Inspection visit
Inspection
25 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 25 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0569
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
closed record review and interview, the facility failed to ensure a final accounting of Resident #408's
resident fund account within 30 days after the resident's discharge from the facility. This affected one
resident (#408) of five residents reviewed for resident fund accounts.
Residents Affected - Few
Findings include:
Review of Resident #408's closed medical record revealed the resident was admitted on [DATE] and
discharged to another facility on 09/08/23 with diagnoses including acute respiratory failure with hypoxia,
malignant neoplasm of the skin and weakness.
Review of Resident #408's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident
exhibited a memory problem.
Review of Resident #408's resident fund account and ending balance statement dated 11/01/23 revealed
the resident had $472.00 in his resident fund account.
Interview on 11/02/23 at 7:05 A.M. with Business Office Manager (BOM) #164 confirmed the monies in
Resident #408's resident fund account were not dispersed within 30 days as required.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 23
Event ID:
366123
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Based on observation, record review, facility policy review and interview, the facility failed to ensure a safe,
homelike environment for Resident #36. This affected one resident (#36) of resident one resident for room
temperature.
Findings include:
Review of the medical record for Resident #36 revealed an admission date of 08/09/23 with diagnoses
including but not limited to adult failure to thrive, alcohol abuse and hypokalemia.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/30/23, revealed Resident #36 had
no cognitive impairment.
On 10/31/23 at 9:39 A.M. interview with Resident #36 revealed she was cold.
Observation and interview on 10/31/23 at 9:58 A.M. with State Tested Nursing Assistant (STNA) #140
verified the resident's room felt cold; the STNA then looked at the thermostat behind the bed that against
the wall. STNA #140 stated that the thermostat was set for 65 degrees Fahrenheit (F). Resident #36 stated
that she could not reach it and STNA #140 turned it up.
Observation and interview on 10/31/23 at 9:58 A.M. with Maintenance Director (MD) #170 revealed that the
temperature of the room was 70.6 degrees F.
Review of the facility policy dated 05/2017 titled, Quality of Life- Homelike Environment, revealed that the
facility staff and management shall maximize, to the extent possible, the characteristics of the facility to
include but not limited to a comfortable and safe temperature between 71 degrees F and 81 degrees F.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 2 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0636
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every
12 months.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and interview, the facility failed to ensure resident admission comprehensive
assessments were accurate. This affected one resident (#11) of 22 residents reviewed for comprehensive
assessments. The facility census was 56.
Findings include:
Medical record review revealed Resident #11 was admitted on [DATE] with diagnoses including
schizophrenia, major depressive disorder and anxiety disorder.
Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was
not currently considered by the State Level II Preadmission Screening and Resident Review (PASRR)
process to have serious mental illness and/or intellectual disability or a related condition.
Further review of the admission MDS assessment dated [DATE] revealed schizophrenia was not coded as
an active diagnosis.
On 11/01/23 at 10:14 A.M. and 10:26 A.M., interview with Clinical Resource Specialist #201 verified
Resident #11 had a diagnosis of schizophrenia, depression and anxiety disorder indicating a serious
mental illness and the MDS assessment dated [DATE] was inaccurate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 3 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical
record review revealed Resident #39 was admitted on [DATE] with diagnoses including but not limited to
bipolar disorder, dementia, dysphagia, cognitive communication deficit and protein calorie malnutrition. The
resident was unable to answer screening questions appropriately at the time of the survey.
Residents Affected - Few
Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #39 was
severely impaired for daily decision-making and was edentulous (no natural teeth).
On 10/31/23 at 12:05 P.M., observation revealed Resident #39 was missing teeth but she had at least two
natural teeth.
On 11/01/23 between 1:27 P.M. and 1:37 P.M., interview with State Tested Nurse Aide #161 verified
Resident #39 had two lower natural teeth and a few back teeth.
On 11/01/23 between 4:35 P.M. and 4:53 P.M., interview with the Director of Nursing and Registered Nurse
#202 verified Resident #39's admission MDS assessment was inaccurate for dental status.
3. Medical record review revealed Resident #11 was admitted on [DATE] with diagnoses including
schizophrenia, major depressive disorder and anxiety disorder.
Review of the quarterly MDS assessments dated 04/24/23, 07/25/23, 09/04/23, and 09/30/23 revealed the
assessments were not coded for a schizophrenia diagnosis.
On 11/01/23 at 10:14 A.M. and 10:26 A.M., interview with Clinical Resource Specialist #201 verified
Resident #11 had a diagnosis of schizophrenia and the quarterly MDS assessments dated 04/24/23,
07/25/23, 09/04/23 and 09/30/23 were not accurate.
Based on record review and interview, the facility failed to ensure comprehensive assessments were
complete and accurate. This affected three residents (#11, #30 and #39) of 22 residents reviewed for
comprehensive assessments.
Findings include:
1. Review of Resident #30's medical record revealed the resident was admitted on [DATE] with diagnoses
including anxiety disorder, depressive disorder and mood disorder.
