Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Manor during CMS and state inspections, most recent first.
Incomplete investigation and delayed assessment after resident incidents. The facility failed to thoroughly investigate a resident fall with fracture and an altercation in which one resident struck another in the face. An LPN admitted not assessing the resident found on the floor or notifying the RN supervisor, and the records lacked timely documentation, assessment, and physician/family notification for the residents involved. The DON and NHA confirmed the missing investigation and delayed assessment in the clinical records.
Wrong Medication Administered to A Resident: An LPN gave a resident the roommate’s meds instead of the ordered meds during a med pass, and the resident also received 30 units of Lantus in error. The resident had Afib, COPD, a hx of falls, and iron deficiency anemia. The resident was assessed, had VS WNL, and did not show signs of hypoglycemia or other ill effects, while the DON and NHA confirmed the med error and failure to follow the physician’s orders.
A resident with dementia and a high risk for wandering exited a secured unit and was found alone in the parking lot. Staff were unaware or confused about the incident, with some believing it was a drill and others not informed. Required documentation, care plan updates, and notifications were not completed, and the facility did not follow its own elopement response policies.
A resident with dementia and other medical conditions eloped from a secured unit, and staff failed to initiate or complete an investigation as required by facility policy. There was no documentation of the incident on the day it occurred, no staff interviews or statements were collected, and the administrator confirmed that no investigation took place, resulting in noncompliance with regulatory requirements.
The NHA did not ensure consistent supervision or maintain required safety interventions to prevent elopement, failing to meet administrative responsibilities and regulatory requirements.
A resident with dementia, repeated falls, and hypertension had a care plan intervention for a pressure sensor pad alarm, but the alarm was discontinued without updating the care plan to reflect this change. Facility leadership confirmed the care plan was not reviewed or revised after the intervention was resolved.
Three residents with dementia and other chronic conditions had incomplete and inaccurate documentation in their medical records, including missing entries for ADLs such as showers, dressing, and eating, as well as continued documentation of discontinued interventions. Facility leadership confirmed these documentation lapses, which did not meet policy standards.
A resident admitted with multiple medical conditions did not receive a summary of the baseline care plan, including physician orders and medications, within 48 hours of admission as required. The DON confirmed there was no documentation that this information was provided to the resident or their representative.
A resident with a history of heart failure and atrial fibrillation was found to be using oxygen tubing and a nasal cannula that had not been changed according to physician orders and facility policy. Observations and staff interviews confirmed that the equipment was overdue for replacement, resulting in a deficiency in providing safe and appropriate respiratory care.
Surveyors found that an opened vial of Humalog insulin on a medication cart was not labeled with an open date, preventing staff from determining when it should be discarded. The ADON and DON confirmed that insulins are required to be labeled with the date opened to ensure timely disposal.
The facility failed to maintain documentation for the semi-annual visual inspection of the fire alarm system and sensitivity testing of smoke detectors, as required by NFPA 70 and NFPA 72. Despite contacting the vendor, the facility could not provide the necessary documentation during a revisit survey.
The facility failed to document the code status for four residents, as required by policy. Despite having documents indicating a DNR status for one resident, the facility would have considered them a full code due to the lack of a physician's order. This deficiency was confirmed through staff interviews and clinical record reviews.
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents with complex medical conditions, as required by policy. The residents did not receive the necessary care plans or summaries, which was confirmed by the RN Assessment Coordinator.
A facility failed to adhere to its policy requiring urinary catheter bags to be covered. Observations showed a resident's catheter bag was visible from the hallway without a privacy cover. The resident had a dislocated hip, COPD, and neurogenic bladder. The DON confirmed the bag should have been covered, violating 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
A facility failed to administer oxygen therapy according to a physician's orders for a resident with COPD and CHF. The resident's order specified oxygen at 3 L/min via nasal cannula, but an observation found the flow meter set at 5 L/min. An LPN confirmed the discrepancy during an interview.
The facility failed to follow infection control practices for disinfecting and storing bedpans and wash basins for two residents. Observations showed an unlabeled bedpan on the floor of a shared bathroom, with a wash basin placed upside down on top. The RN IC confirmed these items should be sanitized, labeled, and stored properly, highlighting a deficiency in the facility's infection control protocols.
