Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Orchard Villa during CMS and state inspections, most recent first.
The facility failed to ensure the confidentiality of residents' health information, affecting 12 residents. An RN left a medication cart unattended with a computer screen displaying a resident's medication information, and paper report sheets with residents' details were left exposed on medication carts. These actions were confirmed by staff interviews and violated the facility's privacy policy.
A resident in a LTC facility, who had difficulty swallowing medications, preferred taking them with pudding. Initially, this preference was honored in the rehabilitation unit, but after moving to the LTC unit, the resident was only given applesauce, which was ineffective. Despite pudding being available, it was not provided, contrary to the facility's policy of respecting resident preferences.
A resident with type II diabetes and gastrostomy status experienced significant weight loss due to inadequate tube feeding management. Despite recommendations to adjust the feeding rate, the facility maintained a lower rate to manage nausea and vomiting, attributed to infections and antibiotics. Staff did not explore alternative feeding methods or provide additional nutritional supplements, leading to a 23-pound weight loss over three months.
The facility failed to administer oxygen as ordered for two residents. One resident's oxygen tank was found empty, despite orders for continuous oxygen, while another resident received oxygen at a higher flow rate than prescribed. These discrepancies were confirmed by nursing staff, highlighting a failure to adhere to facility policies on medication and oxygen administration.
A resident with multiple diagnoses was inappropriately continued on prophylactic Cephalexin for UTIs despite no signs of infection, as confirmed by normal lab results. The facility's policy requires medication clarification if unrelated to the resident's condition, which was not documented. The Infection Control Preventionist confirmed the resident did not need antibiotics per facility protocols.
The facility failed to follow infection control procedures for a resident with an indwelling urinary catheter, allowing the tubing to drag on the floor. Additionally, enhanced barrier precautions were not implemented for a resident with a tracheostomy and feeding tube, as there was no signage or PPE available for staff. These deficiencies were confirmed by staff observations.
The facility failed to maintain clean wheelchairs for two residents, one with multiple medical conditions and another with multiple sclerosis and paraplegia. Both residents' wheelchairs were observed with significant dirt and debris, despite the facility's cleaning schedule. Interviews confirmed the wheelchairs were not cleaned as required.
The facility failed to secure medications and lock administration carts when unattended. A resident received an incorrect number of pills and stored extras in her purse, while a nurse left a medication cart unlocked and unattended. Facility policies require medication carts to be locked when not attended by authorized personnel.
Two residents in an LTC facility did not receive timely incontinence care, leading to discomfort and potential health risks. One resident was left in dried stool for over 4 hours, while another was left in a wet brief and bed for more than 3 hours, resulting in skin irritation. The facility's policy on incontinence care was not followed.
Failure to Maintain Confidentiality of Residents' Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' protected health information, affecting 12 residents. On March 19, 2025, a Registered Nurse (RN) left a medication cart unattended in the hallway with the computer screen open, displaying Resident #52's medication administration information. This occurred while another resident was seated nearby, potentially exposing sensitive information. The RN confirmed the oversight during an interview shortly after the observation. Additional observations on March 17 and March 18, 2025, revealed that paper report sheets containing full names, room numbers, and a list of issues and needs for several residents were left face up on medication carts at different locations within the facility. These observations were confirmed by interviews with the respective nursing staff, who acknowledged the failure to secure the documents. The facility's policy on documentation security and privacy compliance, dated January 6, 2025, mandates that documents be maintained in accordance with the Health Insurance Portability and Accountability Act Privacy and Security Rule. This deficiency was investigated under Complaint Number OH00161938.
