Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**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
(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 7
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
10/31/2024
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)
F 0578
Code or DNR.
Level of Harm - Minimal harm
or potential for actual harm
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.
Residents Affected - Few
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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395793
If continuation sheet
Page 2 of 7
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
10/31/2024
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)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
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)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395793
If continuation sheet
Page 3 of 7
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
10/31/2024
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)
F 0655
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.
Level of Harm - Minimal harm
or potential for actual harm
28 Pa. Code 201.24 (e)(4) Admissions Policy
Residents Affected - Few
28 Pa. Code 211.10(c) Resident care policies
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395793
If continuation sheet
Page 4 of 7
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
10/31/2024
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)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395793
If continuation sheet
Page 5 of 7
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
10/31/2024
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)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
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).
Residents Affected - Few
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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395793
If continuation sheet
Page 6 of 7
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
10/31/2024
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
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).
Residents Affected - Few
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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395793
If continuation sheet
Page 7 of 7
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the October 31, 2024 survey of ORCHARD MANOR?
This was a inspection survey of ORCHARD MANOR on October 31, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ORCHARD MANOR on October 31, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.