Pennsylvania Department of Health
ORCHARD MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ORCHARD MANOR
Inspection Results For:

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ORCHARD MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Complaint Survey completed on August 6, 2026, it was determined that Orchard Manor was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.\~

Plan of Correction:

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations:

Based on review of facility policy and clinical records, review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), and staff interviews, it was determined that the facility failed to notify the resident's representative of a change in condition timely for one of four residents reviewed (Resident R1).

Findings include:

Facility policy entitled "Resident Notification" dated 6/26/26, revealed" Orchard Manor shall promptly notify the resident's representative or responsible party, and the attending physician whenever there is a significant change in the resident's physical, mental, or psychosocial conditions, or when other events requiring notification occur; All notification shall be documented in the resident's medical record, including the date, time, person notified, method of notification, information communicated, and any instructions or orders received; The attending physician and resident representative shall be notified promptly when any of the following occurs: significant change in physical, mental, or emotional condition, serious illness or injury, unexpected accident or incident, any other event requiring physician assessment or family notification under facility policy or applicable regulations."

Resident R1's clinical record revealed an admission date of 5/08/25, with diagnosis that included Cerebral Infarction (a condition where a part of the brain is damaged or dies due to a lack of blood supply), Hyperlipidemia (high cholesterol), and high blood pressure.

Review of the RAI manual for Section C0500 "Brief Interview for Mental Status (BIMS)" revealed that a score of 13-15 identified a resident as cognitively intact and a score of 8-12 identified a resident as moderately impaired, and a score of 0-7 as severely impaired. Resident R1's BIMS score was a 3/15.

Resident R1's clinical record revealed a progress note dated 7/29/26, indicating "called to resident room by staff nurse. Observed three toes on the right foot are necrotic (dead tissue)and dry, on the great toe there was maggots crawling out from under the skin. Called [medical provider name] from [medical provider company name]-new orders to clean wound with normal saline solution (NSS) and increase dressing changes to two time a day."

The clinical record lacked evidence that Resident R1's representative was notified of Resident R1's change in condition/treatments until 8/4/26.

During an interview on 8/5/26, at 12:10 p.m. Director of Nursing confirmed there was no documented evidence that staff attempted to notify Resident R1's family of the above changes in condition and treatments until 8/4/26.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.12 (d)(1)(5) Nursing services

28 Pa. Code 201.18(b)(1) Management

Plan of Correction - To be completed: 08/25/2026

1. Facility contacted R1s responsible party and notified them of change in condition and treatments on 8/4/2026.
2. Director of Nursing/Designee audited previous 30 days of nursing notes for responsible party notification of change in conditions and orders and ensure notification is complete and documented.
3. Facility Licensed nursing staff educated on facilities notification policy for change in condition and orders.
4. Director of Nursing/Designee will audit 24 hour report for responsible party notification of change in condition and orders and documented 5 days a week time 2 weeks, 3 days a week times 1 weeks, 2 days a week times 1 week, then 1 day a week times 2 months.
5. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.

483.20(f)(5),483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:

Based on review of clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete documentation for one of five residents reviewed (Resident R1).

Findings include:

Resident R1's clinical record revealed an admission date of 5/08/25, with diagnoses that included Cerebral Infarction (a condition where a part of the brain is damaged or dies due to a lack of blood supply), Hyperlipidemia (high cholesterol), and high blood pressure.

Review of Resident R1's treatment administration record revealed that from 7/30/26, through 8/3/26, wound care was ordered and completed twice a day for the left fifth toe. The progress note on 7/29/26 mentions a verbal order for the right foot to clean wound with normal saline solution (NSS) and increase dressing changes to two times a day.

During an interview on 8/5/26, at 12:10 p.m. the Director of Nursing (DON) confirmed the following: Facility staff reported maggots were observed on Resident R1's right foot wounds during a routine dressing change on 7/29/26. The RN supervisor notified the on-call provider and verbal orders were given for the right foot to clean wound with normal saline solution (NSS) and increase dressing changes to two times a day, which staff have been doing since 7/30/26. Dressing changes were no longer being completed/needed on Resident R1's left fifth toe, only the left heel, left calf, and right foot and right toes.

