Orchard Manor

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility policy and documentation, and staff and resident interviews, it was determined that the facility failed to implement sufficient monitoring interventions and supervision to prevent elopement (unauthorized leave from the facility). This failure placed residents at the facility in an Immediate Jeopardy situation for one of two residents reviewed who eloped from the facility (Resident R1). Findings include: Review of facility policy entitled, Safety and Supervision of Residents dated 4/1/25, indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our facility-oriented approach to safety address risks for groups of residents. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring and reporting process; Quality Assurance and Performance Improvement (QAPI) reviews of safety and incident/accident date; and a facility-wide commitment to safety at all levels of the organization. Review of facility policy entitled, Wandering and Elopements dated 4/1/25, indicated When the resident returns to the facility, the director of nursing or charge nurse shall: examine the resident for injuries; contact the attending physician and report findings and conditions of the resident; notify the resident's legal representative; complete and file an incident report; document relevant information in the resident's medical record. Resident R1's clinical record revealed an admission date of 3/28/2025, with diagnoses that included Dementia (loss of memory, language, problem-solving, and other thinking abilities), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and high blood pressure. A Minimum Data Set (MDS-a periodic assessment of resident care needs) Section C Cognitive Patterns dated 10/30/2025, identified Resident R1 with a Brief Interview for Mental Status (BIMS-a type of test to determine one's level of cognition) score of 11 and moderately impaired. Review of Resident R1's MDS Section E Behaviors dated 10/30/2025, revealed under section E0900 wandering presence and frequency- Has the resident wandered? with response of 2-Behavior of this type occurred 4-6 days. Review of an Elopement Risk Assessment completed on 4/15/25, indicated Resident R1 had an elopement score of 11. High Risk to Wander. During an onsite investigation on 12/15/25, it was identified that Resident R1 had eloped from the dementia unit of the facility on 12/09/25. Review of Resident R1's clinical record lacked any documentation on 12/9/2025, regarding the elopement until the investigation on 12/16/25. Review of Resident R1's care plans revealed no updates to care plans regarding elopement risk from the date of the elopement on 12/9/25, to investigation on 12/15/25. During an initial interview on 12/15/25, at approximately 9:00 a.m. the Director of Nursing (DON) revealed that he/she was unaware of any elopements or close calls since April 2025, which the facility investigated and reported as required. DON stated that he/she was on vacation last week and just returned this morning. DON stated that the Nursing Home Administration is scheduled to return from vacation tomorrow. Interview with Maintenance Supervisor on 12/15/25 at 11:00 a.m. revealed that he/she heard that there was an elopement last week on the locked unit, Sunshine Way (SSW), but didn't know any details and was not asked to check any door locks in the facility last week or this week. He/she stated all doors and door alarms are checked monthly and were last inspected on 12/1/25. During interviews on 12/15/25, Nursing Assistant (NA) Employee E3 and E4, Licensed Practical Nurse (LPN) Employees E5, E6, E 8, and E11, and Housekeeping Employees E7, and E9 revealed he/she were unaware of an elopement or elopement drill at the facility last week. Interview with NA Employee E1 on 12/15/25 at 11:30 a.m. revealed that he/she was working on SSW 12/9/25. At approximately 10:30 a.m. the door alarms sounded and he/she walked to the nursing station to check to see where the alarm triggered. He/she stated it was the solarium doors in Sunshine Way. NA Employee E1 went to check the doors in the dining area and found the doors locked without any visible tracks in the snow outside the door. NA Employee E1 then went to the kitchen door in SSW and found the doors locked without any tracks visible in the snow outside the door, then proceeded down the hall to the solarium where the RN supervisor, an LPN, and a NA were already looking out and saw Resident R1 walking in the parking lot that was located up a sidewalk and a distance from the exit door of SSW. The RN supervisor unlocked the solarium doors and NA Employee E1 ran through the back parking lot and was able to talk the resident into walking back to the unit. He/she stated the resident was wearing a gray hoodie with the hood up, jeans, tennis shoes and socks. The resident told staff he was cold but denied any injuries. NA Employee E1 stated he/she was not asked to complete an incident report. During an interview on 12/15/25, the Activity Director revealed that on 12/9/25, he/she heard a Code W (the facility alert for an elopement) on the walkie talkie and immediately went to Unit B to check on residents. He/she stated then found out it was for Sunshine Way and was identified as a drill. Interview with the Assistant Director of Nursing (ADON) on 12/15/25, revealed that he/she stated there was an elopement drill last week on Sunshine Way, but no actual elopement. He /she stated the NHA wanted to have a drill, so Resident R1 from Sunshine was chosen as he was steady on his feet. ADON stated the NHA wanted to have an outside drill as it wasn't very cold out that day and the sidewalk was clear. ADON stated Employee E15 assisted by unlocking the doors in Sunshine Way by the solarium, stepped away from the doors into the solarium and let the Resident out the doors onto the sidewalk. ADON stated that he/she was in that area watching from the back door at the employee entrance and that the resident walked approximately to the end of the sidewalk by the dumpsters, the alarms sounded as expected, staff from the unit immediately found the resident and returned him to Sunshine Way. The ADON states that Resident R1 was also seen by Employee E16 during the drill from the window of room [ROOM NUMBER]. During interviews on 12/15/25, LPN Employees E12 and E13 revealed there was an elopement drill at the facility on 12/9/25. Interview on 12/16/25 at 8:45 a.m. with the NHA revealed that the facility conducted an elopement drill last week on SSW. Interview with NA Employee E2 12/16/25, at 9:09 a.m. revealed that he/she was working 12/9/25 in Sunshine Way and the door alarms sounded. He/she went to the solarium doors and saw Resident R1 walking in the employee parking lot at the back of the building. He/she stated staff went out and brought him back into the building. He/she stated that the solarium was cleaned on 12/8/25, with strong chemicals and the solarium doors were open for a while to air it out. He/she stated that the doors must not have locked properly. He/she stated that no one from the