Incomplete investigation and delayed assessment after resident incidents
Penalty
Summary
The facility failed to complete a thorough investigation related to incidents and accidents for three residents. Facility policy required incidents involving residents to be promptly identified, investigated, documented, and reported, including immediate response, notifications, incident documentation, and investigation through interviews, record review, environmental assessment, and root cause analysis. Resident R3 had diagnoses including a displaced intertrochanteric fracture of the right femur, encephalopathy, dementia, and Parkinson’s disease. The clinical record showed that on 4/12/26 at 8:07 a.m., staff were called to the room because the resident was yelling in pain and had difficulty moving the right lower extremity with 10/10 pain on range of motion, and the resident stated the pain was from a previous fall earlier in the week. An x-ray later that day showed a comminuted intertrochanteric fracture of the right hip, and the resident was sent to the ED. The record lacked evidence of a fall, investigation of a fall, or pain caused by a fall during the midnight shift. Witness statements later indicated the resident had been found on knees on the floor with the torso in bed, was yelling and favoring the right lower extremity, and stated, “I broke my hip.” An LPN admitted not assessing the resident after finding him/her on the floor and not informing the RN supervisor because the behavior was considered usual. Resident R2 had diagnoses including CHF, protein calorie malnutrition, macular degeneration of the right eye, and dysphagia. An incident report documented that the resident was hit in the face by another resident, but the clinical record lacked evidence of the incident, lacked evidence of assessment at the time of injury, and lacked timely physician and family notification. A later progress note documented a 2 cm cut below the right eye, bruising around the eye, and that the residents were separated, the DON was notified, statements were collected, family was notified, and the medical provider was notified. Resident R4, who had diagnoses including vascular dementia, hypertension, hyperlipidemia, and lymphedema, also lacked evidence in the clinical record of participation in the incident involving striking Resident R2 in the face, including timely physician and family notification. The DON and NHA confirmed that the records lacked evidence of timely and complete investigation and that Resident R2 was not assessed timely after being struck in the face.
Wrong Medication Administered to Resident
Penalty
Summary
The facility failed to follow physician orders for one resident when a nurse administered the resident’s roommate’s medications instead of the ordered medications. Facility policy required licensed nurses to verify the right resident, right medication, right dose, right route, and right time before administration, but the resident received the wrong medications during the morning medication pass. The resident’s clinical record documented an admission with diagnoses including Afib, COPD, history of falls, and iron deficiency anemia. After the medication error was identified, the resident was assessed and vital signs were within normal limits. The resident did not appear to understand what had occurred when asked how he or she was feeling. The spouse stated not knowing why the resident received a shot, and the nurse explained that the resident had received the roommate’s medications in error. A physician order was entered to send the resident to the ER secondary to receiving 30 units of Lantus and wrong medications to monitor for hypoglycemia and adverse events. The record stated the resident did not show signs or symptoms of hypoglycemia or other ill effects from the inaccurate medication administration. During interview, the NHA confirmed the resident received the roommate’s medications in error and that the facility failed to ensure the resident’s physician orders were safely and accurately followed.
Failure to Prevent and Respond to Resident Elopement
Penalty
Summary
The facility failed to implement sufficient monitoring interventions and supervision to prevent an elopement incident involving a resident with a known high risk for wandering. The resident, who had diagnoses including dementia, Parkinson's disease, and anxiety, was assessed as high risk for elopement and had a documented history of wandering behaviors. Despite these risk factors, the resident was able to exit the secured dementia unit and was found walking alone in the facility's parking lot. There was no documentation in the clinical record regarding the elopement on the day it occurred, and the resident's care plan was not updated to reflect the incident or address the increased risk. Staff interviews revealed a lack of awareness and inconsistent accounts regarding the event, with some staff believing the incident was an elopement drill and others unaware of any such drill or actual elopement. Key staff, including the DON and NHA, were not present at the time of the incident and were unaware of the event until after their return. Maintenance and housekeeping staff were not asked to check door locks or alarms following the incident, and several staff members who responded to the alarm were not asked to complete incident reports or provide documentation of their involvement. Video footage confirmed that the resident exited the building alone and was outside for several minutes before being returned by staff. The facility did not follow its own policies regarding elopement response, which required examination of the resident for injuries, notification of the attending physician and legal representative, completion of an incident report, and documentation in the medical record. There was no evidence that these steps were taken following the incident. The lack of immediate investigation, failure to update care plans, and absence of required documentation and notifications contributed to the deficiency and resulted in the identification of Immediate Jeopardy for resident safety and supervision.
