Provider Name: EAGLE POINTE SKILLED NURSING & REHAB
Address: 87 STALEY ROAD, ORWELL, OH 44076
Phone: (440) 437-7171
County: Ashtabula (030)
Ownership Type: For profit - Corporation
Certified Beds: 60
Average Residents Per Day: 51.1 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: EP OPCO LLC
First Approved Date: March 19, 2003
Affiliated Entity: AOM HEALTHCARE (37)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 2 ()
Health Inspection Rating: 1 ()
QM Rating: 5 ()
Long Stay QM Rating: 5 ()
Short Stay QM Rating: (2)
Staffing Rating: 1 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 1.92991, LPN Staff Hours Per Day: 0.7568, RN Staff Hours Per Day: 0.4758, Licensed Staff Hours Per Day: 1.2326
Total Nurse Staff Hours Per Day, per resident: 3.16259
Weekend Nurse Staff Hours: 2.66318, Weekend RN Staff Hours: 0.3424
PT Staff Hours Per Day, per resident: 0.0000
Nurse Staff Turnover: 59.1, Nurse Turnover Note:
RN Turnover: , RN Turnover Note: 6
Admin Left Number: 0, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 1.9395, Case Mix LPN Hours Per Day: 0.8006, Case Mix RN Hours Per Day: 0.4922
Adjusted Nurse Aide Hours Per Day, per resident: 2.02710, Adjusted LPN Hours Per Day: 0.6975, Adjusted RN Hours Per Day: 0.3642
Total Adjusted Nurse Hours Per Day, per resident: 3.08384
Adjusted Weekend Nurse Hours Per Day, per resident: 2.59686
Health Survey Dates and Scores: Cycle 1: 2022-10-13 (Score: 40), Cycle 2: 2019-10-21 (Score: 318), Cycle 3: 2018-09-06 (Score: 24)
Total Weighted Health Score: 130.00
Reported Incidents: 0, Substantiated Complaints: 2
Infection Control Citations: 0
Fines and Penalties: Number of Fines: 2, Total Fines in Dollars: 1625.00, Payment Denials Number: 0, Total Penalties Number: 2
Location and GPS: 87 STALEY ROAD,ORWELL,OH,44076 (41.5398, -80.844)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Ensure that residents are free from significant medication errors.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-01-11
Type: Health, Deficiency: Reasonably accommodate the needs and preferences of each resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-10-21
Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-10-21
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-10-21
Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-10-21
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-10-21
Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity: K - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Respond appropriately to all alleged violations.
Severity: K - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-11-04
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-11-04
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-09-07
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0161, Version: New
Description: Use approved construction type or materials.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-10-21
Type: Fire Safety, Tag: 0351, Version: New
Description: Install an approved automatic sprinkler system.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-10-21
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-10-21
Type: Fire Safety, Tag: 0372, Version: New
Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-10-21
Type: Fire Safety, Tag: 0511, Version: New
Description: Have properly installed electrical wiring and gas equipment.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-10-21
Type: Fire Safety, Tag: 0741, Version: New
Description: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-10-21
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-10-21
Type: Fire Safety, Tag: 0923, Version: New
Description: Have proper medical gas storage and administration areas.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-10-21
Type: Fire Safety, Tag: 0211, Version: New
Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Fire Safety, Tag: 0345, Version: New
Description: Have approved installation, maintenance and testing program for fire alarm systems.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Fire Safety, Tag: 0711, Version: New
Description: Provide a written emergency evacuation plan.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Fire Safety, Tag: 0006, Version: New
Description: Conduct risk assessment and an All-Hazards approach.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-09-07
Type: Fire Safety, Tag: 0022, Version: New
Description: Establish policies and procedures for sheltering.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-09-07
Type: Fire Safety, Tag: 0211, Version: New
Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-09-07
Type: Fire Safety, Tag: 0345, Version: New
Description: Have approved installation, maintenance and testing program for fire alarm systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-09-07
Type: Fire Safety, Tag: 0923, Version: New
Description: Have proper medical gas storage and administration areas.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-09-07