Review of Resident #30's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident
exhibited intact cognition and during the look back period of 08/03/23 to 08/09/23, the resident received
seven days of a hypnotic, anticoagulant, antibiotic, diuretic and opioid.
Review of Resident #30's medication administration records (MARS) from 08/03/23 to 08/09/23 revealed
the resident did not receive any doses of a hypnotic medication, an anticoagulant medication, an antibiotic
medication, a diuretic medication or an opioid medication.
Interview on 11/01/23 at 8:55 A.M. with Licensed Practical Nurse (LPN) MDS Coordinator #106 confirmed
Resident #30's comprehensive assessment dated [DATE] did not accurately reflect the medications
administered from 08/03/23 to 08/09/23.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 4 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical
record review revealed Resident #11 was admitted on [DATE] with diagnoses including schizophrenia,
major depressive disorder and anxiety disorder.
Review of the diagnosis list and physician orders revealed Resident #11 was newly diagnosed with a mood
disorder on 03/17/23. There was no evidence a significant change in condition PASRR was submitted.
Review of the physician's progress notes dated 09/05/23 revealed Resident #11's schizophrenia was
stable.
Review of the Medication Administration Record dated October 2023 revealed Resident#11 was receiving
medications including, but not limited to, Zoloft (anti-depressant) and Depakene (mood stabilizer).
Review of the significant change in condition PASRR Screen dated 10/31/23 revealed the PASRR did not
include diagnoses including major depressive disorder, mood disorder or schizophrenia.
Review of the PASRR Result Notice issued 10/31/23 revealed Resident #11 had no indicators of serious
mental illness and/or developmental disability effective 10/31/23.
On 10/31/23 at 9:54 A.M., interview with SSD #167 revealed she completed a decline Significant Change in
Condition for Resident #11 without including all the pertinent information including the residents diagnoses
of schizophrenia, major depressive disorder and mood disorder. SSD #167 verified she did not complete
the PASRR accurately which could have changed the outcome of the PASRR determination.
Based on record review and interview, the facility failed to timely complete the Pre-admission Screening
and Resident Review (PASRR) for Resident #11 and #24. This affected two residents (#11 and #24) of two
residents reviewed for PASRR. The census was 56.
Findings include:
1. Review of the medical record for Resident #24 revealed an admission date of 09/16/22 with diagnoses
including dementia with behavioral disturbance, recurrent depressive disorders, brief psychotic disorder,
and cognitive communication deficit. Further review of the diagnoses revealed a new diagnosis of
delusional disorder was added on 03/07/23.
Review of the Pre-admission Screening and Resident Review (PASRR), completed 09/14/22, revealed
Resident #24 had a diagnosis of mood disorder. No other diagnoses were identified on the PASRR and the
results indicated she had no indication of serious mental illness. There was no PASRR completed at the
time of the new diagnosis of delusional disorder, added 03/07/23.
On 11/01/23 at 9:57 A.M., interview with Social Services Designee (SSD) #167 verified Resident #24 had a
new diagnosis of delusional disorder added on 03/07/23 and no PASRR was completed related to this new
diagnosis. She stated a significant change PASRR was just submitted on 10/31/23 due to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 5 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0644
Level of Harm - Minimal harm
or potential for actual harm
increased behaviors and medication changes, but she was unable to state why the PASRR was not
completed after the new diagnosis in March 2023. SSD #167 said the PASRR completed on 10/31/23
indicated Resident #24 had indications of serious mental illness and a referral was made for a level two
PASRR evaluation.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 6 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview, the facility failed to develop comprehensive care plans for all
residents to meet their total care and assessed needs. This affected one resident (#39) of five residents
reviewed for unnecessary medications and one resident (#11) of one resident reviewed for accidents. The
facility census was 56.
Findings include:
1. Medical record review revealed Resident #11 was admitted on [DATE] with diagnoses including
unspecified dementia, anxiety disorder, cerebral infarction without residual deficits, weakness, and
abnormalities of Gait and mobility.
Review of the Restraint Enabler Decision Tree assessment dated [DATE] revealed 1/2 bed side rails did not
prevent the resident from performing an action that they are otherwise capable of performing.
Review of the Potential for ADL Self Care Performance deficit revised 10/30/23 revealed bilateral 1/2 side
rails to assist with bed mobility. Further review of the record revealed no evidence the bed rails were
comprehensively care planned.
Review of the physician orders dated 10/31/23 revealed bilateral 1/2 side rails to assist with bed mobility
and provide independence.
On 10/31/23 at 11:00 A.M. and 11:25 A.M., Resident #11's bed was observed to have bilateral 1/2 bed rails
attached to the upper sides of the bed. The bed rails were observed in the up position.
On 11/01/23 at 10:53 A.M., interview with Registered Nurse #202 verified the resident did not have a
specific care plan for the use of bed rails as an enabler/restraint.
On 11/01/23 at 11:00 A.M., interview with the Director of Nursing verified there was no comprehensive care
plan for Resident #11's bed rails.