Removal Plan
- All secured exit doors are checked and confirmed to be fully operational. Secured doors may not be propped open for any reason. This expectation is communicated to all departments, including housekeeping and maintenance.
- The resident involved and all residents residing on the secured unit are reassessed for elopement risk, and care plans are reviewed and updated as indicated. A head-to-toe skin assessment is completed on the resident involved. Any resident identified as high risk is subject to hourly documented supervision, with continued monitoring based on reassessment.
- The facility implements hourly documented checks following any cleaning, construction, or maintenance activity involving secured exits to ensure doors remain secured and alarms are active.
- All in-house staff are educated on the facility's elopement policy, elopement prevention, door alarm response expectations, supervision requirements, and escalation procedures for any alarm activation involving secured exits. All remaining staff are educated prior to the start of their next scheduled shift until one hundred percent of staff education is completed. Any staff member on vacation or otherwise unavailable in person is educated by telephone. No staff member is permitted to work until education has been completed. Compliance is monitored.
- Elopement risk mitigation is monitored through daily review of door alarm functionality, alarm response, and supervision compliance. Any identified concerns are addressed.
Failure to Investigate Resident Elopement Incident
Penalty
Summary
The facility failed to conduct a thorough investigation following an elopement incident involving a resident with dementia, Parkinson's disease, anxiety, and high blood pressure. The resident was admitted to the facility on 3/28/2025 and eloped from the dementia unit on 12/9/2025. Review of the clinical record showed no documentation regarding the elopement on the day it occurred, and there was no evidence that an investigation was initiated or completed. Staff interviews and incident documentation were lacking, with no staff interviews or handwritten statements present in the clinical record. Video footage confirmed the resident was outside the facility and was later returned by staff, but the staff involved were not asked to complete incident reports. During interviews, a nursing assistant described the sequence of events, including responding to door alarms, searching for the resident, and ultimately assisting in returning the resident to the unit. Despite these actions, the facility administrator confirmed that no investigation was conducted into the elopement. The facility's policy required all accidents or incidents to be investigated and reported to the administrator, but this was not followed in this case, resulting in noncompliance with state regulations regarding management, resident rights, and nursing services.
Failure to Ensure Effective Supervision and Elopement Prevention
Penalty
Summary
The Nursing Home Administrator (NHA) failed to effectively manage the facility to ensure proper supervision and implementation of elopement prevention measures. Review of facility records, job descriptions, and staff interviews revealed that the NHA did not fulfill essential job duties related to the general administration and supervision of all departments, as required by facility policy and applicable laws. Specifically, the facility did not consistently supervise residents or maintain all safety interventions necessary to prevent elopement, resulting in noncompliance with Federal and State guidelines and regulations.
Failure to Update Care Plan After Change in Resident's Fall Prevention Intervention
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident following a change in care and services. The resident, who had diagnoses including dementia, repeated falls, need for assistance with personal care, and hypertension, had a care plan intervention for a pressure sensor pad alarm to be used at all times while in bed. However, the resident's physician orders did not include the pressure sensor pad alarm, and documentation showed that the use of the alarm was discontinued on 4/10/25. Despite this change, the care plan was not updated to reflect the discontinuation of the intervention. Facility leadership confirmed that the care plan was not reviewed or revised to match the resident's current care and services.
Incomplete and Inaccurate Documentation of ADLs and Interventions
Penalty
Summary
The facility failed to maintain complete and accurate documentation of activities of daily living (ADLs) and interventions for three residents with diagnoses including dementia, repeated falls, hypertension, and diabetes. For one resident, documentation indicated that body pillows were in place to prevent rolling out of bed even after the intervention had been discontinued and the pillows were no longer available. Additionally, there were multiple instances where documentation for showers, dressing, personal hygiene, and eating was missing for all three residents over several dates. Interviews with the Director of Nursing, Nursing Home Administrator, and Assistant Director of Nursing confirmed the inaccuracies and omissions in the clinical records. Facility policies required that all services provided to residents be documented objectively, completely, and accurately, but these requirements were not met for the residents reviewed.
