residents residing in the facility. Findings include: Review of the Employee Phone List form dated 09/02/24 revealed 3 Registered Nurses (RNs), 13 Licensed Practical Nurses (LPNs) and 27 State Tested Nursing Assistants (STNAs) were employed in the facility. Observation on 09/04/24 at 8:30 A.M. revealed State Tested Nursing Assistant (STNA) #134 donned an N95 duck bill type respirator mask and gloves. STNA #134 took the resident's breakfast tray into the resident's room, adjusted the resident's bedside table and took the covers off of the food. STNA #134 walked back into the hall and asked STNA #149 to help pull the resident up for the breakfast meal. STNA #149 implemented an isolation gown, gloves and N95 duck bill type respirator mask. STNA #134 at that…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-05 · tag F0569 — pattern
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review and review of the facility policy, facility failed to provide spend-down letters for each month residents were approaching or over the resource limit. This affected three residents (#13, #32 and #33) of five residents reviewed for resident funds. The facility census was 45. Findings include: 1. Review of Resident #13's medical record revealed an admission date of 10/28/19 and diagnoses including cerebral infarction, dementia with other behavioral disturbance, adjustment disorder and schizoaffective disorder. Review of Resident #13's quarterly financial report for April 2024 through June 2024 revealed a balance of $4868.52 on 04/01/24, a balance of $3815.35 on 05/01/24 and a balance of $3810.19 on 06/04/24. Review of available spend-down letters for 2024 revealed one letter on 07/17/24. Interview on 09/04/24 at 12:15 P.M. with Business Office Manager (BOM) #105 and Sister Facility Business Office Manager (SFBOM) #106 revealed SFBOM #106 was assisting in training BOM #105 in her role, including with resident funds. BM #105 indicated as of this week…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-05 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure appropriate personal protective equipment (PPE) was maintained while providing care for Resident #41 who was in isolation precautions related to a COVID-19 diagnosis. This finding affected one resident (Resident #41) and had the potential to affect an additional 26 residents who reside on the second floor including Residents #1, #2, #12, #13, #14, #15, #16, #17, #18, #22, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #39, #40, #42, #43, #47 and #96. The facility census was 45. Findings include: Review of Resident #41's medical record revealed the resident was admitted on [DATE] with diagnoses including spastic quadriplegic cerebral palsy, COVID-19 and impulse disorder. Review of Resident #41's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #41's progress note dated 08/30/24 at 10:18 A.M. authored by Licensed Practical Nurse (LPN) #113…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-05 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and review of the facility policy and procedure, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected one resident (#17) of five residents. The facility census was 45. Findings include: Review of the medical record for Resident #17 revealed an admission date of 04/05/24. Diagnoses included anxiety disorder, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, and schizoaffective disorder. Review of the physician orders for September 2024 for Resident #17 revealed an active order for Olanzapine (antipsychotic) oral tablet 5 milligrams (mg). Give one tablet by mouth at bedtime related to dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with a start date of 04/05/24. Review of the consultant pharmacist medication regimen reviews dated 04/01/24, 05/01/24, 06/01/24, and 08/01/24 revealed a recommendation, noting for the resident is receiving the antipsychotic agent Olanzapine, but lacks an allowable…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-05 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to monitor residents using anticoagulant medications. This affected one resident (#27) out of five residents reviewed for medications. The facility census was 45. Findings include: Review of Resident #27's medical record revealed an admission date of 12/07/23 and diagnoses including bipolar disorder, hypertension, vitamin D deficiency, depression, generalized anxiety disorder, mild protein-calorie malnutrition and dementia with other behavior disturbance, schizoaffective disorder-bipolar type. Review of Resident #27's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had moderate cognitive impairment, was dependent on staff for bathing utilized a wheelchair for mobility and received antipsychotic medications, antidepressant medications and anticoagulants. Review of Resident #27's physician's orders revealed an order dated 04/17/24 for Eliquis (anticoagulant or blood thinning medication) oral tablet five milligrams (mg) with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-05 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure influenza and pneumococcal vaccines were adminsitered as required. This finding affected two (Residents #6 and #30) of five residents reviewed for immunizations. Findings include: 1. Review of Resident #6's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, bipolar disorder and diffuse traumatic brain injury with loss of consciousness of unspecified duration. Review of Resident #6's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #6's Pneumococcal Vaccine Consent form dated 10/25/20 revealed the resident wished to receive the pneumococcal vaccine. Review of Resident #6's Influenza Vaccine Consent form dated 10/25/20 revealed the resident wished to receive the influenza vaccine on an annual basis while he/she was residing in the facility. Review of Resident #6's medical record did not reveal evidence…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-03-21 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on review of facility staffing schedules and interview, the facility failed to ensure staffing included a Registered Nurse (RN) for at least eight hours a day, seven days a week and a full-time Director of Nursing (DON). This had the potential to affect all the residents in the facility. The facility census was 41 residents. Findings Include: Review of facility staffing schedules and posted staffing information from 03/01/24 through 03/14/24 revealed the facility did not have a full-time DON nor RN coverage eight consecutive hours daily from 03/01/24 to 03/10/24. Interview on 03/24/24 at 4:00 P.M. with the Administrator verified there was no full-time Director of Nursing (DON) from 03/01/24 through 03/10/24 and there was no Register Nurse (RN) scheduled eight consecutive hours a day. This deficiency represents noncompliance identified during the investigation of Complaint Number OH00151741.