On 11/01/23 at 1:41 P.M., observation revealed Resident #11 was laying in bed on her back with bilateral
1/2 bed rails in the up position.
2. Medical record review revealed Resident #39 was admitted on [DATE] with diagnoses including bipolar
disorder, dementia, dysphagia, cognitive communication deficit and protein calorie malnutrition.
Review of the Emergency Dental Form 09/07/23 revealed Resident #39 was having some issues with her
teeth hurting and family wanted her to be evaluated. The resident had several broken teeth with intermittent
pain.
Review of the medical record revealed no evidence of a comprehensive care plan for Resident #39's dental
concerns.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 7 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
On 10/31/23 at 12:05 P.M., observation revealed Resident #39 had some missing upper and lower teeth;
however, at least two natural teeth were observed.
On 11/01/23 from 4:35 P.M. through 4:53 P.M., interview with the Director of Nursing verified there was no
comprehensive dental care plan for Resident #39.
Residents Affected - Few
3. Medical record review revealed Resident #39 was admitted on [DATE] with diagnoses including insomnia
and epilepsy.
Review of the Medication Administration Record dated October 2023 revealed Resident #39 received
Trazadone 100 milligrams (mg) for insomnia and Levetiracetam 500 mg seizures.
Review of the record revealed no evidence of a comprehensive care plan for Resident #39's insomnia or
epilepsy.
On 11/01/23 at 11:04 A.M., interview with Clinical Resource Specialist #201 verified the lack of care plan
for Resident #39 related to insomnia and epilepsy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 8 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview, the facility failed to timely revise resident care plans. This affected
one resident (#39) of 22 residents reviewed for assessment and care planning. The census was 56.
Findings include:
Medical record review revealed Resident #39 was admitted on [DATE] with diagnoses including but not
limited to bipolar disorder, dementia, dysphagia, cognitive communication deficit and protein calorie
malnutrition. The resident was unable to answer screening questions appropriately at the time of the survey.
Review of the Base-Line admission Care Plan dated 07/24/23 revealed Resident #39 had natural teeth.
Staff was to observe the oral cavity, report abnormal findings, evaluate need for dental services, provide
oral care, monitor and report dental pain as indicated.
Review of the Emergency Dental Form 09/07/23 revealed Resident #39 was having some issues with her
teeth hurting and family wanted her to be evaluated. The resident had several broken teeth and was having
intermittent pain.
Review of the Care Plan: Alteration in Nutrition revised 10/02/23 revealed the resident was edentulous.
On 10/31/23 at 12:05 P.M., observation revealed Resident #39 had some missing upper and lower teeth;
however, at least two natural teeth were observed.
On 11/01/23 at 4:35 P.M. through 4:53 P.M., interview with the Director of Nursing verified Resident #39's
nutrition care plan was inaccurate and had not been updated related to the resident's current oral status.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 9 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview, the facility failed to ensure Resident #3's percutaneous
endoscopic gastrostomy (PEG) tube dressing was changed per the physician's orders. This affected one
resident (#3) of two residents reviewed for PEG tubes.
Residents Affected - Few
Findings include:
Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses including cerebral infarction, spastic hemiplegia affecting the left non-dominant side and
encounter for attention to gastrostomy.
Review of Resident #3's physician orders revealed an order revised 05/15/22 to cleanse the PEG tube site
with soap and water and cover with a dry sterile dressing every night shift.
Review of Resident #3's medication administration records (MAR) and treatment administration records
(TAR) from 10/01/23 to 10/31/23 revealed documentation on the TAR revealed the resident's PEG tube
dressing was changed as ordered on 10/29/23, 10/30/23 and 10/31/23.
Observation on 10/31/23 at 5:03 P.M. with Licensed Practical Nurse (LPN) #116 revealed Resident #3's
PEG tube dressing was dated 10/29/23.
Interview on 10/31/23 at 5:06 P.M. with LPN #116 confirmed Resident #3's PEG tube dressing was not
completed per the physician's orders.
Review of the Enteral Nutrition policy revised 11/2018 indicated adequate nutritional support through
enteral nutrition was provided to residents as ordered. The recommendation to initiate the use of enteral
nutrition was based on the results of the comprehensive nutritional assessment, and was consistent with
current standards of practice, the resident's advance directives, treatment goals and facility policies.
Review of the Gastrostomy/Jejunostomy Site Care policy revised 10/11 indicated the purpose of the
procedure was to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation,
breakdown and infection. Steps for the procedure include to place the equipment at the bedside; wash and
dry the hands thoroughly; wear clean gloves; using gauze pads, gently clean the area with soap and warm
water; after cleaning allow to air dry; and unless indicated, do not place a dressing over the site.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 10 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview, the facility failed to ensure Resident #3's left thumb pressure ulcer
wound care was completed per the physician's order. This affected one resident (#3) of one resident
reviewed for pressure ulcers.
Residents Affected - Few
Findings include:
Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses
including cerebral infarction, aphasia and spastic hemiplegia affecting the right dominant side.