Failure to Provide Baseline Care Plan Summary to Resident or Representative
Penalty
Summary
The facility failed to provide a resident and/or their representative with a summary of the baseline care plan, including physician's orders and medications, within 48 hours of admission as required by facility policy. The policy states that a baseline care plan must be developed within 48 hours to address the resident's immediate needs, and a summary of this plan, including initial goals, physician and dietary orders, therapy and social services, and PASARR recommendations if applicable, must be provided to the resident or their representative. In the case reviewed, a resident admitted with diagnoses including Parkinson's disease, high blood pressure, orthostatic hypotension, and high cholesterol did not have evidence in their clinical record that a copy of the baseline care plan, including physician orders and medications, was provided to them or their representative. This was confirmed during an interview with the Director of Nursing, who acknowledged the absence of documentation showing that the required information was given.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician's orders and facility policy for a resident requiring supplemental oxygen. Facility policy required nasal cannulas to be replaced every 7 days and oxygen tubing every 14 days, or sooner if visibly soiled or compromised. A review of the resident's clinical record showed physician's orders for continuous oxygen at bedtime and for oxygen tubing to be changed on the 2nd and 15th of each month during the night shift. Observations revealed that the resident was receiving oxygen via nasal cannula, but the tubing in use was dated from over a month prior, indicating it had not been changed as required. The resident involved had a history of atrial fibrillation, heart failure, and high blood pressure, and was admitted with orders for supplemental oxygen due to shortness of breath. During interviews, an LPN confirmed that the nasal cannula in use was dated from a previous month and acknowledged it should have been changed according to the schedule. This failure to follow physician's orders and facility policy resulted in a deficiency related to the provision of safe and appropriate respiratory care.
Failure to Properly Date and Discard Opened Insulin Vial
Penalty
Summary
The facility failed to ensure that medications were properly dated when opened and discarded in a timely manner, as required by facility policy and manufacturer recommendations. During a review of the B Wing medication cart 2, surveyors observed an opened vial of Humalog insulin that was not labeled with an open date, making it impossible for staff to determine the appropriate discard date. The Assistant Director of Nursing confirmed that the vial lacked an open date, and the DON acknowledged that insulins should be labeled with the date opened to ensure proper discard timing. This deficiency was identified through policy review, manufacturer guidelines, direct observation, and staff interviews.
Fire Alarm System Documentation Deficiency
Penalty
Summary
The facility failed to meet the fire alarm system requirements as outlined by NFPA 70 and NFPA 72, which are essential for ensuring safety in healthcare occupancies. During a document review on October 31, 2024, it was discovered that the facility did not have documentation for the semi-annual visual inspection of the fire alarm system and the sensitivity testing of the smoke detectors. This lack of documentation was confirmed in an interview with the administrator and maintenance supervisor, indicating a lapse in maintaining the necessary records for fire safety compliance. During an onsite revisit survey on December 17, 2024, the facility still failed to provide documentation for the sensitivity testing of the smoke detectors. The facility had contacted the vendor to verify whether the test was completed or needed to be completed, but at the time of the survey, the issue remained unresolved. This was confirmed in an interview with the chief operating officer and administrator, highlighting a continued deficiency in meeting the fire alarm system requirements.
Plan Of Correction
Corrective Action Taken: 1. The semi-annual visual inspection of the fire alarm system was completed on December 13, 2024. 2. The sensitivity testing of the smoke detectors has been scheduled for January 8, 2024. Systemic Changes: 1. The facility has implemented a tracking system to ensure timely scheduling and documentation of all fire alarm system inspections and testing. 2. The maintenance supervisor will review the schedule monthly to verify compliance with inspection and testing requirements.