The DON confirmed staff had not accurately entered the verbal order given on 7/29/26 and were not accurately documenting the wound care location for twice a day dressing changes for wounds located on Resident R1's right foot. The DON further confirmed that the verbal order entered on 7/29/26 should have been for the right foot, not the left.

28 Pa. Code 211.5(f)(i)(viii)Medical records

28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 08/25/2026

1. Director of Nursing/designee immediately verified and corrected the treatment order for R1s right foot.
2. Director of Nursing/designee audited all wounds to verify all have orders and orders are accurate entered.
3. Facility educated all Licensed Nursing Staff on transmitting accurate verbal physician wound orders in to the electronic health record system.
4. Director of Nursing/Designee will audit all new wound orders for accuracy for 5 days a week time 2 weeks, 3 days a week times 1 weeks, 2 days a week times 1 week, then 1 day a week times 2 months.
5. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions for one of four residents reviewed (Resident R1).

Findings include:

A facility policy entitled "Enhanced Barrier Precautions" dated 6/26/26, indicated that" Orchard Manor will implement Enhanced Barrier Precautions (EBP) for residents who meet established criteria to reduce the transmission of Multidrug Resistant Organisms (MDROs) (a germ resistant to many antibiotics) during high-contact resident care; Gown and gloves are required during activities such as wound care; An EBP sign will be placed at the entrance to the resident's room indicating that gown and gloves are required for specific high contact care activities and that hand hygiene is required before and after resident care."

The Center for Disease Control and Prevention (CDC) defines Enhanced Barrier Precautions as an infection control intervention designed to reduce transmission of MDRO's using an approach of isolation gown and gloves during high-contact resident care activities including wound care. CDC further indicates that facilities should post clear signage indicating EBP requirements.

Resident R1's clinical record revealed an admission date of 5/08/25, with diagnoses that included Cerebral Infarction (a condition where a part of the brain is damaged or dies due to a lack of blood supply), Hyperlipidemia (high cholesterol), and high blood pressure.

Resident R1's clinical record revealed physician's orders dated 7/30/26, for wound care: Right Foot-cleanse all areas with vashe (a type of wound cleanser), pat dry, paint with betadine (liquid antiseptic) to 2nd MTP (metatarsophalangeal joint), 4th MTP, lateral foot. Cover all area with ABD (absorbent medical wound dressing) and wrap with kerlix (type of gauze), secure with tape. Daily/PRN (as needed) every day shift AND as needed for soilage/dislodgement; Wound care: cleanse right great toe with Dakins solution 0.125% (antiseptic solution used on wounds to kill bacteria and stop infections) apply medi honey (Medical grade wound dressing) to open wound bed and betadine to eschar(a thick ,dry layer of dead tissue that forms over a skin wound), cover with abd and wrap with kerlix secure with tape every day shift.

Resident R1's physician orders failed to include an order for EBP's.

Observation on 8/4/26, at 9:42 a.m. revealed that Resident R1 was lying in his/her bed with gauze dressings covering both feet. Further observation revealed there was no signage alerting persons entering the room of EBP for infection control.

During an interview on 8/4/26, at 2:15 p.m. Registered Nurse Employee E1 confirmed that Resident R1's room lacked signage of EBP and that physician orders were not in place regarding EBP for Resident R1.

28 Pa. Code 211.10(c)(d) Resident care policies

28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 08/25/2026

1. Facility immediately placed the appropriate EBP signage for R1 and ensured that EBP orders were in place and reflected in the careplan for R1.
2. Director of Nursing/designee audited all facility residents with EBP requirements for appropriate orders, care plans and signage.
3. Nursing Home Administrator educated the Director of Nursing and Infection Preventionist on the facilities EBP policy.
4. Director of Nursing/Designee will audit all new admissions and change of conditions for EBP need, orders, careplans and appropriate signage 5 days a week time 2 weeks, 3 days a week times 1 weeks, 2 days a week times 1 week, then 1 day a week times 2 months.
5. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.

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