Review of Resident #3's nursing progress note dated 10/30/23 at 3:59 A.M. indicated the resident's left
thumb was slightly edematous with serous and bloody discharge noted. The measurements were unable to
be obtained and the resident's thumb was cleansed with warm water and soap, the wound was dried, a
nonstick Telfa dressing was applied and the thumb was wrapped with Kerlix. The wound nurse, physician
and Director of Nursing (DON) was notified.
Review of Resident #3's physician orders revealed an order dated 10/30/23 to cleanse the left thumb with
normal saline, pat dry, apply calcium alginate and wrap with a Kerlix every day and as needed at bedtime.
Review of Resident #3's Skin Grid Pressure 3.0 form dated 10/30/23 revealed a Stage II (partial-thickness
loss of skin with exposed dermis, presenting as a shallow open ulcer) left thumb pressure wound measured
2.3 cm (centimeters) length by 1.3 cm width with 0.2 cm depth with moderate serous drainage and no odor.
Review of Resident #3's medication administration records (MAR) and treatment administration records
(TAR) from 10/30/23 to 11/01/23 revealed the left thumb pressure dressing was due at 8:00 P.M. daily and
the documentation indicated the wound care was completed as ordered.
Observation on 10/31/23 at 5:02 P.M. with Licensed Practical Nurse (LPN) #116 of the resident's left thumb
revealed the dressing was not in place at the time of the observation.
Interview on 10/31/23 at 5:06 P.M. with LPN #116 confirmed she had noticed Resident #3's left thumb
dressing was not implemented approximately thirty minutes prior to the interview but she was busy with
another resident and she was in the process of getting the supplies to change the dressing.
Interview on 10/31/23 at 5:18 P.M. with State Tested Nursing Assistant (STNA) #118 confirmed Resident #3
was on her assignment and the resident did not have a pressure ulcer wound care dressing on her left
thumb when she provided care to the resident. STNA #118 confirmed her assignment on 10/31/23 was
6:00 A.M. to 6:00 P.M.
Review of the Pressure Ulcer/Skin Breakdown Clinical Protocol form revised 04/2018 indicated the
physician would order pertinent wound treatments, including pressure reduction surface, wound cleansing
and debridement approaches, dressings (occlusive, absorptive, etc), and application of topical agents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 11 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, medical record review and interview, the facility failed to ensure respiratory supplies
were changed weekly as ordered and nebulizer masks stored appropriately for Resident #5. This affected
one resident (#5) of one resident reviewed for respiratory services. The facility census was 56.
Residents Affected - Few
Findings include:
Review of Resident #5's medical record revealed an admission date of 08/07/20 with diagnoses that
included chronic obstructive pulmonary disease, diabetes mellitus and congestive heart failure.
Further review of the medical record including physician's orders revealed orders for supplemental oxygen
use to maintain oxygen saturation levels above 92%, change oxygen tubing weekly on Saturday and
change nebulizer kit/tubing weekly on Saturday.
Review of the Medication Administration Record (MAR) for the month of October 2023 revealed oxygen
tubing and nebulizer tubing documented as changed on 10/07/23, 10/14/23, 10/21/23 and 10/28/23.
Observation of Resident #5 on 10/31/23 at 9:40 A.M. revealed the resident lying in bed with supplemental
oxygen in place by nasal cannula. Observation of the oxygen tubing revealed a tape tag dated 10/21/23
and the humidification bottle on the oxygen concentrator was completely empty.
Additional observation of Resident #5 revealed a nebulizer machine on the resident's night stand next to
the bed. Nebulizer tubing was observed to be dated with a tape tag which indicated 10/15/23. Additional
observation revealed the resident's nebulizer mask lying on top of clothing on the nightstand with no
evidence of a protective bag for appropriate storage in use.
On 10/31/23 at 10:31 A.M. interview with Licensed Practical Nurse (LPN) #137 verified oxygen tubing was
dated as changed on 10/21/23, nebulizer tubing and mask were dated as changed on 10/15/23 and the
nebulizer mask was improperly stored. LPN #137 indicated oxygen tubing and nebulizer tubing and mask
were to be changed weekly as ordered and nebulizer mask was to be stored inside a protective plastic bag.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 12 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a
resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed
consent; and (4) Correctly install and maintain the bed rail.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, policy review and interview, the facility failed to provide appropriate
alternatives prior to the use of bed rails for Resident #11. This affected one resident (#11) of one resident
reviewed for bed rails. The facility census was 56.
Findings include:
Medical record review revealed Resident #11 was admitted on [DATE] with diagnoses including unspecified
dementia, lack of coordination, major depressive disorder, anxiety disorder and cerebral infarction without
residual deficits, weakness, and abnormalities of gait and mobility. Resident #11 resided on the secured
memory care unit and was unable to be interviewed due to cognitive impairment and an inability to answer
questions appropriately.
Review of the Restraint Enabler Decision Tree assessment dated [DATE] revealed Resident #11 used a left
enabler bar to move in and out of bed. The assessment indicated the enabler bar improved the resident's
function.
