F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
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
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
12/09/2025
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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 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
Event ID:
Facility ID:
395793
If continuation sheet
Page 2 of 2