Failure to Honor Resident's Medication Preference
Penalty
Summary
The facility failed to honor a resident's choice for medication administration, specifically the preference to take medication with pudding instead of applesauce. This deficiency affected a resident who was cognitively intact and had difficulty swallowing medications. The resident, who was initially on the rehabilitation unit, had no issues receiving pudding with her medication as requested. However, after being transferred to the long-term care unit, the resident's requests for pudding were not honored, and she was only provided with applesauce, which she stated did not help her swallow the pills effectively. Interviews with staff revealed that pudding was available in the kitchen, and the nurses could obtain it for medication administration. Despite this, the medication cart did not have pudding readily available, and a nurse admitted to not having pudding on hand during medication rounds. The facility's policy emphasized the importance of considering each resident's preferences and needs in medication administration, yet this was not adhered to in the case of the resident. The resident expressed frustration and considered purchasing her own pudding to ensure her needs were met.
Inadequate Tube Feeding Management Leads to Resident Weight Loss
Penalty
Summary
The facility failed to ensure adequate tube feeding for a resident, leading to significant weight loss. Resident #16, who had diagnoses including type II diabetes mellitus and gastrostomy status, was dependent on staff for nutrition and hydration via tube feeding. Despite recommendations to adjust the tube feeding rate to meet nutritional needs, the facility did not implement these changes effectively, resulting in a weight loss of 23 pounds over three months. The resident experienced episodes of nausea and vomiting, which were attributed to infections and antibiotics rather than the tube feeding formula. The facility reduced the tube feeding rate from 65 ml per hour to 50 ml per hour to manage these symptoms, but this adjustment was insufficient to meet the resident's nutritional requirements. The staff did not explore alternative feeding methods, such as a more concentrated formula or bolus feedings, nor did they provide additional nutritional supplements. Interviews with staff revealed a lack of awareness and coordination in addressing the resident's nutritional needs. The Dietetic Technician and Nurse Practitioner were aware of the weight loss and emesis but did not take further steps to adjust the feeding plan. The facility's policy on weight monitoring was not effectively implemented, as the resident continued to lose weight without adequate intervention to address the deficiency.
Oxygen Administration Deficiency
Penalty
Summary
The facility failed to ensure oxygen was administered as ordered for two residents. Resident #50, who was admitted with chronic respiratory failure, COPD, emphysema, obstructive sleep apnea, and chronic heart failure, had a provider order for a CPAP machine with three liters of oxygen while sleeping and continuous oxygen via nasal cannula at three liters. However, an observation revealed that the oxygen tank on Resident #50's motorized wheelchair was empty, which was confirmed by a registered nurse. Resident #29, diagnosed with COPD, anxiety, and dependence on supplemental oxygen, had a physician order for oxygen at two liters per minute via nasal cannula. Observations on two consecutive days showed that Resident #29 was receiving oxygen at three and a half liters per minute, contrary to the physician's order. This discrepancy was verified by an LPN. The facility's policies on medication and oxygen administration require that medications be administered as prescribed and that staff check the physician's order for the correct oxygen flow rate and method of delivery.
Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically antibiotics. A resident with diagnoses including dementia, depression, myocardial infarction, pulmonary fibrosis, and syncope was receiving Cephalexin prophylactically for urinary tract infections. Despite the absence of any signs or symptoms of an active infection, as confirmed by urinalysis and blood tests showing no infection and normal white blood cell counts, the resident continued to receive the antibiotic. The facility's policy requires that if a medication seems unrelated to the resident's current diagnosis or condition, the nurse should seek clarification from the provider pharmacy or prescriber, which was not documented in this case. The resident had a history of infections, including a diagnosis of cystitis in September 2024, for which they received a different antibiotic, Levaquin. However, the prophylactic use of Cephalexin continued without documented rationale, despite the resident not showing any signs or symptoms of urinary tract infections. The Infection Control Preventionist confirmed that the resident did not require antibiotics per the McGeer's protocols, which the facility follows. This oversight in medication management led to the deficiency noted in the report.