Review of the Restraint Enabler Decision Tree assessment dated [DATE] revealed Resident #11 was
ordered 1/2 bed side rails, it did not prevent the resident from performing an action that they are otherwise
capable of performing and it improved the resident's functional status.
Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #11 was
severely impaired for daily decision-making, required extensive assist of two staff for transfers and bed
mobility, and had no restraints in use.
Review of the Care Plan: Potential for ADL Self-Care Performance Deficit related to dementia, impaired
balance, limited mobility and ROM (range of motion) revised 10/20/23 revealed bilateral 1/2 side rails to
assist with mobility was added on 10/30/23. There was no other bed rail plan of care for review.
Review of the physician orders dated 10/31/23 revealed bilateral 1/2 side rails to assist with bed mobility
and provide independence. There was no evidence of a physician order prior to 10/31/23 for the use of the
bed rails.
Further review of the record revealed no comprehensive assessment or consent for the use of bed rails.
On 10/31/23 at 11:00 A.M. and 11:25 A.M., observations revealed Resident #11's bed had bilateral 1/2 bed
rails attached to the bed in the up position.
On 11/01/23 at 1:41 P.M., observation revealed Resident #11 was laying in bed on her back with bilateral
1/2 bed rails in the up position.
On 11/01/23 at 10:53 A.M., interview with Registered Nurse #202 revealed Resident #11 had used 1/4 rail
enablers prior to her room move on 09/21/23 and those were effective. Upon return to the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 13 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Minimal harm
or potential for actual harm
facility from the hospital the resident was admitted to a different room and it was unknown if when she
moved to her new room if the bilateral 1/2 side rails were already on the bed or not. RN #202 verified
Resident #11 resided on the memory care unit, and she did not have a comprehensive care plan or
assessment for the use of the bed rails. RN #202 stated she would have to look to see if a consent had
been obtained prior to the use of bed rails.
Residents Affected - Few
Review of the Policy: Proper Use of Side Rails revised December 2016 revealed side rails were only
permissible if they were used to treat a resident's medical symptoms or to assist with mobility and transfer
of residents. An assessment to determine the resident's symptoms, risk of entrapment and reason for using
side rails was to be done. When used for mobility or transfer, an assessment was to include a review of the
resident's bed mobility, ability to change positions, transfer to and from bed or chair, and to stand and toilet.
Risk of entrapment from the use of side rails; and that the bed's dimensions are appropriate for the
resident's size and weight. The use of side rails as an assistive device will be addressed in the resident
care plan. Less restrictive interventions will be incorporated in care planning including providing restorative
care to enhance abilities to stand safely and to walk, provide a trapeze to increase bed mobility, placing the
bed lower to the floor and surrounding the bed with a soft mat, equipping the resident with a device that
monitors attempts to arise; staff monitoring at night with periodic assisted toileting for residents attempting
to arise to the use the bathroom; furnishing visual and verbal reminders to use the call bell for residents
who can comprehend this. Documentation will indicate if less restrictive approaches are not successful,
prior to considering the use of side rails. Risks and benefits of side rails will be considered for each
resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 14 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0790
Provide routine and 24-hour emergency dental care for each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, policy review and interview, the facility failed to ensure timely and
accurate dental evaluations were completed. This affected one resident #39) of one resident reviewed for
dental services. The facility census was 56.
Residents Affected - Few
Findings include:
Medical record review revealed Resident #39 was admitted on [DATE] with diagnoses including but not
limited to bipolar disorder, dementia, dysphagia, cognitive communication deficit and protein calorie
malnutrition. The resident was unable to answer screening questions appropriately at the time of the survey.
Review of the Base-Line admission Care Plan dated 07/24/23 revealed Resident #39 had natural teeth.
Staff was to observe the oral cavity, report abnormal findings, evaluate need for dental services, provide
oral care, monitor and report dental pain as indicated.
Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #39 was
severely impaired for daily decision-making, had no dental concerns and was edentulous (no natural teeth).
Review of the Emergency Dental Form 09/07/23 revealed Resident #39 was having some issues with her
teeth hurting and family wanted her to be evaluated. The resident had several broken teeth and was having
intermittent pain.
Review of the medical record dated 09/07/23 through 10/30/23 revealed no documented evidence of an
oral assessment, documented pain or comprehensive care plan for dental concerns.
On 10/31/23 at 12:05 P.M., observation revealed Resident #39 had some missing upper and lower teeth;
however, at least two natural teeth were observed.
On 11/01/23 at 1:27 P.M. through 1:37 P.M., interview with State Tested Nurse Aide (STNA) #161 revealed
Resident #39 had several natural teeth, had no complaints of dental pain and was able to eat mechanical
soft foods without difficulty.
On 11/01/23 at 4:35 P.M. through 4:53 P.M., interview with the Director of Nursing (DON) and Registered
Nurse #202 revealed Social Service Designee (SSD) #167 documented the resident was in pain so she
could be seen sooner than January 2023. The DON stated she was not previously aware of any dental
concerns for Resident #39, the admission MDS assessment was inaccurate, and there was no
comprehensive assessment of the residents oral status.