facility asked him/her to complete an incident report or sign anything. Interview with LPN Employee E16 on 12/16/25, at 9:30 a.m. revealed that on 12/9/25, he/she was walking in the back parking lot to the employee entrance around 10:30 a.m. He/she saw a man walking with jeans and a hoodie up by the dumpsters but thought it was one of the maintenance employees. He/she stated that when they got inside, heard the alarms and walked to SSW. He/she stated they do not remember seeing anyone else outside at the time but couldn't say for sure. He/she stated that no one from the facility asked him/her to complete an incident report or sign anything. Interview with LPN Employee E15 on 12/16/25, at 11:30 a.m. revealed that he/she was walking on Unit A when the door alarms went off. He/she walked to Unit B to check those doors as everything was secure on Unit A. He/she stated while on Unit B, that he/she received a call from ADON that the alarm had sounded on Sunshine Way and that staff got Resident R1 from outside. LPN Employee E15 then walked to SSW and the resident was back inside by that point. He/she stated later was told by the NHA that it was a drill. He/she was not asked to complete any paperwork after, except to sign an elopement drill sign-in sheet. During a follow up interview with the NHA 12/16/25, at 12:19 p.m. revealed that he/she was in the NHA office sitting with the facility owner when he/she received a call that Resident R1 got out the solarium doors in SSW but that Resident R1 was only out a few steps. NHA stated he/she was unable to remember who called and supplied that information. He/she went to SSW right after the call and Resident R1 was back inside and ok and was told that LPN Employee E16 had eyes on him/her the whole time and as was always visible, treated the elopement as a drill. NHA confirms that the elopement on 12/9/25 was not investigated. During a follow up interview on 12/16/25, at 12:30 p.m. the ADON, confirmed Resident R1 eloped from the facility on 12/9/25 and there was no evidence that the facility examined the resident for injuries; contacted the attending physician and reported findings and conditions of the resident; successfully notified the resident's legal representative; completed and filed an incident report; investigated or documented relevant information in Resident R1's clinical record. Review of video footage on 12/16/25, supplied by the facility of the rear camera that captured the sidewalk for SSW solarium doors, the employee entrance, and rear employee parking lot revealed that on 12/9/25 at 10:29 a.m. Resident R1 is seen walking alone on partially snow-covered sidewalk from the direction of the solarium doors toward the rear employee parking lot. Resident R1 was wearing a hoodie, jeans, and shoes. As Resident R1 was walking, he/she put the hood of his/her hoodie up. At 10:30 a.m., a facility staff member is seen walking from his/her car to the rear employee entrance and Resident R1 is within view of this employee near the facility dumpsters. Video footage at 10:30 a.m. revealed an employee walking from a fenced area at the back of the facility between the solarium sidewalk and the employee entrance and proceeds to walk to the employee entrance area and enter the building. Video footage at 10:31 a.m. revealed three facility staff running from the direction of the SSW solarium doors towards Resident R1 who is walking in the far front corner of the rear employee parking lot. Video footage at 10:33 a.m. revealed a facility staff member in a red hoodie seen walking from the employee parking lot to the employee entrance and Resident R1 and the three staff seen passing in front of the employee in the red hoodie walking back toward the SSW solarium doors. Video footage at 10:33 a.m. revealed Resident R1 and three facility employees approaching the area of the solarium doors. Immediate Jeopardy (IJ) was identified 12/16/25 at 2:45 p.m. to the NHA and DON and the IJ template was provided to the NHA at that time, related to resident safety/elopement. The NHA and DON were made aware that the Immediate Jeopardy existed for the failure to take appropriate safety actions/investigation after the event to ensure safety of all residents at the facility and an immediate action plan was requested. On 12/16/25, at 4:25 p.m. an acceptable immediate action plan was approved which included the following interventions:1. All secured exit doors were checked and confirmed to be fully operational. Director of Nursing reinforced that secured doors may not be propped open for any reason. This expectation was communicated to all departments, including housekeeping and maintenance, effective immediately.2. The resident involved and all residents residing on the secured unit were reassessed for elopement risk, and care plans were reviewed and updated as indicated. A head-to-toe skin assessment was completed on the resident involved with no findings. Any resident identified as high risk is subject to hourly documented supervision for a minimum of twenty-four hours, with continued monitoring based on reassessment.3. Effective immediately, the facility will implement hourly documented checks for 24 hours following any cleaning, construction, or maintenance activity involving secured exits to ensure doors remain secured and alarms are active.4. All in-house staff will be educated by the Director of Nursing or designee by 5:00 p.m. today 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 will be 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 will be educated by telephone. No staff member will be permitted to work until education has been completed. Compliance will be monitored by the Director of Nursing or designee.5. The Director of Nursing or designee is actively monitoring elopement risk mitigation through daily review of door alarm functionality, alarm response, and supervision compliance. Any identified concerns are addressed immediately. After review of facility documentation, observations, and staff interviews, the implementation of the above stated action plan was confirmed on 12/17/2025, at 4:12 p.m. and the NHA and DON was informed that the Immediate Jeopardy situation was removed. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing Services

