Health inspection·July 6, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. 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). Residents Affected - Few 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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395793 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Manor 20 Orchard Drive Grove City, PA 16127 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)