Review of the Policy: Dental Services revised December 2016 revealed routine and emergency dental
services were available to meet the resident's oral health services in accorcance with the resident's
assessment and plan of care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 15 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
Based on observation, consumption of pureed foods, record review and policy review, the facility failed to
ensure pureed foods were prepared to a proper consistency and failed to substitute an appropriate food
item for pureed rice during the meal on 11/01/23 to ensure the meal was palatable, appetizing and ensured
safe swallowing. This affected two residents (#12 and #39) of two residents identified by the facility to have
orders for pureed diets.
Findings include:
Observation of pureed food preparation on 11/01/23 at 10:31 A.M. revealed Dietary Manager (DM) #165
was observed to puree rice for the lunch meal. Following the preparation, the pureed rice was tasted and
noted to have small pieces of rice in it. DM #165 verified the rice was not pureed enough and proceeded to
puree the rice for several more minutes. DM #165 could not get the rice to puree smoothly, so she then
changed the puree starch to mashed potatoes for the meal (as opposed to substituting the mashed
potatoes for the rice to begin with).
Continued observation on 11/01/23 revealed DM #165 was observed to pureed chicken and vegetables.
After preparation, a first taste test at 10:46 A.M. revealed the chicken was gritty and not a smooth
consistency. The DM replaced the Robot Coupe blade at 10:50 A.M. and pureed the chicken and
vegetables more until reaching a desired consistency at 11:00 A.M.
The facility identified two residents, Resident #12 and #39 who had orders for pureed diets.
Review of the undated facility recipe, titled Pureed [NAME] Recipe revealed all pureed foods should be
mixed until very smooth.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 16 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0806
Level of Harm - Minimal harm
or potential for actual harm
Ensure each resident receives and the facility provides food that accommodates resident allergies,
intolerances, and preferences, as well as appealing options.
Based on observation, record review and interview the facility failed to ensure resident food preferences
were honored. This affected one resident (#32) of one resident reviewed for food preferences.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #32 revealed an admission date of 10/16/23 with diagnoses
including ulcerative colitis, alcohol abuse, and cirrhosis of liver.
Review of Resident #32's preference sheet dated 10/16/23 revealed Resident #32 stated her preference
was to be gluten free.
Review of the Resident Preference Interview dated 10/16/23 for Resident #32 revealed Resident #32 does
not eat gluten for personal comfort.
Review of the physician's orders for November 2023 identified orders for a no added salt, low fat and low
cholesterol diet with regular texture and regular liquid consistency.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 10/23/23 revealed
Resident #32 had no cognitive impairment.
Interview on 10/31/23 at 9:31 A.M. with Resident # 32 revealed that she is on a gluten free diet. Resident
#32 stated that the facility will send gluten items or no tray at all.
Observation and interview on 10/31/23 at 11:58 A.M. of Resident # 32 's lunch tray had beef stroganoff and
a slice of bread. This was verified by Licensed Practical Nurse (LPN) #137 at time of observation. LPN #137
stated that Resident #32 says she has a gluten free allergy but has never been tested.
Review of Resident #32's lunch diet ticket dated 10/31/23 revealed a no added salt diet with no dislikes or
mention of a preference of gluten free.
Interview on 11/01/23 at 7:09 A.M. with [NAME] President of Operations (VPO) #171 verified the orders for
Resident #32 didn't match her diet or preference for gluten free diet was not included on her meal ticket.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 17 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on record review and interview the facility failed to ensure resident medical records were accurate
and completed to reflect incidents and the residents current status. This affected two residents (#24 and
#51) of two residents reviewed for abuse and one resident (#24) of 22 residents reviewed for assessments
and care planning. The census was 56.
Findings include:
1. Review of a facility Self-Reported Incident (SRI), tracking number 240551, dated 10/25/23, revealed
there was an incident between Residents #24 and #51 that occurred on 10/24/23.
Review of the medical record for Resident #24 revealed an admission date of 09/16/22 with diagnoses
including dementia with behavioral disturbance, recurrent depressive disorders, brief psychotic disorder,
and cognitive communication deficit.
Review of the progress notes for October 2023 for Resident #24 revealed there were no progress notes
regarding the incident that occurred on 10/24/23 between Residents #24 and #51.
Review of the medical record for Resident #51 revealed an admission date of 10/24/22 with diagnoses
including Alzheimer's disease, coronary artery disease, hyperlipidemia, insomnia, chronic pain syndrome,
cardiac arrhythmia, delusional disorder, major depressive disorder, overactive bladder, obesity, heart failure,
and gastroesophageal reflux disease.
Review of the progress notes for October 2023 revealed there were no progress notes regarding the
incident that occurred on 10/24/23 between Residents #51 and #24.
On 11/02/23 at 8:57 A.M., interview with the Administrator verified there was an alleged incident of abuse
between Residents #24 and #51 on 10/24/23. She also confirmed there was no documentation regarding
the incident in the medical records of Resident #24 and #51.