Failure to Document Code Status for Residents
Penalty
Summary
The facility failed to ensure that a physician's order was completed to indicate the code status for four residents. The facility policy required the attending physician to write an order for any valid advanced directive on the physician order sheet and document it in the progress notes. However, the clinical records of four residents lacked a physician's order to indicate whether they were Full Code or Do Not Resuscitate (DNR). This deficiency was confirmed through staff interviews and a review of clinical records. Resident R56's clinical record did not have a physician's order for code status, and although documents in the Admissions Director's office indicated a DNR status, the facility would have considered the resident a full code. Similarly, the clinical records of Residents R58, R65, and R225 also lacked a physician's order for code status. Interviews with the Director of Nursing and other staff confirmed these omissions, indicating a failure to document and honor the residents' code status preferences as per facility policy.
Failure to Develop Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for three residents, as required by their policy. The policy mandates that a baseline care plan, which includes necessary instructions for effective and person-centered care, be developed within 48 hours of a resident's admission. Additionally, a written copy of this care plan should be provided to the resident and their representative in an understandable language. However, for three residents reviewed, there was no evidence that such a care plan was developed or provided within the stipulated timeframe. The residents involved had various medical conditions requiring specific care plans. One resident had a dislocated left hip, COPD, and neurogenic bladder; another had a fractured left arm, acute kidney failure, morbid obesity, and osteoarthritis; and the third had diabetes mellitus, dementia, protein-calorie malnutrition, and cerebral infarction. Despite these complex medical needs, the facility did not provide the necessary baseline care plans or summaries to the residents or their representatives. This deficiency was confirmed by the Registered Nurse Assessment Coordinator during an interview.
Failure to Cover Urinary Catheter Bag
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, as observed during a survey. The facility's policy, dated 10/1/24, required that catheter bags be covered. However, observations on two separate occasions revealed that the urinary drainage bag of a resident with a dislocated left hip, COPD, and neurogenic bladder was hanging from the bed and visible from the hallway without a privacy cover. This was confirmed by the Director of Nursing during an interview, acknowledging that the catheter drainage bag should have been covered. The deficiency was noted under 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to provide oxygen therapy according to physician's orders for a resident with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and high blood pressure. The resident's clinical record included a physician's order for oxygen at 3 liters per minute (L/min) via nasal cannula continuously every shift for shortness of breath. However, an observation revealed that the resident's oxygen flow meter was set at 5 L/min, contrary to the prescribed order. During an interview, an LPN confirmed that the oxygen administration level was incorrectly set at 5 L/min, not following the physician's orders.
Infection Control Deficiency in Bedpan and Wash Basin Storage
Penalty
Summary
The facility failed to adhere to appropriate infection control practices concerning the disinfection and storage of bedpans and wash basins for two residents. The facility's policy, dated 10/01/24, outlines specific procedures for disinfecting bedpans and urinals, including wearing gloves, covering the items before transport, emptying contents into a toilet or hopper, rinsing with cool water, applying disinfectant, and ensuring items are stored properly. However, observations revealed that an unlabeled bedpan was found on the floor of a shared bathroom used by two residents, with a wash basin placed upside down on top of it. The wash basin was labeled with one resident's name, indicating improper storage and potential cross-contamination. Resident R29 had a medical history that included a head injury, concussion, and facial fractures, while Resident R58 had a history of colon cancer, cardiac heart failure, weakness, and repeated falls. The Registered Nurse Infection Control (RN IC) confirmed the improper storage and labeling of the bedpan and wash basin, acknowledging that these items should be sanitized, labeled, and stored in a clean bag in the resident's bedside stand after use. This failure to follow established infection control protocols was noted as a deficiency in the facility's practices.
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Illustrative
What surveyors actually found near you
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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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Illustrative
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Nursing homes near Grove City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grove Manor | 1.1 mi | ★★★★★ | 19 | 0 |
| Quality Life Services - Grove City | 1.2 mi | ★★★★★ | 6 | 0 |
| Transitions Healthcare Autumn Grove Care Center | 3.8 mi | ★★★★★ | 0 | 0 |
| Avalon Springs Care Center | 11.3 mi | ★★★★★ | 6 | 0 |
| Quality Life Services - Mercer | 11.3 mi | ★★★★★ | 0 | 0 |
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