Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
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, 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.
Residents Affected - Few
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 grabbed a female
resident's breasts while in the dining room. This resident was later identified as Resident #1.
Review of the medical record for Resident #1 revealed she was admitted on [DATE] with diagnosis of
Parkinson's disease, dementia without behavioral disturbance, hypertensive heart disease, functional
quadriplegia, and major depressive disorder.
Review of nursing progress notes and assessment for Resident #1 revealed no information regarding any
alleged abuse on 04/22/22.
Interview on 04/27/22 at 2:30 P.M. with the Administrator revealed she was unaware of any allegation of
abuse involving Resident #16's towards Resident #1. The Administrator verified their abuse policy directed
all staff to report all allegations of abuse immediately for investigation.
Interview on 04/27/22 at 4:42 P.M. with Licensed Practical Nurse (LPN) #512 revealed she was at nurses'
station when State Tested Nursing Assistant (STNA) #546 told her she needed to chart in the medical
record that Resident #16 grabbed Resident #1's breast. LPN #512 stated she assessed Resident #1 and
charted in Resident #16's chart about the behavior. LPN #512 verified she did not report this allegation of
abuse to any management staff.
(continued on next page)
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 11
Event ID:
366203
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
366203
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Orrville Pointe
230 South Crown Hill Road
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 0607
Interview on 04/28/22 at 2:26 P.M. with Resident #1 revealed she felt safe in the facility.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 04/28/22 at 2:29 PM with STNA #546 indicated on 04/22/22 when she returned from lunch,
she was told by Activities Aid #574 that Resident # 16 was trying to grab Resident #1. STNA #546 said she
reported the incident to LPN #512 per the facility's abuse policy.
Residents Affected - Few
Interview on 04/28/22 at 2:37 P.M. with Activity Aide #574 revealed she and Resident #1 were at table for
an activity when Resident #16 reached down inside Resident #1's shirt. Activity Aid #574 told Resident #16,
No, we do not do that, and he moved his hand away. Activity Aide #574 stated Resident #1 also told
Resident #16 to stop.
Review of the facility Abuse Investigation and Reporting Policy, last revised 12/2017, revealed all alleged
violations of abuse would be reported immediately, but no later than two hours of the alleged abuse, and
thoroughly investigated.
2. Review of medical record for Resident #35 revealed she was admitted on [DATE] with diagnoses
including cerebral palsy and anxiety disorder. Review of progress notes dated 04/14/22 through 04/16/22
revealed no entries for any alleged abuse.
Interview with Resident #35 on 04/25/22 at 9:36 A.M. revealed she was afraid of Resident #16 because he
had touched her before.
Review of the facility investigation dated 04/14/22 at 1:30 P.M. revealed Resident #16 was observed in the
dining room by an STNA, rubbing Resident #35's thigh area on top of the blanket on her lap. Resident #35
was smiling and talking. The STNA intervened and removed Resident #16. Resident #35 verified Resident
#35 had touched her leg, denied feeling unsafe and said that it didn't mean anything.
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.
Observation on 04/28/22 at 2:22 P.M. revealed Resident #35 wheeling herself around unit interacting with
staff and other residents without any signs of distress.
Interview on 04/27/22 at 2:30 P.M. with the Administrator verified she was unaware of this alleged allegation
of abuse and verified she did not complete this investigation. The investigation was completed by the
director of nursing according to the signature. Their investigation only included an interview of Resident
#35, Resident #16 and the STNA who observed the interaction. The Administrator verified they did not
follow their abuse policy and procedure to complete a thorough investigation to include interviews with other
residents, other staff working at the time of the incident and with resident physicians.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366203
If continuation sheet
Page 2 of 11
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
366203
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Orrville Pointe
230 South Crown Hill Road
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 0607
Level of Harm - Minimal harm
or potential for actual harm
The facility Abuse Investigation and Reporting Policy of Abuse, last revised 12/2017, directed them to
complete a thorough investigation which included interviews with any witnesses, family, visitors, the
attending physician, staff on all shifts who had contact with residents at the time of the alleged incident, and
other residents who may have been affected.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366203
If continuation sheet
Page 3 of 11
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
366203
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Orrville Pointe
230 South Crown Hill Road
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**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 breasts while in the dining room. This resident was later identified as Resident #1.
Review of the medical record for Resident #1 revealed she was admitted on [DATE] with diagnosis of
Parkinson's disease, dementia without behavioral disturbance, hypertensive heart disease, functional
quadriplegia, and major depressive disorder.
Review of nursing progress notes and assessment for Resident #1 revealed no information regarding any
alleged abuse on 04/22/22.
Interview on 04/27/22 at 2:30 P.M. with the Administrator revealed she was unaware of any allegation of
abuse involving Resident #16's towards Resident #1. The Administrator verified their abuse policy directed
all staff to report all allegations of abuse immediately.