2. Review of the medical record for Resident #24 revealed an admission date of 09/16/22 with diagnoses
including dementia with behavioral disturbance, recurrent depressive disorders, brief psychotic disorder,
and cognitive communication deficit. Further review of the diagnoses revealed a new diagnosis of
delusional disorder was added on 03/07/23.
Review of the physician's orders for October 2023 identified no orders for antipsychotic medications.
Review of the past physician's orders identified orders for Abilify (an antipsychotic) which was discontinued
on 03/16/23.
Review of the care plan, revised 09/16/22, indicated Resident #24 received an antipsychotic medication.
On 11/01/23 at 11:09 A.M., interview with the Director of Nursing verified Resident #24 had a care plan in
place for antipsychotic medications and her antipsychotic was discontinued on 03/16/23. She confirmed
Resident #24 did not have current physician's orders for an antipsychotic medication.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 18 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0851
Level of Harm - Minimal harm
or potential for actual harm
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and
other verifiable and auditable data.
THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS
SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Residents Affected - Many
Based on record review and interview, the facility failed to ensure Payroll Based Journal (PBJ) tracking
information submitted by the facility accurately reflected the actual working staff and census. This finding
had the potential to affect all 56 residents currently residing in the facility.
Findings include:
Review of the PBJ Staffing Data Report form submitted from 04/01/23 to 06/30/23 revealed one star
staffing rating and excessively low weekend staff.
Review of a statement dated 11/02/23 authored by [NAME] President (VP) of Operations #171 indicated
the facility was acquired on 01/01/23. The first two quarters of the PBJ data submitted did not have all the
working hours reported, nor an organizational process for recording the hours for the PBJ submissions.
Interview on 11/02/23 at 10:45 A.M. with VP of Operations #171 indicated the facility did not have all the
working hours and inaccurate documentation was submitted on the PBJ reporting website from 04/01/23 to
06/30/23. She indicated she had revised the reporting process to include the development and
implementation of a new tracking tool which was used by the Information Technologies (IT) Department to
track the actual staff who worked each day to ensure all PBJ staffing documentation was accurate. She
also indicated audits of the actual staffing documentation to be submitted to the PBJ website was audited
by herself, the Administrator and Director of Nursing (DON) prior to submission to ensure accurate
documentation. VP of Operations #171 confirmed the Administrator was educated on the new process
including sending accurate staffing hours to the IT Department as well as review the documentation for
accuracy prior to submission to the website.
The deficient practice was corrected on 08/21/23 when the facility implemented the following corrective
actions:
- A new tracking tool for PBJ and staffing hours was developed on 08/18/23 and sent to the IT Department
to ensure accurate tracking of staffing hours.
- The facility implemented a new process on 08/18/23 including sending the PBJ staffing hours on a
monthly basis to the IT Department, who completes the actual submission, so the hours may be audited in
real time to ensure they are accounted for accurately and all required elements are present.
- Education was provided to the Administrator on 08/18/23 on what information was needed to the IT
company so they could complete accurate PBJ reporting as well as auditing the final documentation prior to
submission to the PBJ website.
- The facility contacted the IT Department on 08/21/23 to notify them of the new process for submission of
PBJ staffing hours.
- The PBJ submission report receives a final audit between IT, Administrator and VP of Operations
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 19 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0851
#171 to ensure all required elements were submitted, including but not limited to, salaried staff covering
direct care hours and all agency staff hours were being accounted for.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 20 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, facility policy review, review of the Centers for Disease Control (CDC) guidance and
interview, the facility failed to ensure influenza and pneumococcal vaccines were offered and/or
administered as required and the facility failed to ensure residents/responsible parties were educated on
the risks and/or benefits of receiving the influenza and pneumococcal vaccines per the facility policy and
Centers for Disease Control (CDC) guidelines. This affected five residents (#11, #30, #34, #39 and #49) of
six residents reviewed for immunizations.
Residents Affected - Some
Findings include:
1. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses including unspecified dementia, other lack of coordination and major depressive disorder.
Review of Resident #11's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident
exhibited severe cognitive impairment.
Review of Resident #11's medical record revealed the resident refused the influenza vaccine and the
pneumococcal vaccine on 04/18/23. The record did not have evidence the resident and/or family were
educated on the risks and benefits of the influenza and/or pneumococcal vaccine.
Interview on 10/31/23 at 4:20 P.M. with Registered Nurse (RN) Assistant Director of Nursing (ADON) #166
confirmed Resident #11's medical record did not have evidence the resident and/or family were educated
on the risks and/or benefits of the influenza and pneumococcal vaccines.
Interview on 11/01/23 at 4:09 P.M. with Licensed Practical Nurse (LPN) Clinical Resource Specialist #201
confirmed she could not find the vaccine education provided to Resident #11 and/or the resident's family on
the risks and/or benefits of the influenza and pneumococcal vaccines. She stated she called Resident #11's
daughter on 11/01/23 and the daughter refused the vaccine.
2. Review of Resident #30's medical record revealed the resident was admitted on [DATE] with diagnoses
including unspecified lack of coordination, weakness and diabetes type two.
