Orchard Manor

In the surveyor’s words

From the most serious findings on record at Orchard Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 18, 2025

  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. […]

• Actual harm, isolatedF689Sep 26, 2023

  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. […]

• No harm, potential for more than minimal, patternF610May 21, 2026

  Based on review of facility policy, clinical and facility records, and staff interviews, it was determined that the facility failed to complete a thorough investigation related to incidents and accidents for three of five residents reviewed (Residents R2, R3, and R4). Findings include: Review of facility policy, Incident Reporting dated 3/12/26, revealed the purpose of this policy is to ensure that all incidents involving residents, staff, visitors, or facility operations are promptly identified, investigated, documented, and reported in accordance with federal regulations, state law, and facility standards to protect resident health, safety, and rights. […]

• No harm, potential for more than minimal, patternF756Jan 26, 2023

  Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that pharmacy recommendations were completed for one resident and acted on in a timely manner for three of 18 residents reviewed (Residents R11, R23, and R26). Findings include: Review of Resident R11's clinical record revealed an admitted [DATE], with diagnoses that included psychotic disorders with delusions (a false, fixed belief involving a real-life situation that could be true but isn't), mood disorder, Alzheimer's Disease (progressive neurologic disorder that causes the brain to shrink (atrophy) and brain cells to die), anxiety disorder, and depression. […]

• No harm, potential for more than minimal, isolatedF726Aug 31, 2026

  Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure all nursing staff had proper competencies to provide tracheostomy (surgical procedure that creates an opening in the front of the neck into the trachea to allow air to reach the lungs) care for one of one residents reviewed with a tracheostomy (Resident R1). Findings include: Review of a facility policy dated 7/01/26, Tracheostomy Care and Suctioning revealed under 11. Staffing and Competency-the Director of Nursing or designee will ensure that personnel assigned to residents requiring tracheostomy care have appropriate education, training, and documented competency. […]