Infection Control Deficiencies in Catheter and Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control procedures for a resident with an indwelling urinary catheter. The resident, who was diagnosed with multiple sclerosis, paraplegia, and neuromuscular dysfunction of the bladder, was observed wheeling herself in a wheelchair with approximately five to seven inches of urinary catheter tubing dragging on the floor. This observation was confirmed by a Certified Nursing Assistant, indicating a lapse in ensuring the catheter tubing was properly managed to prevent potential infection or trauma. Additionally, the facility did not implement enhanced barrier precautions for a resident with a tracheostomy and feeding tube. The resident's room lacked signage to alert staff of the need for enhanced barrier precautions, and there was no personal protective equipment available for staff to use during high-contact care. This was confirmed by a Registered Nurse, who acknowledged the absence of necessary precautions and equipment, despite the facility's policy requiring gowns and gloves for high-contact interactions with residents having indwelling medical devices.
Failure to Maintain Clean Wheelchairs for Residents
Penalty
Summary
The facility failed to ensure that wheelchairs were clean, affecting two residents. Resident #58, who has multiple medical conditions including hemiplegia, COPD, diabetes, heart failure, hypertension, and dysphagia, was observed in a power wheelchair with significant debris, dirt, and dust accumulation. Despite the facility's cleaning schedule indicating that wheelchairs should be cleaned nightly, Resident #58's wheelchair had only been cleaned once in the past year. Interviews with the resident and staff confirmed the wheelchair's unclean state. Similarly, Resident #9, who has multiple sclerosis, paraplegia, and neuromuscular dysfunction of the bladder, was observed in a wheelchair heavily coated with dirt and dust. The resident was dependent on the wheelchair for mobility and had a urinary catheter. The facility's cleaning schedule indicated that wheelchairs were to be cleaned on Sundays, but interviews with the resident and staff confirmed that the wheelchair was dirty and in need of a deep cleaning.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure medications were stored securely and that administration carts were locked when left unattended. This deficiency was identified through observation, record review, and interviews with residents and staff. One incident involved a resident who was given an incorrect number of pills and subsequently stored the extra pills in her purse. The resident, who was cognitively intact, revealed during an interview that she had received an incorrect number of pills the previous day. A Licensed Practical Nurse confirmed the presence of the extra pills, identified as Zoloft and Senna, in the resident's purse. Another incident was observed where a Registered Nurse left a medication cart unlocked and unattended while administering medication to a resident. The cart was left out of sight, and a resident in a wheelchair was observed sitting next to it. The nurse confirmed the cart had been left unattended and unlocked. Additionally, it was noted that two residents on the same hall were independently mobile and cognitively impaired, increasing the risk associated with the unsecured medication cart. The facility's policies require that medication carts be locked when not attended by authorized personnel, which was not adhered to in these instances.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to significant discomfort and potential health risks. Resident #84, who has a history of cognitive impairment, osteoarthritis, and ulcerative colitis, was observed sitting in a wheelchair in the hallway, visibly upset and vocalizing that he had been left in a soiled state. Upon assistance by a State tested Nurse Aide (STNA), it was discovered that the resident had been sitting in dried stool for an extended period, indicating that incontinence care had not been provided since the beginning of the aide's shift, approximately 4.5 hours earlier. Similarly, Resident #102, who is cognitively intact but requires assistance with personal hygiene due to conditions such as chronic respiratory failure and diabetes, reported not receiving incontinence care since 2:00 A.M. Despite requesting assistance, the resident was left in a wet brief and bed until after breakfast. When care was finally provided, a strong urine odor and skin irritation were noted, with peeling skin on the left upper buttock. The STNA confirmed that the resident had not been checked or changed for over 3 hours since the start of the shift. The facility's policy on incontinence care, which emphasizes keeping residents' skin dry and clean, was not adhered to in these instances.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oregon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbors At Oregon | 0.4 mi | ★★★★★ | 9 | 1 |
| Ayden Healthcare Of Oregon | 1.4 mi | ★★★★★ | 11 | 0 |
| Majestic Care Of Toledo Snf | 1.6 mi | ★★★★★ | 6 | 0 |
| The Gardens Of St. Francis | 2.7 mi | ★★★★★ | 12 | 0 |
| Majestic Care Of Perrysburg | 5.3 mi | ★★★★★ | 39 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.