Review of Resident #30's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact
cognition.
Review of Resident #30's medical record revealed the resident was administered the pneumococcal
(PPSV23) vaccine on 10/18/21. The medical record did not have evidence the second dose as
recommended by the CDC was administered and/or refused.
Interview on 10/31/23 at 4:21 P.M. with RN ADON #166 confirmed Resident #30 was not offered and/or
refused the PCV15 OR PCV20 as indicated in the CDC guidance.
Interview on 11/01/23 at 4:09 P.M. with LPN Clinical Resource Specialist #201 confirmed she could not find
the education provided to Resident #30 and/or the resident's family on the risks and/or benefits of the
influenza and pneumococcal vaccines. She indicated she talked to Resident #30 today and he refused the
next pneumococcal vaccine.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 21 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
3. Review of Resident #34's medical record revealed the resident was readmitted on [DATE] with diagnoses
including unspecified severe protein-calorie malnutrition, type two diabetes and repeated falls. The medical
record revealed the resident had a guardian of person and estate.
Review of Resident #34's MDS 3.0 assessment dated [DATE] revealed the resident had severe cognitive
impairment.
Review of Resident #34's medical record revealed the resident refused the influenza vaccine and
pneumococcal vaccine on 04/18/23.
Interview on 10/31/23 at 4:20 P.M. with RN ADON #166 confirmed Resident #34's medical record did not
have evidence the resident and/or guardian were educated on the risks and/or benefits of receiving or
refusing the influenza and pneumococcal vaccines.
Interview on 11/01/23 at 4:08 P.M. with LPN Clinical Resource Specialist #201 confirmed she could not find
the education provided to Resident #34 and/or the resident's family on the risks and/or benefits of the
influenza vaccine and pneumococcal vaccine. LPN Clinical Resource Specialist #201 confirmed the
resident's guardian had requested the resident should receive the pneumococcal vaccine now.
4. Review of Resident #49's medical record revealed the resident was admitted on [DATE] with diagnoses
including epilepsy, personal history of a traumatic brain injury and muscle weakness.
Review of Resident #49's MDS 3.0 assessment dated [DATE] revealed the resident exhibited a memory
problem.
Review of Resident #49's medical record dated 04/18/23 revealed the resident was not eligible for the
pneumococcal vaccine.
Interview on 11/01/23 at 4:16 P.M. with RN ADON #166 confirmed Resident #49's medical record did not
have evidence the resident and/or family were educated and the resident and/or family had refused or
accepted the pneumococcal vaccine.
Interview on 11/01/23 at 4:10 P.M. with LPN Clinical Resource Specialist #201 confirmed she could not find
the education on the risks and/or benefits of the vaccine education that was provided to Resident #49 or
the resident's family.
5. Medical record review revealed Resident #39 was admitted on [DATE] with diagnoses including but not
limited to bipolar disorder, dementia, dysphagia, cognitive communication deficit and protein calorie
malnutrition. The resident was unable to answer screening questions appropriately at the time of the survey.
Review of the Historical Update Immunization record revealed Pneumococcal Polysaccharide PPSV23 was
administered on 08/15/18.
Review of the record revealed no documented evidence the facility offered the PPSV15 or PCV20
vaccination or provided education, risks and benefits regarding the PPSV15 or PCV20 vaccination.
On 11/02/23 at 11:30 A.M., interview with Clinical Resource Specialist #201 verified PPSV15 or PCV20
was not offered and/or refused as indicated in the CDC guidance.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366123
If continuation sheet
Page 22 of 23
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366123
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Accord Care Community Orrville LLC
1980 Lynn Drive
Orrville, OH 44667
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Review of the CDC Pneumococcal Vaccination: Summary of Who and When to Vaccinate form revealed for
the adults, regardless of the risk condition, give one dose of PCV15 or PCV20 at least one year after the
most recent PPSV23 vaccination.
Review of the facility policy titled Vaccination of Residents revised 03/2023 indicated prior to receiving
vaccinations, the resident or legal representative would be provided information and education regarding
the benefits and potential side effects of the vaccinations. Provision of such education shall be documented
in the resident's medical record. All new residents shall be assessed for current vaccination status upon
admission. If vaccines were refused, the refusal shall be documented in the resident's medical record.
Event ID:
Facility ID:
366123
If continuation sheet
Page 23 of 23
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
25 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
F790 - Dental services
Provide routine and 24-hour emergency dental care for each resident.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F851 - Mandatory submission of staffing information based on payroll data in a
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
F569 - Notice of certain balances
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
FAQ · About this visit
Common questions about this visit
What happened during the November 2, 2023 survey of ACCORD CARE COMMUNITY ORRVILLE LLC?
This was a inspection survey of ACCORD CARE COMMUNITY ORRVILLE LLC on November 2, 2023. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ACCORD CARE COMMUNITY ORRVILLE LLC on November 2, 2023?
Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Keep aisles, corridors, and exits free of obstruction in case of emergency."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.