Based on review of facility records and job descriptions, and staff interviews, it was determined that the Nursing Home Administrator (NHA) failed to effectively manage the facility to make certain that proper supervision and elopement prevention were effectively implemented in the facility. Findings include: Review of the job description for the NHA revealed The administrator is charged with the general administration of the facility; Manage subordinate supervisors who supervise all employees in all departments; Responsible for the overall direction, coordination, and evaluation of these units; and directly or through delegation, carries out supervisory responsibilities in accordance with the facility's policies and applicable laws. Based on the findings in this report that identified the facility failed to consistently supervise and maintain all safety interventions to prevent elopement for their residents, the NHA failed to fulfill their essential job duties to ensure that the Federal and State guidelines and Regulations were followed. Refer to F689 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an elopement for one of two residents reviewed (Resident R1).Findings include: Review of facility policy entitled Accidents and Incidents - Investigating and Reporting dated 4/1/25, revealed all accidents or incidents involving residents, employees, visitors, vendors etc , occurring on our premises shall be investigated and reported to the Administrator. Resident R1's clinical record revealed an admission date of 3/28/2025, with diagnoses that included dementia (loss of memory, language, problem-solving, and other thinking abilities), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and high blood pressure. During an onsite investigation on 12/15/25, it was identified that Resident R1 had eloped from the dementia unit of the facility on 12/09/25. Review of Resident R1's clinical record lacked any documentation on 12/9/2025, regarding the elopement until after the investigation on 12/15/25. Review of Resident R1's clinical record, incident documentation, and staff interviews revealed a lack of evidence that an investigation was started or completed. Further review of the clinical record lacked evidence of interviews from staff present at the time of the incident or handwritten statements from staff. Interview with Nursing Assistant (NA) Employee E1on 12/15/25 at 11:30 a.m. revealed that he/she was working on SSW 12/9/25. At approximately 10:30 a.m. the door alarms sounded and he/she walked to the nursing station to check to see where the alarm triggered. He/she stated it was the solarium doors in Sunshine Way. NA Employee E1 went to check the doors in the dining area and found the doors locked without any visible tracks in the snow outside the door. NA Employee E1 then went to the kitchen door in SSW and found the doors locked without any tracks visible in the snow outside the door, then proceeded down the hall to the solarium where the RN supervisor, a LPN, and a NA were already looking out and saw Resident R1 walking in the parking lot. The RN supervisor unlocked the solarium doors and NA Employee E1 ran through the back parking lot and was able to talk the resident into walking back to the unit. He/she stated the resident was wearing a gray hoodie with the hood up, jeans, tennis shoes and socks. The resident told staff he was cold but denied any injuries. NA Employee E1 stated he/she was not asked to complete an incident report. Review of video footage on 12/16/25 supplied by the facility of the rear camera that captures the sidewalk for SSW solarium doors, the employee entrance, and rear employee parking lot revealed that on 12/9/25 at 10:29 a.m. Resident R1 was seen walking alone on partially snow-covered sidewalk from the direction of the solarium doors toward the rear employee parking lot. Resident R1 was wearing a hoodie, jeans, and shoes. As Resident R1 was walking, he/she put the hood of his/her hoodie up. At 10:30 a.m., a facility staff member was seen walking from his/her car to the rear employee entrance and Resident R1 was within view of this employee near the facility dumpsters. Video footage at 10:30 a.m. revealed an employee walking from a fenced area at the back of the facility between the solarium sidewalk and the employee entrance and proceeds to walk to the employee entrance area and enter the building. Video footage at 10:31 a.m. revealed three facility staff running from the direction of the SSW solarium doors towards Resident R1 who was walking in the far front corner of the rear employee parking lot. Video footage at 10:33 a.m. revealed a facility staff member in a red hoodie seen walking from the employee parking lot to the employee entrance and Resident R1 and the three staff seen passing in front of the employee in the red hoodie walking back toward the SSW solarium doors. Video footage at 10:33 a.m. revealed Resident R1 and three facility employees approaching the area of the solarium doors. During a follow-up interview on 12/16/25, at approximately 12:19 p.m. the NHA confirmed that he/she was aware of Resident R1's elopement from the facility on 12/9/25 and failed to conduct an investigation of the elopement. 28 Pa. Code 201.18 (e)(1)(2) Management28 Pa. Code 201.29 (a)(c) Resident Rights28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for one of three residents reviewed (Residents R1).Findings include:Review of facility policy entitled Care Plan Revisions Upon Status Change dated 4/1/25, indicated The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Review of Resident R1's clinical record revealed an admission date of 2/23/23, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), repeated falls, need for assistance with personal care, and hypertension (high blood pressure). Review of Resident R1's current care plans revealed a risk for falls care plan with an intervention for a pressure sensor pad alarm at all times while resident is in bed and to check placement and function every shift. Review of Resident R1's current physician orders revealed no order for a pressure sensor pad alarm and Resident R1's task history revealed the pressure sensor pad alarm was resolved on 4/10/25. During an interview on 12/9/25, at 9:49 a.m. the Nursing Home Administrator and the Assistant Director of Nursing confirmed that Resident R1's risk for falls care plan was not reviewed/revised to reflect current resident care and services. 28 Pa. Code 211.5(f) Medical records28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to have complete and accurate documentation regarding activities of daily living (ADLs) and interventions for three of three residents reviewed. (Residents R1, R2, and R3).Findings include: Review of facility policy entitled Charting and Documentation dated 4/1/25, indicated All services provided to the resident. shall be documented in the resident's medical record.Documentation in the medical record will be objective, complete, and accurate . Review of policy entitled Activities of Daily Living dated 4/1/25, indicated Care and services will be provided for the following activities of daily living: bathing, dressing, grooming. eating including meals and snacks. Review of Resident R1's clinical record revealed an admission date of 2/23/23, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), repeated falls, need for assistance with personal care, and hypertension (high blood pressure). Review of Resident R1's discontinued orders revealed an order for body pillows bilaterally under fitted sheet at edges of mattress to prevent uncontrolled rolling out of bed with a discontinue date of 11/10/25. Review of Resident R1's ADLs/task (where the nursing assistants document in the clinical record) revealed an intervention for body pillows under fitted sheet at edge of mattress to prevent rolling out of bed with documentation being completed after the discontinued date of 11/10/25, that