Cycle 1
Health 2025-03-20 · Fire 2025-03-20
9 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Oregon, OH
Orchard Villa
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2841 Munding Drive, Oregon, OH
(419) 697-4100
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
136
Certified beds
Average residents
121
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Health Services
Operator or chain grouping
Approved since
1996-07-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.32
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,447
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.72
Composite VBP score used to determine payment impact.
Payment multiplier
0.9843
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.68
Baseline 20.13% · Performance 18.80% · Measure score 5.68 · Achievement 5.68 · Improvement 3.78
Healthcare-associated infections
0
Baseline 6.10% · Performance 7.88% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.01
Baseline 74.84% · Performance 47.29% · Measure score 5.01 · Achievement 4.01 · Improvement 5.01
Adjusted total nurse staffing
0
Baseline 3.15 hours · Performance 3.13 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.78% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 128 · Observed rate 9.38% · Lower 95% interval 6.6% |
| Discharge to community | 54.44% |
50.57%
3.9 pts better
|
No Different than the National Rate · Eligible stays 111 · Observed rate 45.95% · Lower 95% interval 45.75% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 83 · Denominator 83 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 83 |
| Discharge self-care score | 54.72% |
53.69%
1 pts better
|
Numerator 29 · Denominator 53 |
| Discharge mobility score | 56.6% |
50.94%
5.7 pts better
|
Numerator 30 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 83 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.88% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 10.47% · Lower 95% interval 4.39% |
| Staff COVID-19 vaccination coverage | 1.44% |
8.2%
6.8 pts worse
|
Numerator 2 · Denominator 139 |
| Staff flu vaccination coverage | 0.38% |
42%
41.6 pts worse
|
Numerator 1 · Denominator 265 |
| Discharge function score | 64.15% |
56.45%
7.7 pts better
|
Numerator 34 · Denominator 53 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 35.48% |
25.2%
10.3 pts better
|
Numerator 11 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
92.4%
2.6 pts better
|
93.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.7% · Q2 93.8% · Q3 94.6% · Q4 98.9% · 4Q avg 95.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.7% |
94.5%
2.8 pts worse
|
95.5%
3.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.3%
0.7 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.1% · Q3 4.3% · Q4 4.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.7% |
26.1%
21.4 pts better
|
11.4%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 4.6% · Q3 1.2% · Q4 3.5% · 4Q avg 4.7% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
6.2%
0.3 pts better
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.5% · Q3 6.0% · Q4 8.5% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.6% |
25.4%
2.2 pts worse
|
19.6%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 28.1% · Q3 25.0% · Q4 34.1% · 4Q avg 27.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.8% |
11.5%
3.7 pts better
|
16.7%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 4.4% · Q3 9.0% · Q4 10.8% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.6% |
7.7%
2.1 pts better
|
16.3%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 8.6% · Q3 2.8% · Q4 5.4% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.6% |
6.2%
1.6 pts better
|
14.9%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 8.1% · Q3 5.1% · Q4 2.6% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.2%
0.1 pts worse
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
0.5%
0.8 pts worse
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.0% · Q3 1.1% · Q4 1.1% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
21.7%
4.3 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 32.8% · Q3 26.1% · Q4 19.9% · 4Q avg 26.0% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
3.7%
0.2 pts worse
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.7% · Q3 4.9% · Q4 5.6% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.1% |
78.1%
2 pts better
|
81.7%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.9% · Q2 72.5% · Q3 82.1% · Q4 89.8% · 4Q avg 80.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
12.5%
6 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 7.7% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.8% · Q4 0.6% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.6% |
75.6%
12 pts worse
|
79.7%
16.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.8% |
25.1%
8.3 pts better
|
23.9%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 21.5% · Expected 30.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-24 · Fire 2023-08-24
16 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
10 fire-safety deficiencies
Top issue: Miscellaneous (4 deficiencies)
Cycle 3
Health 2021-05-17 · Fire 2021-05-17
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-09
E · Potential for more than minimal harm
2025-03-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-09
E · Potential for more than minimal harm
2025-03-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-09
F · Potential for more than minimal harm
2023-08-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-09-13
F · Potential for more than minimal harm
2023-08-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-13
F · Potential for more than minimal harm
2023-08-24
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-09-13
F · Potential for more than minimal harm
2023-08-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-13
F · Potential for more than minimal harm
2023-08-24
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2023-09-13
F · Potential for more than minimal harm
2023-08-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-08-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-08-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-08-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-08-24
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-09-13
E · Potential for more than minimal harm
2021-05-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-05-26
E · Potential for more than minimal harm
2021-05-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-05-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-20
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-20
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-20
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-04-09
D · Potential for more than minimal harm
2024-07-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-03-25
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2024-04-04
E · Potential for more than minimal harm
2023-12-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-08-24
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-08-24
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-13
C · Minimal harm
2023-08-24
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-09-13
D · Potential for more than minimal harm
2021-05-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-05-26
D · Potential for more than minimal harm
2021-05-17
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-05-26
D · Potential for more than minimal harm
2021-05-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-05-26
D · Potential for more than minimal harm
2021-05-17
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2021-05-26
D · Potential for more than minimal harm
2021-05-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-26
D · Potential for more than minimal harm
2021-05-17
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-05-26
D · Potential for more than minimal harm
2021-05-17
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-05-26
Penalties and ownership
What sits behind the stars
Ownership
Oh 10 Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Cc Oh10 Opco LLC
5% Or Greater Indirect Ownership Interest · Organization
Chavos221 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Chavos221 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Lionsview Opco Nr LLC
5% Or Greater Indirect Ownership Interest · Organization
Lionsview Sc LLC
5% Or Greater Indirect Ownership Interest · Organization
Living26 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Living26 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Sapphire143 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Sapphire143 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Sharvit, Eliav
Corporate Officer · Individual
Stump, Barry
Corporate Officer · Individual
Stump, Barry
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Arbors At Oregon
Oregon, OH
1-star overall rating with 1-star inspections with $20,881 in total fines with 19 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Ayden Healthcare Of Oregon
Oregon, OH
2-star overall rating with 2-star inspections with 17 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#3
Majestic Care Of Toledo SNF
Toledo, OH
4-star overall rating with 4-star inspections with $22,432 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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