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-28 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the facility failed to implement their abuse policy to report and thoroughly investigate allegations of abuse involving Resident #1, #16, and #35. This affected three of four residents reviewed for abuse. Facility census was 40. Findings include: 1. Review of the medical record reveal Resident #16 was admitted on [DATE] with diagnoses of unspecified dementia without behavioral disturbance, dementia, and Alzheimer's disease. Review of Resident #16's admission record revealed the diagnosis of other sexual disorders was added on 08/30/21. Review of the plan of care last revised on 02/17/22 revealed Resident #16 was intrusive and wandered into other resident rooms, had a history of inappropriately touching female peers, and was not being easily redirectable. The diagnosis of unspecified dementia with behavioral disturbance was added for Resident #16 on 03/01/22. Review of a nursing progress note dated 04/22/22 at 12:30 P.M. revealed Resident #16…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-28 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to promptly report allegations of abuse involving Resident #1 and Resident #16 to the administrator and State Agency as required. This affected two of four residents reviewed for abuse. The facility census was 40. Findings include: Review of the medical record reveal Resident #16 was admitted on [DATE] with diagnoses of unspecified dementia without behavioral disturbance, dementia, and Alzheimer's disease. Review of Resident #16's admission record revealed the diagnosis of other sexual disorders was added on 08/30/21. Review of the plan of care last revised on 02/17/22 revealed Resident #16 was intrusive and wandered into other resident rooms, had a history of inappropriately touching female peers, and was not being easily redirectable. The diagnosis of unspecified dementia with behavioral disturbance was added on 03/01/22. Review of a nursing progress note dated 04/22/22 at 12:30 P.M. revealed Resident #16 grabbed a female resident's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-28 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of facility policy, the facility failed to thoroughly investigate an allegation of abuse involving Resident #16 and #35. This affected two out of four residents reviewed for abuse. Facility census was 40. Findings include: Review of medical record for Resident #35 revealed she was admitted on [DATE] with diagnosis of cerebral palsy, and anxiety disorder. Interview on 04/26/22 with Resident #35 at 9:36 A.M. revealed she was afraid of Resident #16. Resident #35 said Resident #16 had touched her but never hurt her and she did not want to be touched. She said staff redirect him to his room. Review of the medical record reveal Resident #16 was admitted on [DATE] with diagnoses of unspecified dementia without behavioral disturbance, dementia, and Alzheimer's disease. Review of Resident #16's admission record revealed the diagnosis of other sexual disorders was added on 08/30/21. Review of the plan of care plan last revised 02/17/22 revealed Resident #16 had an increase in…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to properly transcribe and obtain physician orders for necessary care/treatment for collection of a stool sample for Resident #8 and for a skin tear for Resident #33. This affected two out of 16 resident records reviewed for care and treatment. Facility census was 40. Findings include: 1. Review of medical record revealed Resident #8 was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary (lung) disease with hypoxia (low oxygen levels), gastroparesis, diarrhea, and irritable bowel syndrome. Review of a nursing progess note dated 04/04/22 at 6:10 P.M. revealed a physician order was received for Resident #8 to have a stool sample collected and checked for clostridioides difficile (bacterium that causes severe diarrhea and inflammation of the colon). Review of the physician handwritten order dated 04/04/22 revealed Resident #8 was to be checked for clostridioides difficile due to having loose stools. Review of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was changed weekly for Resident #8 and #26. This affected two (Residents #8 and #26) out of nine residents sampled with oxygen. The facility census was 40. Findings include: 1. Review of the medical record revealed Resident #8 was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary (lung) disease, chronic respiratory failure with hypoxia (low oxygen levels), and anxiety. Review of the plan of care dated 12/03/20 revealed Resident #8 was at risk for ineffective airway clearance and breathing patterns. Interventions included provision of oxygen via nasal cannula two-to-five liters as needed for shortness of breath or comfort. Observation on 04/26/22 at 11:19 A.M. and 04/27/22 at 9:43 A.M. revealed Resident #8 had a nasal cannula in place and was using oxygen. There was no date noted on the oxygen tubing to indicate how long this nasal cannula/oxygen tubing had been un use. Interview on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-28 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #33 and #37 had appropriate diagnoses for the use of antipsychotic medication. This affected two (Resident #33 and #37) out of five residents reviewed for unnecessary medications. The facility census was 40. Findings