the body pillows were in place. Further review of Resident R1's ADLs/task for the months of November 2025, and December 2025, revealed his/her showers lacked documentation that he/she received a shower on 11/21/25, 11/25/25, 11/28/25, and 12/2/25, and his/her dressing, personal hygiene, and/or eating lacked documentation on 11/1/25, 11/2/25, 11/3/25, 11/5/25, 11/9/25, 11/10/25, 11/12/25, 11/14/25, 11/15/25, 11/16/25, 11/17/25, 11/19/25,11/20/25, 11/21/25, 11/22/25, 11/23/25, 11/24/25, 11/25/25, 11/29/25, 12/1/25, 12/2/25, 12/3/25, 12/4/25, and 12/6/25. Review of Resident R2's clinical record revealed an admission date of 4/5/21, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), need for assistance with personal care, and hypertension (high blood pressure). Review of Resident R2's ADLs for the months of November 2025, and December 2025, revealed his/her shower information lacked documentation that he/she received a shower on 11/19/25, and his/her dressing, personal hygiene, and/or eating lacked documentation on 11/19/25, 11/20/25, 11/27/25, and 11/28/25. Review of Resident R3's clinical record revealed an admission date of 11/28/22, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), need for assistance with personal care, and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Review of Resident R3's ADLs for the months of November 2025, and December 2025, revealed his/her shower information lacked documentation that he/she received a shower on 11/10/25, 11/13/25, 11/17/25, and 12/4/25, and his/her dressing, personal hygiene, and/or eating lacked documentation on 11/7/25, 11/8/25, 11/10/25, 11/11/25, 11/12/25, 11/13/25, 11/19/25, 11/22/25, 11/25/25, 11/30/25, 12/1/25, 12/2/25, 12/4/25, and 12/5/25. During an interview on 12/5/25, at 12:37 p.m. the Director of Nursing confirmed that the body pillows were being inaccurately documented as in place although the body pillows were no longer ordered as an intervention or available for Resident R1. During an interview on 12/9/25, at 9:49 a.m. the Nursing Home Administrator and the Assistant Director of Nursing confirmed that the clinical records for Residents R1, R2, and R3 lacked complete and accurate documentation for ADLs/tasks. 28 Pa. Code 211.5(f)(ix) Medical records28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a resident and/or his/her representative with a summary of the baseline care plan including physician's orders and medications for one of 21 residents reviewed (Resident R60). Findings include: A facility policy entitled Care Plans - Baseline dated 4/01/25, revealed a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. The interdisciplinary team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including, but not limited to the following: Initial goals based on admission orders; Physician orders; Dietary orders; Therapy services, Social services; and PASARR recommendations, if applicable. The resident and their representative will be provided a summary of the baseline care plan that includes, but is not limited to the following: The initial goals of the resident; A summary of the resident's medications and dietary instructions; Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and Any updated information based on the details of the comprehensive care plan, as necessary. Resident R60's clinical record revealed an admission date of 3/28/25, with diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), high blood pressure, orthostatic hypotension (a sudden drop in blood pressure when you stand from a seated or lying down position), and high cholesterol. Review of Resident R60's clinical record lacked evidence that the resident and/or the resident representative was provided a copy of the baseline care plans to include physician orders and medications. During an interview on 9/05/25, at approximately 12:10 p.m. the Director of Nursing confirmed there was no evidence that a copy of the baseline care plan including physician orders and medications was provided to Resident 60 and/or their representative. 28 Pa. Code 211.10(c) Resident Care Plan 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen and change/date of oxygen tubing according to physician's orders for one of two residents reviewed for respiratory services (Resident R26).Findings include: Review of facility policy entitled Oxygen Administration Procedure dated 4/1/25, indicated Nasal Cannula: generally replaced every 7 days and when visibly soiled or compromised, and Tubing (extension/primary): usually every 14 days unless visibly soiled, cracked, or per manufacturer's guidance. Resident R26's clinical record revealed an admission date of 3/31/23, with diagnoses that included Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), heart failure (condition when your heart does not pump the blood as well resulting in difficulty breathing, tiredness, and swelling), and high blood pressure. Resident R26's clinical record revealed a physician's order dated 8/29/25, for oxygen at two liters per minute (2L/min) via nasal cannula (N/C - a tube that delivers oxygen to your nose through soft prongs) continuous at HS (bedtime) for shortness of breath; a physician's order dated 8/28/25, to change oxygen concentrator tubing every 2 weeks on 2nd and 15th of each month on 11-7 shift. Observations on 9/2/25, at 11:27 a.m. and 9/3/25, at 9:00 a.m. revealed Resident R26 lying on his/her bed with supplemental oxygen in place and the oxygen concentrator liter flow set at 2 L/min via nasal cannula. Further observation of the oxygen tubing revealed a date of 7/15/25. During an interview on 9/3/25, at 9:00 a.m. Licensed Practical Nurse Employee E1confirmed that Resident R26's nasal cannula was dated 7/15/25 and it should have been changed. 28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, manufacturer's recommendations, observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly dated when opened and discarded in a timely manner for one of three medication carts reviewed (B Wing medication cart 2). Findings include: Review of a facility policy entitled Labeling of Medication Containers dated 4/01/25, revealed all medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. Manufacturer's recommendations for Humalog insulin (a type of short-acting insulin), indicated that an opened multiple-dose vial stored at room temperature should be discarded after 28 days. Observations of the B Wing's medication cart 2 on 9/02/25, at 2:10 p.m. revealed an opened vial of Humalog insulin without an open date, therefore the staff were unable to determine the discard date. The Assistant Director of Nursing confirmed at that time, that the opened Humalog insulin vial lacked an opened date, and staff were unable to determine the discard date. During an interview with the Director of Nursing on 9/05/25, at 12:10 p.m. it was confirmed that insulins should be properly labeled with an opened date for staff to determine the discard date. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen for one of four residents reviewed for respiratory services according to physician's orders (Resident R19).