Interview on 04/27/22 at 4:42 P.M. with Licensed Practical Nurse (LPN) #512 revealed she was at nurses'
station when State Tested Nursing Assistant (STNA) #546 told her she needed to chart in the medical
record that Resident #16 grabbed Resident #1's breast. LPN #512 stated she assessed Resident #1 and
charted in Resident #16's chart about the behavior. LPN #512 verified she did not report this allegation of
abuse to any management staff.
Interview on 04/28/22 at 2:26 P.M. with Resident #1 revealed she felt safe in the facility.
Interview on 04/28/22 at 2:29 PM with STNA #546 indicated on 04/22/22 when she returned from lunch,
she was told by Activities Aid #574 that Resident # 16 was trying to grab Resident #1. STNA #546 said she
reported the incident to LPN #512 per the facility's abuse policy.
Interview on 04/28/22 at 2:37 P.M. with Activity Aide #574 revealed she and Resident #1 were at table for
an activity when Resident #16 reached down inside Resident #1's shirt. Activity Aid #574 told Resident #16,
No, we do not do that, and he moved his hand away. Activity Aide #574 stated Resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366203
If continuation sheet
Page 4 of 11
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
366203
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Orrville Pointe
230 South Crown Hill Road
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 0609
#1 also told Resident #16 to stop.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility Abuse Investigation and Reporting Policy, last revised 12/2017, revealed all alleged
violations of abuse would be reported immediately, but no later than two hours of the alleged abuse.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366203
If continuation sheet
Page 5 of 11
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
366203
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Orrville Pointe
230 South Crown Hill Road
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 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**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.
Residents Affected - Few
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 advances
towards women, was intrusive and wandered into other resident rooms, had a history of inappropriately
touching female peers, and was not being easily redirectable. He would attempt to kiss, hold hands or put
his hands on female peers legs while in the dining room. The diagnosis of unspecified dementia with
behavioral disturbance was added on 03/01/22.
Review of the facility investigation dated 04/14/22 at 1:30 P.M. revealed Resident #16 was observed
touching Resident #35 on her thigh on top of the blanket on her lap. There was documentation of one
interview with the state tested nursing assistant and Resident #35. No other staff or residents were listed as
interviewed regarding this abuse allegation and it was not thoroughly investigated.
Interview with the Administrator on 04/26/22 at 2:30 P.M. revealed a thorough investigation was not
included in the file presented to the surveyor. The Administrator stated she normally completes/investigates
allegations of abuse but she did not complete this investigation. The Administrator verified there was no
evidence the resident's physician was interviewed, no interviews with staff from all shifts who had contact
with resident during period of alleged allegation, any other potential witnesses/visitors and other residents
to see if any other residents had experience similar incidents.
Review of the facility policy, Abuse Investigating and Reporting, last revised 12/2017 revealed each
allegation of abuse would be thoroughly investigated and would include interviews with involved parties, the
physician of the residents, all staff on all shifts with contact with the resident during the time period of the
allegation, all witnesses, resident roommates, family and visitors and other residents who may also be
affected.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366203
If continuation sheet
Page 6 of 11
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
366203
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Orrville Pointe
230 South Crown Hill Road
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, 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.
Residents Affected - Few
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 medical record revealed there was no evidence a stool sample was collected for Resident #8.
The nursing progress notes from 04/05/22 to 04/22/22 revealed Resident #8 had loose stools daily.
Interview on 04/28/22 at 2:56 P.M. with Licensed Practical Nurse (LPN) #512 verified Resident #8 had
loose stools daily and the physician ordered stool sample had not been collected.
Interview on 04/28/22 at 4:33 P.M. with the Director of Nursing verified there was no evidence a stool
sample had been collected and there were no laboratory results for a stool sample for Resident #8.
2. Review of medical record revealed Resident #33 was admitted on [DATE] with diagnoses which included
fracture of left pubis, Alzheimer's disease, dementia, and acute kidney failure.
Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #33 was
cognitively impaired and required extensive staff assistance with one staff for bed mobility, transfers, and
toilet use.
Review of the nursing progress note dated 04/13/22 at 2:56 P.M. revealed Resident #33 reported she had
fallen while trying to use the bathroom. The nurse had been in the resident's room two minutes prior and
the resident was sitting in her wheelchair. The nurse examined Resident #33 and found a skin tear to her
right wrist which measured 1.125 centimeters (cm) long and 0.75 cm wide. A dry sterile dressing was
applied. The note indicated that due to Resident #33's mental status and functional ability, it was likely
Resident #33 attempted to use the bathroom unassisted and fell back into the chair which caused the skin
tear.