include: 1. Review of the medical record revealed Resident #33 was admitted on [DATE] with diagnoses which included fracture of left pubis, Alzheimer's disease, dementia, and brief psychotic disorder. Review of the plan of care dated 02/16/22 revealed Resident #33 exhibited behavioral symptoms of inappropriate behaviors, hallucinations, delusions, and was wandering/exit seeking. Interventions included for staff to medicate per physician orders and to monitor mood/behavior/affect with all hands-on care/interactions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had cognitive impairment. Review of the March 2022 pharmacy recommendation revealed Resident #33 received Seroquel (an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2019-05-16 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview the facility failed to ensure a registered nurse was scheduled at least eight consecutive hours every day as required. This had the potential to affect all 32 residents residing in the facility. Findings include: Review of the posted staffing hours for May 2019 revealed the facility had a registered nurse (RN) in the building for five hours on 05/05/19 and for four hours on 05/11/19 and 05/12/19. During an interview with the Administrator on 05/15/19 at 8:20 A.M., the staffing hours for 2019 were reviewed. The Administrator verified they were aware of the requirement for an RN to be working in the facility each day for at least eight consecutive hours. The Administrator said they had an open RN position and were working to hire new RN staff. The Administrator said the director of nursing was working part of each weekend in addition to weekdays to provide an RN in the building each day. The Administrator confirmed the facility had been unable to provide an RN for eight consecutive hours on 05/05/19, 05/11/19 and 05/12/19 as required.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-05-16 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, Resident Assessment Instrument (RAI) manual review, form review, and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments for five residents (Residents #5, #11, #14, #15, and #24) out of 13 residents reviewed for assessments. Findings include: 1. Resident #5 was initially admitted to the facility on [DATE] with diagnoses including bipolar disorder, major depressive disorder, dementia with behavioral disturbance, and epilepsy. Review of Resident #5's May 2019 physician orders included an order for padded half side rails secondary to a history of seizures. Review of Resident #5's admission MDS assessment, with an Assessment Reference Date (ARD) of 01/02/19, revealed Resident #5 utilized side rails as a physical restraint daily. Review of Resident #5's quarterly MDS assessment, with an ARD of 02/18/19, revealed Resident #5 had intact cognition and required staff supervision with bed mobility. The 02/18/19 quarterly MDS also indicated Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-09-05 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview the facility failed to ensure the daily nursing staff information was posted. This had the potential to affect all 45 residents who reside in the facility. Findings include: Observation on 09/05/24 between 11:32 A.M. and 2:05 P.M. revealed no posted nursing staff information was identified throughout the facility. Interview on 09/05/24 at 2:34 P.M., Human Resources (HR) #105 verified no posted nursing staff information was posted in a prominent area within the facility.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-09-05 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility assessment review and interview, the facility failed to ensure the facility assessment was complete and accurate. This finding had the potential to all 45 residents who reside in the facility. Findings include: Review of the facility assessment form dated 08/2024 under Part 3: Facility Resources Needed to Provide Competent Support and Care for the Resident Population Every Day and During Emergencies, Section 3.1 Staff Type, revealed the staffing included the Administrator and administrative support staff; Director of Nursing (DON); Minimum Data Set (MDS) Coordinator; Social Service/Designee; Environmental Services; Registered Nurses; Licensed Practical Nurses; State Tested Nursing Assistants; Culinary Personnel; Activities Staff; Therapy Personnel and Registered Dietitian. The list also included contracted staff and volunteers. Review of the facility assessment form dated 08/2024 under Part 3: Facility Resources Needed to Provide Competent Support and Care for the Resident Population Every Day and During Emergencies, Section 3.2 Staff Plan, indicated the facility…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to JAG HEALTHCARE — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.3-1.3 vs chain
Health inspection 1 of 52.9-1.9 vs chain
Staffing 1 of 52.4-1.4 vs chain
Quality measures 5 of 54.6+0.4 vs chain
The other 8 homes this chain runs (chain average 3.3★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
GRIFFITHS, JAMESIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2013
JAG HEALTHCARE INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2013
ORRVILLE POINTE RE, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/03/2016
COLE, CASEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2024
LEHNER, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2015

CMS files one row per role, so the 12 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$4.0M
Net patient revenuemost recent cost report
-4.2%
Operating marginrevenue minus expenses
$439K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 32%Medicare 2%Other / private 67%

This home reported $439K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$266per resident / day
operating cost
$8,089per month
≈ monthly operating cost
$255per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.

Typical monthly cost in Ohio
$9,186/mo
Nursing home (semi-private)
$10,389/mo
Nursing home (private)
$6,103/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366203. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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