Findings include:
Review of facility policy entitled Oxygen Therapy via Concentrator or Portable dated 10/1/24, indicated To administer oxygen for the treatment of certain disease or conditions per physician's orders And Nurse responsibility for oxygen therapy includes but isn't limited to checking physician order and set control to the prescribed liters per minute.
Resident R19's clinical record revealed an admission date of 2/02/22, with diagnoses that included chronic obstructive pulmonary disease (COPD - a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing, and wheezing), congestive heart failure (CHF - condition where the heart muscle don't pump blood as well causing difficulty breathing and fluid retention), and high blood pressure.
Resident R19's clinical record revealed a physician's order dated 9/12/23, for oxygen at three liter per minute (3L/min) via nasal cannula (N/C - a tube that delivers oxygen to your nose through soft prongs) continuous every shift for shortness of breath.
Observation of Resident R19's oxygen flow meter (a medical device used for oxygen flow measurement) on 10/28/24, at 4:06 p.m. revealed the oxygen flow measurement was at 5L/min via N/C. At the time of observation Resident R19 stated he/she was not to have their oxygen concentrator set at 5L/min.
During an interview at the time of observation Licensed Practical Nurse Employee E3 confirmed the oxygen administration level was set at 5L/min via N/C and did not follow the physician's orders.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, and clinical records, and staff interview, it was determined that the facility failed to assure a physician's order was completed to indicate the code status as Full Code (Cardiopulmonary Resuscitation-CPR/Attempt Resuscitation) or Do Not Resuscitate (DNR/Do Not Attempt Resuscitation-Allow Natural Death) for four of 19 residents reviewed (Residents R56, R58, R65, and R225).
Findings include:
A facility policy entitled Patient Self Determination Act / Resident Rights dated [DATE], indicated The Attending Physician will write an order for any valid Advanced Directive on the Physician Order sheet and document on the progress notes.
Resident R56's clinical record revealed an admission date of [DATE], with diagnoses that included dislocated left hip, chronic obstructive pulmonary disease (COPD - a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing, and wheezing) and neurogenic bladder (disorder where normal bladder function is disrupted due to nerve damage).
Resident R56's clinical record lacked a physician's order to indicate a code status as Full Code or DNR. Further review of Resident R56's clinical record lacked evidence of an advanced directive, living will, healthcare status form, or Physician Order for Life sustaining Treatment (POLST) on the electronic health record or paper chart.
During an interview on [DATE], at 12:28 p.m. the Director of Nursing (DON) and Registered Nurse (RN) Employee E1 confirmed Resident R56's clinical record lacked evidence of a physician's order addressing his/her code status and stated the facility would consider him/her a full code.
Further investigation and interview with Admissions Director revealed he/she had documents located in his/her office for Resident R56 indicating he/she was a DNR.
During an interview on [DATE], at 12:43 p.m. the DON and RN Employee E1 confirmed the facility failed to obtain a physician's order to honor Resident R56's DNR wishes and would have considered him/her a full code.
Resident R58's clinical record revealed an admission date of [DATE], with diagnoses that included malignant neoplasm of colon (a cancerous tumor of the large intestine), cardiac heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), weakness, and repeated falls. Resident R58's clinical record lacked a physician's order to indicate a code status as Full Code or DNR.
Resident R65's clinical record revealed an admission date of [DATE], with diagnoses that included fracture of left arm, acute kidney failure (a condition when the kidneys suddenly cannot filter waste from the blood), morbid obesity (a serious condition being more than 100 pounds over your recommended weight), and osteoarthritis (a type of arthritis that occurs when tissue at ends of bones wears down). Resident R65's clinical record lacked a physician's order to indicate a code status as Full Code or DNR.
Resident R225's clinical record revealed an admission date of [DATE], with diagnoses that included diabetes mellitus (a chronic disease that occurs when the body has high blood sugar levels), dementia (a disease of the brain affecting mood, behavior, and decision making), protein-calorie malnutrition (weight loss contributed to inadequate protein and calorie intake), and cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked resulting in brain tissue death). Resident R225's clinical record lacked a physician's order to indicate a code status as Full Code or DNR.