Review of the facility's non-pressure related skin issues log dated 04/13/22 revealed Resident #33 had a
skin tear to her right wrist.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366203
If continuation sheet
Page 7 of 11
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
366203
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Orrville Pointe
230 South Crown Hill Road
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
Level of Harm - Minimal harm
or potential for actual harm
Review of the weekly non-pressure wound tracking dated 04/20/22 revealed Resident #33 had a skin tear
to her right wrist which measured two cm long and 0.2 cm wide.
Observations on 04/25/22 at 8:40 P.M. and 04/26/22 at 9:33 A.M. revealed Resident #33 had a dressing to
her right wrist dated 04/20/22.
Residents Affected - Few
Interview on 04/26/22 at 9:47 A.M. with LPN #519 verified Resident #33 had a dressing to her right wrist
dated 04/20/22. Dark drainage could be seen coming through the dressing. LPN #519 verified she did not
see a physician order for the dressing to be changed but would change the dressing at that time.
Interview on 04/27/22 at 2:59 P.M. with the Director of Nursing verified there were no physician orders or
treatments in place since the day Resident #33 obtained the skin tear on 04/13/22 to aid in healing and for
nursing staff to routinely monitor the skin condition until healed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366203
If continuation sheet
Page 8 of 11
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
366203
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Orrville Pointe
230 South Crown Hill Road
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
**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.
Residents Affected - Few
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 04/27/22 at 9:43 A.M. with Registered Nurse (RN) #504 verified there was not a date on
Resident #8's oxygen tubing. RN #504 could not verify when the oxygen tubing had last been changed.
Review of the Departmental (Respiratory Therapy)-Prevention of Infection policy, revised December 2017,
revealed oxygen cannula and tubing was to be changed every seven days or as needed.
2. Review of medical record revealed Resident #26 was admitted on [DATE] with diagnoses which included
rheumatoid arthritis and Felty's Syndrome (a rare disorder associated with rheumatoid arthritis resulting in
an enlarged spleen and a very low white blood cell count which increases their susceptibility to infections).
Review of the medical record revealed Resident #26 received hospice services and no order was found for
the use of oxygen.
Observation on 04/26/22 at 9:39 A.M. and 04/27/22 at 9:43 A.M. revealed Resident #26 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 in use.
Interview on 04/27/22 at 9:43 A.M. with RN #504 verified there was not a date on Resident #26's oxygen
tubing. RN #504 could not verify when the oxygen tubing had last been changed.
Review of the Departmental (Respiratory Therapy)-Prevention of Infection policy, revised December 2017,
revealed oxygen cannula and tubing was to be changed every seven days or as needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366203
If continuation sheet
Page 9 of 11
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
366203
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Orrville Pointe
230 South Crown Hill Road
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**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
antipsychotic medication) for psychosis, however psychosis was not listed as a diagnosis.
Review of Resident #33's physician orders and medication administration records (MARs) revealed
dementia was the diagnosis given for the use of Seroquel.
A handwritten note authored by the certified nurse practitioner (no date) directed the staff at the facility to
add a diagnosis of brief psychotic disorder, but it was unclear when this note was written.
Interview on 04/28/22 at 3:23 P.M. with the Director of Nursing (DON) verified dementia was not an
appropriate diagnosis for the use of the antipsychotic medication Seroquel.
2. Review of medical record for Resident #37 revealed an admission date of 10/22/21 with diagnoses which
included dementia and major depressive disorder.
Review of the plan of care revised on 03/29/22 revealed Resident #37 demonstrated signs and symptoms
consistent with depression such as being withdrawn and reluctant to participate in therapy and activities.
Interventions included for staff to administer medications as ordered and monitor mood, affect and
behaviors with all hands-on care and contacts.
Review of the pharmacy recommendation dated March 2022 revealed the diagnosis for behaviors needed
to be verified for Resident #37's use of Zyprexa (an antipsychotic medication).
Review of Resident #37's March 2022 MAR revealed the diagnosis given for the use of the Zyprexa was
dementia with behavioral disturbances.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366203
If continuation sheet
Page 10 of 11
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
366203
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Orrville Pointe
230 South Crown Hill Road
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
A handwritten note by the certified nurse practitioner (no date) revealed the diagnosis for the use of the
Zyprexa was dementia with behavioral disturbances, but it was unclear when this note was written.
Interview on 04/28/22 at 3:24 P.M. with the DON verified dementia was not an appropriate diagnoses for the
use of the antipsychotic medication Zyprexa. The DON also verified there was no documentation of
Resident #37 having behaviors that would require the use of antipsychotic medication.
Event ID:
Facility ID:
366203
If continuation sheet
Page 11 of 11
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
6 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.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F758 - Medication Errors
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.
FAQ · About this visit
Common questions about this visit
What happened during the April 28, 2022 survey of ORRVILLE POINTE?
This was a inspection survey of ORRVILLE POINTE on April 28, 2022. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ORRVILLE POINTE on April 28, 2022?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement policies and procedures to prevent abuse, neglect, and theft."
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.