Cycle 1
Health 2024-09-05 · Fire 2024-09-05
10 health deficiencies
Top issue: Infection Control (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Orrville, OH
Orrville Pointe
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
230 South Crown Hill Road, Orrville, OH
(330) 682-2273
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
47
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Jag Healthcare
Operator or chain grouping
Approved since
2000-08-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 4 overall / 3 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
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
0.92
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.18
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.32
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,979
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.85
Baseline 42.86% · Performance 56.10% · Measure score 1.85 · Achievement 1.85 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.46 hours · Performance 2.94 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 2 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.9% |
8.2%
4.3 pts worse
|
Numerator 3 · Denominator 77 |
| Staff flu vaccination coverage | 9.72% |
42%
32.3 pts worse
|
Numerator 7 · Denominator 72 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 77.6% |
92.4%
14.8 pts worse
|
93.4%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.9% · Q2 68.1% · Q3 84.8% · Q4 91.3% · 4Q avg 77.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.9% |
94.5%
3.4 pts better
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.3%
0.6 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.4% · Q3 2.2% · Q4 2.2% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 74.4% |
26.1%
48.3 pts worse
|
11.4%
63 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.7% · Q2 87.2% · Q3 70.7% · Q4 67.4% · 4Q avg 74.4% |
| Percentage of long-stay residents who lose too much weight | 10.3% |
6.2%
4.1 pts worse
|
5.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 4.5% · Q3 9.8% · Q4 14.6% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 53.3% |
25.4%
27.9 pts worse
|
19.6%
33.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.3% · Q2 50.0% · Q3 58.5% · Q4 53.7% · 4Q avg 53.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.4% |
11.5%
14.9 pts worse
|
16.7%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 28.6% · 4Q avg 26.4% · 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 5.2% · Q2 4.5% · Q3 4.3% · Q4 8.3% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
6.2%
1.2 pts better
|
14.9%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.7% · Q3 2.5% · Q4 12.8% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
0.5%
About the same
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
21.7%
0.5 pts better
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 22.1% · Q3 15.2% · Q4 13.0% · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
3.7%
3.2 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-28 · Fire 2022-04-28
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-05-16 · Fire 2019-05-16
2 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-09-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-09-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-09-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-09-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-09-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-05
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-24
F · Potential for more than minimal harm
2022-04-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-05-27
E · Potential for more than minimal harm
2022-04-28
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-05-27
C · Minimal harm
2022-04-28
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2022-05-27
E · Potential for more than minimal harm
2019-05-16
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 2019-06-21
E · Potential for more than minimal harm
2019-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-21
E · Potential for more than minimal harm
2019-05-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-06-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-09-05
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-09-05
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-09-05
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-05
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-05
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 2024-10-24
D · Potential for more than minimal harm
2024-09-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-24
C · Minimal harm
2024-09-05
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-10-24
C · Minimal harm
2024-09-05
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-03-21
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-03-30
D · Potential for more than minimal harm
2022-04-28
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-28
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-05-27
F · Potential for more than minimal harm
2019-05-16
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2019-06-21
E · Potential for more than minimal harm
2019-05-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-06-21
Penalties and ownership
What sits behind the stars
Ownership
Griffiths, James
5% Or Greater Direct Ownership Interest · Individual
Cole, Casey
Operational/Managerial Control · Individual
Griffiths, James
Operational/Managerial Control · Individual
Griffiths, James
Corporate Director · Individual
Griffiths, James
Corporate Officer · Individual
Jag Healthcare Inc
Operational/Managerial Control · Organization
Lehner, Thomas
Operational/Managerial Control · Individual
Orrville Pointe Re, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Accord Care Community Orrville LLC
Orrville, OH
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Glendora Health Care Center
Wooster, OH
2-star overall rating with 1-star inspections with $17,080 in total fines with 15 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Shady Lawn Nursing Home
Dalton, OH
1-star overall rating with 1-star inspections with abuse icon flag with $40,950 in total fines with 24 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
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