Orrville Pointe

In the surveyor’s words

From the most serious findings on record at Orrville Pointe, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 3, 2026

  Based on observations, interviews, medical record review, police reports, emergency medical services (EMS) run reports, hospital records, and review of facility Self-Reported Incidents (SRIs), the facility failed to provide adequate supervision and ensure effective systems were in place to prevent the elopement of two residents (#40 and #37) on multiple occasions, without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or negative health outcomes when on 06/27/26 at approximately 4:35 A.M., Resident #40, who had diagnoses including Alzheimer's disease and dementia, with a known history of exit seeking behaviors, exited the facility's secured/locked first floor unit through his room window without staff awareness. […]

• Immediate jeopardy, isolatedF761Jun 24, 2026

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

• No harm, potential for more than minimal, widespreadF940Aug 3, 2026

  Based on interview and personnel file review, the facility failed to ensure an effective training program was in place before staff provided resident care upon hire. This had the potential to affect all 39 residents residing in the facility. Findings include :1. Review of Certified Nursing Assistant (CNA) #144's personnel file revealed a date of hire of 04/22/26. Online training modules for fall prevention, being with the person with dementia, assisting residents with dressing, abuse, neglect and exploitation and resident patient rights were all listed as having been over due. CNA #144's personnel file did not include an orientation skill checklist.Interview on 07/27/26 at 9:55 A.M. […]

• No harm, potential for more than minimal, widespreadF949Aug 3, 2026

  Based on interview and personnel file review, the facility failed to ensure all staff received behavioral health training. This had the potential to affect all residents residing in the facility. The facility census was 39.Findings include :1. Review of Certified Nursing Assistant (CNA) #309's personnel file revealed a date of hire of 07/22/26. The personnel file did not include evidence of behavioral health training.Interview on 07/24/26 at 10:10 A.M. with CNA #309 revealed she had not received any training on behaviors.Interview on 07/27/26 at 2:57 P.M. with Administrator confirmed staff training was not specific to behaviors. 2. Review of Licensed Practical Nurse (LPN) #123's personnel file revealed a date of hire of 06/11/26. […]

• No harm, potential for more than minimal, widespreadF727Apr 15, 2026

  Based on interviews, review of the facility assessment, and staff schedule review the facility failed to ensure a full time Director of Nursing (DON) was employed by the facility and involved in direct oversight of nursing services. This had the potential to affect all residents in the facility. The facility census was 44.Findings include: Review of the staff schedule from 04/06/26 through 04/12/26 revealed the interim DON, Registered Nurse/DON #450, was in the facility for 11 hours on 04/07/26.An interview on 04/13/26 at 8:34 A.M. with the Assistant Director of Nursing (ADON) (a Licensed Practical Nurse) revealed DON #500 was terminated in February for a bunch of different reasons. DON #450 was the DON at another building but came to the facility once or twice a week to assist the ADON. […]