During an interview on [DATE], at 2:00 p.m. Licensed Practical Nurse (LPN) Employee E2 confirmed that he/she would refer to the electronic health record where all the physician orders could be readily accessed when a resident had a change in condition and the code status would need to be referenced. LPN E2 further confirmed that R225's clinical record lacked a physician order for code status.
During an interview on [DATE], at 10:30 a.m. the DON confirmed that Resident R58, Resident R65, and Resident R225's clinical records lacked a physician's order to indicate a code status as Full Code or DNR.
28 Pa. Code 201.18 (b)(1)(e)(1) Management

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to ensure that a baseline care plan was developed/implemented within the required timeframe and failed to ensure that a written copy including a summary of the resident's medications and dietary instructions was provided to residents and residents' representatives for three of five residents reviewed (Residents R56, R65, and R225).
Findings include:
Review of facility policy entitled, Baseline Care Plan dated 10/1/24, indicated Orchard Manor will develop and implement a baseline care plan for each Resident that includes the instructions needed to provide effective and person centered care of the Resident that meet professional standards of quality of care. The baseline care plan will be developed within 48-hours of a Resident's admission. and A copy of the baseline care plan shall be provided to the Resident and Resident representative in a language that the Resident and/or Resident representative can understand.
Resident R56's clinical record revealed an admission date of 9/12/24, with diagnoses that included dislocated left hip, chronic obstructive pulmonary disease (COPD - a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing, and wheezing), and neurogenic bladder (disorder where normal bladder function is disrupted due to nerve damage).
Review of Resident R56's clinical record lacked evidence that a baseline care plan was developed / implemented within 48-hours of admission, and that a written summary of the baseline care plan was provided to the resident and resident representative.
Resident R65's clinical record revealed an admission date of 8/19/24, with diagnoses that included fracture of left arm, acute kidney failure (a condition when the kidneys suddenly cannot filter waste from the blood), morbid obesity (a serious condition being more than 100 pounds over your recommended weight), and osteoarthritis (a type of arthritis that occurs when tissue at ends of bones wears down).
Review of Resident R65s clinical record lacked evidence that a baseline care plan was developed / implemented within 48-hours of admission, and that a written summary of the baseline care plan was provided to the resident and resident representative.
Resident R225's clinical record revealed an admission date of 10/25/24, with diagnoses that included diabetes mellitus (a chronic disease that occurs when the body has high blood sugar levels), dementia (a disease of the brain affecting mood, behavior, and decision making), protein-calorie malnutrition (weight loss contributed to inadequate protein and calorie intake), and cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked resulting in brain tissue death).
Review of Resident R225's clinical record lacked evidence that a baseline care plan was developed / implemented within 48-hours of admission, and that a written summary of the baseline care plan was provided to the resident and resident representative.
During an interview on 10/31/24, at 11:40 a.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed that the baseline care plans were not developed / implemented within 48 hours and there was no evidence that a written summary was provided to Residents R56, R65, and R225 and their representatives.
28 Pa. Code 201.24 (e)(4) Admissions Policy
28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide appropriate care regarding a urinary catheter (a tube inserted into the bladder to drain urine into a bag) for one of two residents reviewed for catheters (Resident R56).
Findings include:
Review of facility policy entitled Indwelling Catheter Use and Removal dated 10/1/24, indicated Catheter bag should be in a cover.
Resident R56's clinical record revealed an admission date of 9/12/24, with diagnoses that included dislocated left hip, chronic obstructive pulmonary disease (COPD - a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing, and wheezing) and neurogenic bladder (disorder where normal bladder function is disrupted due to nerve damage).
Resident R56's clinical record revealed a physician's order dated 9/13/24, that indicated to Check urinary drainage bag to ensure it is covered
Observations on 10/28/24, at 3:30 p.m. and 10/29/24, at 12:50 p.m. revealed that Resident R56 was laying in his/her bed and the urinary drainage bag was hanging from their bed and was visible from the hallway and lacking a privacy cover.
During an interview on 10/29/24, at 1:36 p.m. the Director of Nursing confirmed that the catheter drainage bag should be covered.
28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records and facility policy, observations, and staff interview, it was determined that the facility failed to use appropriate infection control practices for disinfection and storage of bedpans and wash basins for two of 19 residents reviewed (Residents R29 and R58).
Findings include:
Review of a facility policy entitled, Disinfection of Bedpans and Urinals, dated 10/01/24, revealed purpose to provide guidelines for disinfection of bedpans and urinals to put on gloves, cover bedpan or urinal before taking it to the bathroom or to the dirty utility room, empty contents (urine & feces) into toilet or hopper, flush the toilet or hopper, rinse bedpan or urinal with cool water to remove feces and urine, pour small amount of disinfectant solution (enough to thoroughly wet all surfaces) on and into bedpan or urinal or spray disinfectant liberally to thoroughly wet the surfaces. (May use a disinfectant cloth instead), wash hands, cover and return bedpan or urinal to resident's cabinet, wash hands. Nursing considerations: disposable bedpans and urinals are for single resident use only. [NAME] with the resident's name and discard upon discharge.
Resident R29's clinical record revealed an admission date of 2/14/23, with diagnoses that included injury of head, concussion (a brain injury caused by a blow to the head or shaking of the head and body), fracture of facial bones, and a maxillary fracture (a facial injury to the upper jawbone).
