Orrville Pointe

Inspectors wroteBased on medical record review, review of an emergency medical services (EMS) run report, review of hospital records, staff and family interviews, and facility policy review, the facility failed to ensure medications were appropriately secured and inaccessible to residents. This resulted in Immediate Jeopardy and serious life-threatening harm and negative health outcomes on 06/05/26 at approximately 9:00 A.M. when Resident #46 was observed to have multiple empty medication cards (packaged by pharmacy and provided specific labeling including the resident's name, medication name and dosage, and administration times) of Keppra (an anticonvulsant medication used to treat seizures) and Baclofen (a skeletal muscle relaxant and antispasmodic) each which had an original quantity of 30 and belonged Resident #11. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to protect Resident #31 from abuse and mistreatment on 06/11/26 at approximately 10:00 P.M. when Registered Nurse (RN) #107 forced a spoonful of applesauce and medications into Resident #31's mouth as she was unresponsive. This affected one Resident (#31) of three residents reviewed for abuse. The facility census was 45.

Inspectors wroteBased on interview, record review, review of the Ohio Department of Health's Certification and Licensure System, and facility policy review, the facility failed to ensure an allegation of staff to resident abuse was reported to the State Agency as required. This affected one resident (#31) of three residents reviewed for abuse. The facility census was 45.

Inspectors wroteBased on interview, record review, review of the Ohio Department of Health's Certification and Licensure System, and facility policy review, the facility failed to ensure an investigation into alleged of staff to resident abuse was timely and thoroughly investigated. This affected one Resident (#31) of three residents reviewed for abuse. The facility census was 45.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications were administered per physician orders. This affected one Resident (#25) of three residents observed and reviewed for medication administration. The facility census was 45.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to prevent a significant medication error for Resident #31, when routine and as-needed medications for end-of-life comfort were unavailable for administration. This affected one Resident (#31) of five residents reviewed for medication administration. The facility census was 45.

Inspectors wroteBased on interview and record review the facility failed to maintain an accurate and complete medical records which included documentation of resident to resident altercations. This affected two residents (#6 and #47) of three residents reviewed for abuse. The facility census was 45.

Inspectors wroteBased on record review, review of the Self-Reported Incident (SRI), interviews and review of facility policy, the facility failed to ensure that Resident #41 was adequately supervised to prevent elopement and risk of accident hazards. This affected one resident (#41) out of three residents reviewed for accident hazards. The facility census was 44.

Inspectors wroteBased on interviews, review of the facility assessment, and staff schedule review the facility failed to ensure a full time Director of Nursing (DON) was employed by the facility and involved in direct oversight of nursing services. This had the potential to affect all residents in the facility. The facility census was 44.

Inspectors wroteBased on personnel record review, and interview, the facility failed to be effectively and efficiently administered in a manner that allowed all residents to attain or maintain their highest level of well-being when the administrator failed to ensure concerns regarding Director of Nursing (DON) #500's (who was part of the facility administration) performance and allegations of DON #500 working under the influence of alcohol were thoroughly investigated and timely and necessary protective measures were implemented to safeguard the residents. This had the potential to affect all 44 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a skin alteration was comprehensively assessed, monitored and a treatment was ordered after a fall. This affected one (Resident #45) of three residents reviewed for falls. Facility census was 44.

Inspectors wroteBased on record review, staff interviews, incident report review, and policy review, the facility failed to ensure Resident #37 received medication labeled with Resident #37's name. This affected one (Resident #37) of three residents reviewed for medication administration. The facility census was 44.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and staff interview, the facility failed to maintain registered nurse (RN) coverage in the facility at least eight consecutive hours a day seven days a week as required. This had the potential to affect all 45 residents who reside in the facility.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to completely and accurately report staff hours worked in Payroll Based Journal (PBJ). This had the potential to affect all 45 residents residing in the facility.

Inspectors wroteBased on observation, Employee Phone List review and interview, the facility infection preventionist (IP) failed to ensure staff were appropriately fit tested for N95 respirator masks to prevent the potential for cross contamination and spread of infectious diseases in the facility. This finding had the potential to affect all 45 residents residing in the facility.

Inspectors wroteBased on interview, record review and review of the facility policy, facility failed to provide spend-down letters for each month residents were approaching or over the resource limit. This affected three residents (#13, #32 and #33) of five residents reviewed for resident funds. The facility census was 45.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure appropriate personal protective equipment (PPE) was maintained while providing care for Resident #41 who was in isolation precautions related to a COVID-19 diagnosis. This finding affected one resident (Resident #41) and had the potential to affect an additional 26 residents who reside on the second floor including Residents #1, #2, #12, #13, #14, #15, #16, #17, #18, #22, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #39, #40, #42, #43, #47 and #96. The facility census was 45.

Inspectors wroteBased on record review, interview, and review of the facility policy and procedure, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected one resident (#17) of five residents. The facility census was 45.

Inspectors wroteBased on interview and record review the facility failed to monitor residents using anticoagulant medications. This affected one resident (#27) out of five residents reviewed for medications. The facility census was 45.

Inspectors wroteBased on record review and interview, the facility did not ensure influenza and pneumococcal vaccines were adminsitered as required. This finding affected two (Residents #6 and #30) of five residents reviewed for immunizations.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the daily nursing staff information was posted. This had the potential to affect all 45 residents who reside in the facility.

Inspectors wroteBased on facility assessment review and interview, the facility failed to ensure the facility assessment was complete and accurate. This finding had the potential to all 45 residents who reside in the facility.

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

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interview the facility failed to ensure a registered nurse was scheduled at least eight consecutive hours every day as required. This had the potential to affect all 32 residents residing in the facility.

Inspectors wroteBased on observation, record review, Resident Assessment Instrument (RAI) manual review, form review, and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments for five residents (Residents #5, #11, #14, #15, and #24) out of 13 residents reviewed for assessments.