Above average — CMS composite of the measures below.
The next survey window likely opens around November 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.
Two residents experienced inadequate pressure ulcer care, leading to deterioration and infection. One resident's existing heel ulcers worsened due to lack of timely offloading and physician updates, while another developed a facility-acquired ulcer that became infected. Facility policies on pressure injury care were not followed, resulting in significant deficiencies.
The facility failed to conduct routine diabetic foot checks for residents with type 2 diabetes, as recommended by professional standards. Four residents were affected, with records showing either no documentation or only monthly checks, contrary to the American Diabetes Association's guidelines for daily checks. The facility's policy did not address diabetic foot checks, and the DON was unaware of the standard practice.
A facility failed to report an alleged verbal abuse incident between two residents, where one resident made derogatory comments to another, causing distress. The incident was documented by a CNA and reported to a nurse, but no follow-up action was confirmed. The Social Services Manager did not recall receiving the report, and the Nursing Home Administrator acknowledged a breakdown in the reporting process, noting that the incident should have been reported to the state agency.
A facility failed to investigate an alleged abuse incident where a resident verbally abused another, causing emotional distress. Despite documentation by a CNA, the facility did not follow its abuse investigation protocol, and no investigation was conducted.
A resident's electric wheelchair was improperly charged in their room, contrary to facility policy, which led to a deficiency. The resident, who is cognitively intact, confirmed the charging location. Staff inconsistencies were noted, with a CNA and LPN indicating the correct charging area should be the day room. The Nursing Home Administrator acknowledged the error.
Deficient Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, R9 and R3, leading to the deterioration of existing pressure injuries and the development of new ones. R9 was admitted with bilateral heel pressure injuries, but the facility did not implement immediate offloading of the heels, resulting in the deterioration of the wounds. The facility also failed to measure R9's wounds weekly and did not update the physician timely on changes to the wounds. Observations noted that R9's heels were not offloaded while seated in a recliner, further contributing to the deterioration of the pressure injuries. R3 developed a facility-acquired pressure injury, which the facility failed to measure and assess weekly. This lack of proper assessment and intervention led to the pressure injury becoming infected multiple times, requiring antibiotic treatment. The facility's documentation inconsistently described R3's pressure injury, referring to it as a Stage 3 pressure injury, an abscess, and a diabetic wound, indicating a lack of clarity and consistency in the care provided. The facility's policies on pressure injury treatment, prevention, and risk assessment were not followed, as evidenced by the lack of timely interventions and updates to the care plans for both residents. The facility's failure to adhere to its own policies and professional standards of practice resulted in the worsening of pressure injuries for R9 and R3, highlighting significant deficiencies in the care provided to these residents.
Failure to Conduct Routine Diabetic Foot Checks
Penalty
Summary
The facility failed to ensure that diabetic residents received routine foot checks in accordance with professional standards of practice. This deficiency was identified for four residents, all diagnosed with type 2 diabetes mellitus. The facility's policy, dated 7/15/21 and last revised on 5/9/24, did not address diabetic foot checks or ongoing monitoring, which is contrary to the American Diabetes Association's recommendation for daily foot checks and annual comprehensive exams. The Director of Nursing (DON) was unaware of the standard of practice for diabetic foot checks, indicating a lack of adherence to established guidelines. Resident 11 had no documentation of diabetic foot checks for June, July, and August 2024. Resident 27's records showed foot checks only once per month during the same period. Resident 3's Treatment Administration Record (TAR) indicated monthly foot checks from March to August 2024, while Resident 9's TAR showed monthly checks from October 2023 to August 2024. These findings highlight the facility's failure to perform daily diabetic foot checks, as recommended by professional standards, potentially compromising the residents' foot health.
Failure to Report Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime, specifically in the case of alleged abuse between two residents, R13 and R34. On May 5, 2024, an incident occurred where R13 was verbally abusive towards R34, making derogatory comments that upset R34. This incident was documented by CNA H, who witnessed the event and reported it to a nurse, although she could not recall the nurse's name. CNA H also sent an internal electronic message to the Social Services Manager (SSM I) but could not confirm if any follow-up occurred. The Social Services Manager, SSM I, was interviewed and indicated that she did not recall receiving the report from CNA H or taking any action regarding the incident. SSM I acknowledged that such incidents should be reported to the charge nurse, DON, or NHA, especially since it was a weekend and she was not in the office. SSM I also mentioned that she tries to check her electronic messages daily but did not follow up on the message from CNA H regarding the incident. The Nursing Home Administrator, NHA A, confirmed that the incident should have been reported to her and the state agency as an allegation of verbal abuse. She noted a breakdown in the reporting process, emphasizing that an electronic message does not constitute immediate reporting. The failure to report the incident to the NHA or state agency within the required timeframes constitutes a deficiency in the facility's handling of abuse allegations.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged abuse incident involving two residents. On May 5, 2024, an incident occurred where one resident verbally abused another, causing emotional distress. The Certified Nursing Assistant (CNA) documented the behavior, noting that the resident made demeaning comments and accusations, which exacerbated the other resident's emotional state. Despite the documentation and awareness of the incident, the facility did not initiate an investigation as required by their abuse investigation protocol. The facility's policy mandates that all allegations of abuse, including resident-to-resident abuse, be promptly and thoroughly investigated. However, the Nursing Home Administrator (NHA) acknowledged that the incident should have been investigated but was not. This oversight indicates a failure to adhere to the facility's established procedures for handling allegations of abuse, neglect, exploitation, or mistreatment, as no investigation was conducted, and no report was submitted to the state survey and certification agency.
Deficiency in Charging Location for Electric Wheelchair
Penalty
Summary
The facility failed to ensure an environment free from accident hazards for a resident using a power wheelchair. The resident, who is cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15 out of 15, was observed with their electric wheelchair being charged in their room. The facility's policy on motorized scooters and wheelchairs did not specify where electric chairs should be charged. During the survey, it was noted that the wheelchair was plugged into a cord behind the nightstand in the resident's room, and both the resident and their husband confirmed that the wheelchair was charged there. Further investigation revealed inconsistencies in staff knowledge and practice regarding the charging location for electric wheelchairs. A Certified Nursing Assistant (CNA) initially confirmed that the wheelchair was charged in the lounge but noted it might have been moved during their absence. Later, the CNA moved the cord to the designated charging area in the day room. A Licensed Practical Nurse (LPN) also confirmed that wheelchairs should be charged in the middle day rooms, not in the resident's room. The Nursing Home Administrator acknowledged that the wheelchair should not be charged in the resident's room, indicating a lapse in adherence to the facility's intended procedures.
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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 Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lancaster Health Services | 1.4 mi | ★★★★★ | 15 | 1 |
| Dove Healthcare - Fennimore | 10.9 mi | ★★★★★ | 33 | 0 |
| Edenbrook Of Platteville | 12.5 mi | ★★★★★ | 0 | 0 |
| Stonehill Care Center | 20.2 mi | ★★★★★ | 0 | 0 |
| Sunnycrest Manor | 20.3 mi | ★★★★★ | 6 | 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.