Resident R58's clinical record revealed an admission date of 10/02/24, with diagnoses that included malignant neoplasm of colon (a cancerous tumor of the large intestine), cardiac heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), weakness, and repeated falls.
Observations on 10/29/24, at 10:30 a.m. and 12:30 p.m. revealed an unlabeled bedpan on the floor of Resident R29 and Resident R58's shared bathroom. Further observations on 10/30/24, at 12:00 p.m. and 1:30 p.m. revealed a bedpan, with a wash basin laying upside down on top of the bedpan, in the residents' shared bathroom. The wash basin was labeled with Resident R29's name.
The Registered Nurse Infection Control (RN IC) employee confirmed on 10/30/24, at 1:30 p.m. that the unlabeled bedpan was observed on the floor of Resident R29 and R58's shared bathroom with a wash basin resting on top of the bedpan. The RN IC further confirmed that the bedpan should be labeled with an individual resident's name, sanitized, and stored in a clean bag immediately after use in the individual resident's bedside stand, and the wash basin should also be clean and stored after individual resident use and not laying on the floor.
28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on review of clinical records, facility policy and facility records, and staff interview, it was determined that the facility failed to follow physician's orders to consult psychology/psychiatry per physician orders for one of 17 residents (Resident R23).
Findings include:
Review of facility policy entitled Psychiatric Consultation dated 3/13/23, indicated that the psychiatrist will complete a follow-up form on all visits, and this form will be located in the resident's medical record.
Review of Resident R23's clinical record revealed an admission date of 4/3/2019, with diagnoses that included Dementia with other behavioral disturbance (a disease that affects short term memory and the ability to think logically which include having behaviors such as yelling, hitting individuals, mumbling and banging on objects), hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), and Alzheimer's disease (a disease that affects short term memory and the ability to think logically).
Review of Resident R23's clinical record revealed that on 10/9/23, the CRNP (Certified Registered Nurse Practitioner) ordered to Consult Psychology/Psychiatry.
Review of Resident R23's clinical record as of 11/8/23, revealed no evidence indicating the psychiatrist had seen Resident R23 per the order to consult dated 10/9/23.
Review of psychiatric appointment schedule revealed Resident R23 was on the schedule to be seen in the month of October 2023. The appointment schedule lacked evidence that the resident had been seen during the month of October.
During an interview on 11/8/23, at 12:15 p.m. the Director of Nursing (DON) revealed that the psychiatrist makes rounds in the facility every two weeks.
During an interview on 11/8/23, at 1:35 p.m. the DON confirmed that Resident R23 was not seen by psychology/psychiatry as ordered and also confirmed that Resident R23 should have been seen by psychology/psychiatry on the following scheduled visit after the consult order was written on 10/9/23.
28 Pa. Code 211.5(f)(ix) Medical records
28 Pa. Code 211.12(d)(1)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, facility policies and facility documentation, and staff and resident interviews, it was determined that the facility failed to provide adequate supervision that resulted in actual harm including a laceration requiring seven sutures (stitches to close a wound), head injury, and skin tear of forearm, to one of two residents reviewed (Resident R1).
Findings include:
Review of the facility policy entitled, Comprehensive Care Plan dated 3/13/23, revealed that the care plan will describe at a minimum, the following: (a) the services that are to be furnished to attain or maintain the Resident's highest practical physical, mental and psychosocial well being . 6. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.
Review of the facility policy entitled, Fall Prevention Program dated 3/13/23, revealed that residents that have a fall history will be placed on the fall prevention precautions, .6. fall risk interventions will at a minimum: include educating staff, resident, and family to increase the awareness of residents risk for falling and possible interventions to minimize the risk .8. Certified Nursing Assistants may assist with fall prevention as follows: 9a) follow the interventions as outlined on the care plan and [NAME] [system for resident care information to be relayed to staff] .
Review of Resident R1's clinical record revealed an original admission date of 12/14/2017, with diagnoses that included heart failure, weakness of the right side of the body following a stroke, diabetes, difficulty walking, obesity, low back pain, legal blindness, Alzheimer's disease and dementia (condition characterized by progressive, persistent severe impairment of intellectual capacity, including memory loss and confusion).
Review of the physician order sheet, dated 9/26/23, revealed that on 1/03/23 an order was written Do Not leave unattended in bathroom.
Review of a care plan entitled I am at high risk for falls care plan, revealed don't leave me unattended in the bathroom and was created on 1/03/23.
Review of nursing documentation, dated 9/11/23, written by Registered Nurse (RN) Employee E1, stated that Resident R1 experienced leaning back on the toilet for about 20 seconds with some tremors but was still alert and talking.
Review of nursing documentation dated 9/14/23, written by RN Employee E2 stated called to hallway due to resident going unresponsive when staff stood Resident R1 up. Resident was unresponsive for approximately three minutes. Upon arrival resident was alert and oriented but unaware of recent incident .Staff reported these episodes usually happened when resident is straining during bowel movement and occasionally when urinating .
Review of nursing documentation dated 9/15/23, written by Licensed Practical Nurse (LPN) Employee E3 revealed that he/she was called to the shower room by the Nurse Aide (NA) as Resident R1 had an unresponsive episode while getting on toilet lasting five seconds .
