Orwigsburg Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Orwigsburg Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 11, 2025

  Based on clinical record review, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to ensure each resident's environment was free of accident hazards by ensuring illegal substances were not accessible to two of six sampled residents. (Residents 1 and 2) In addition, the facility failed to ensure the safety of residents in all areas of the facility in one of two nursing units (Unit A) and first floor common areas. This failure resulted in an Immediate Jeopardy situation.Based on clinical record review, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to ensure each resident's environment was free of accident hazards by ensuring illegal substances were not accessible… […]

• No harm, potential for more than minimal, patternF684Aug 7, 2025

  Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement physicians' orders for four of 25 sampled residents. (Residents 8, 62, 86 and 115)Findings include: Clinical record review revealed that Resident 8 had diagnoses that included chronic kidney failure, congestive heart failure, and diabetes. A physician's order dated March 24, 2025, directed staff to administer a medication (isosorbide mononitrate) daily in the morning for heart disease. The medication was to be held if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 115 millimeters of mercury (mm/Hg). […]

• No harm, potential for more than minimal, patternF697Oct 29, 2021

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure pain management included the attempt to provide non-pharmacological interventions to alleviate pain prior to or in conjunction with the administration of pain medication prescribed on an as needed basis for two of 19 sampled residents. (Residents 1, 2) Findings include: Clinical record review revealed that Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was ordered pain medication ([MEDICATION(S)]), 5 milligrams (mg) every four hours as needed for moderate pain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF583Nov 12, 2025

  Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to protect the residents' right to privacy and confidentiality through the use of photography for one of six sampled residents. (Resident 1)Findings include:Review of the facility policy entitled, Compliance Risks - Privacy, Security, and Breach Notifications, last reviewed January 2025, revealed that the facility complies with the laws governing privacy and security to ensure resident privacy and confidentiality. Clinical record review revealed that Resident 1 had diagnoses that included multiple sclerosis. Review of the Minimum Data Set assessment, dated August 2, 2025, revealed the resident had no cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF641Aug 7, 2025

  Based on clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one of 25 sampled residents. (Resident 3)Findings include:Clinical record review revealed that Resident 3 had diagnoses that included anxiety, depression, and atrial fibrillation (irregular heartbeat). Review of Resident 3's MDS assessment dated [DATE], indicated that Resident 3 had a tracheostomy (surgical hole in the front of the neck for breathing). Review of Resident 3's clinical record revealed no physician's orders or care plan indicating the resident had a tracheostomy. In an interview on August 7, 2025, at 9:02 a.m., the Administrator confirmed Resident 3's MDS was inaccurate and that Resident did not have a tracheostomy.