Review of nursing documentation dated 9/15/23, written by RN Employee E4 stated the RN was requested to go to Resident R1's room at approximately 4:00 p.m. Resident R1 was found lying on his back in his bedroom in a pool of blood. Resident R1 was noted as having a laceration above his right elbow, an abraded area on his right arm and in between the pinkie and ring finger of the right hand. Notifications were made and resident was sent to hospital.
Review of nursing documentation dated 9/15/23, stated the LPN E3 was called to the Resident R1's bathroom. Resident R1 was on the floor in his bathroom on right side, head against door frame, blood on floor. Resident R1 was alert, talking, complained of some discomfort to right eyebrow, no other complaint of pain. Laceration noted to the right eyebrow, skin tear to left forearm and left hand. Wound to head covered with gauze and wrapped with kling Xeroform applied to left arm and wrapped, steri strips to skin tear between finger of left hand.
Review of facility incident report and NA Employee E5's statement revealed that Resident R1 was assisted to the bathroom by two staff. NA Employee E5 was with the resident and the second NA left the room. NA Employee E5 left the resident alone in the bathroom to retrieve a brief (incontinence product) for Resident R1. When NA Employee E5 returned, Resident R1 had fallen off the toilet in the bathroom.
Observation on 9/26/23, of the location of the briefs revealed that their storage area was approximately 30 plus feet from Resident R1's door. NA Employees E6 and E7 confirmed that the briefs were kept at the location observed which was on the right side of the shower room.
Review of hospital records revealed the final diagnoses from Resident R1's admission to the hospital was fall, eye brow laceration requiring seven sutures, head injury, skin tear of forearm without complication and contusion.
Observation of Resident R1 on 9/26/23, at 10:15 a.m. noted, healing area from eye brow laceration with discoloring of yellow, purple and black colors with slight swelling still apparent. Left forearm wrapped, small bruised areas noted on both arms and large dark red purple area on the right arm from the elbow to shoulder area. Resident R1 stated at the time of the observation I took a tumble out the door.
During an interview on 9/26/23, at 3:24 p.m. the Director of Nursing confirmed that Resident R1 should not have been left unsupervised in the bathroom.
The facility failed to provide adequate supervision that resulted in actual harm to Resident R1.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.18(b)(3)(e)(1) Management
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical record and staff interviews, it was determined that the facility failed to have documented evidence of a physician's order for one of three residents reviewed (Resident R1).
Findings include:
Review of Resident R1's clinical record revealed an admission date of 12/14/17, with diagnoses that included cellulitis (bacterial skin infection causing the affected area to become swollen, inflamed, painful, and warm to the touch) of the left lower leg, atrial fibrillation (irregular heart beat causing the heart to beat too quickly), heart failure, and diabetes.
Review of Resident R1's clinical record revealed that Resident R1 was to have a procedure done at the hospital on 6/7/23. A physician's order written on 6/4/23, revealed to hold the medication Eliquis (a medication that makes the blood thin preventing clotting) 5 milligrams (mg) tablet by mouth two times per day, and was to be held starting 6/4/23, at the evening dose and held the following day 6/5/23, for both doses and 6/6/23, both doses for resident safety to prevent bleeding. The medication was normally administered during the 8:00 a.m. and 8:00 p.m. medication passes. A review of the June 2023 Medication Administration Record (MAR) revealed that the medication Eliquis 5 mg by tablet by mouth twice per day, was held according to the written physician's order.
Review of Resident R1's clinical record revealed that upon return from the procedure on 6/7/23, the surgeon's office sent post operative instructions with Resident R1 to the facility. The instructions reviewed gave general information to restart all medications previously on the resident's medication list.
During an interview with the Registered Nurse (RN) Supervisor on 7/6/23, at 12:30 p.m. it was identified that the surgeon's office was called to double check for resident safety due to bleeding precautions, if Eliquis 5 mg by mouth twice per day should be restarted on 6/7/23. The surgeon's office was unable to be reached and a message was left for a return call. The resident's primary care physician's office was then called for guidance. The Certified Registered Nurse Practitioner (CRNP) was contacted by phone and gave the verbal instruction to hold the medication for bleeding precautions until the surgeon returned call.
During a telephone interview with the CRNP on 7/6/23, at 12:36 p.m. it was confirmed that the RN Supervisor contacted him/her on 6/7/23, in the evening questioning if Eliquis 5 mg one tab by mouth twice per day should be restarted that evening after the surgical procedure. The RN Supervisor was informed to hold the medication Eliquis 5 mg by mouth twice per day due to bleeding precautions after surgery until the surgeon could give the clarification to reorder it. The CRNP confirmed that a verbal order was given to the RN Supervisor.
Review of Resident R1's clinical record lacked documentation regarding contacting the CRNP and a physician's order regarding the Eliquis medication.
Review of physician's orders revealed that on 6/9/23, the surgeon's office returned the call and ordered to restart Eliquis 5 mg one tablet by mouth twice per day. The next dose was reordered to be given on 6/9/23, at the 8:00 p.m. medication pass. Review of the June 2023 MAR revealed that the medication was given as ordered on 6/9/23, during the 8:00 p.m. medication pass.
During an interview on 7/6/23, at approximately 1:00 p.m. the Director of Nursing, confirmed that the clinical record lacked documented evidence as to whether the Eliquis was to be restarted on 6/7/23, after the surgical procedure, lacked a written physician's order and lacked documentation that the CRNP had been contacted and gave a verbal order to hold the Eliquis until confirmation by the surgeon's office.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
28 Pa. Code 211.5(f) Medical records