Orwigsburg Nursing And Rehabilitation Center

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. Further review of the clinical record revealed that Resident 1 had declined authorization and consent for the production and use of any images taken on behalf of Orwigsburg Center or its agent on January 4, 2023.Review of facility documentation dated November 1, 2025 revealed that Nurse Aide 1 (NA 1) stated that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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). Review of Resident 8's medication administration records (MARs) revealed that staff administered the medication six times in May 2025, five times in June 2025, and four times in July when the resident's SBP was less than 115 mmHg.Clinical record review revealed that Resident 62 had a diagnosis of hypertension (high blood pressure). On March 5, 2025, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide services to maintain adequate grooming and personal hygiene for four of 20 sampled residents. (Residents 17, 31, 68 and 87) Findings include: Clinical record review revealed that Resident 17 had diagnoses that included diabetes and a history of respiratory disease. According to the Minimum Data Set (MDS) assessment, dated June 10, 2024, she could communicate her needs and required supervision with her activities of daily living (ADLs) such as personal hygiene. The resident was hospitalized from [DATE] to 18, 2024, after a decline in condition. After returning from the hospital, she was more dependent on staff for all mobility and care, including her ADLs. On July 23, 2024, at 12:28 p.m., the resident was observed in bed with long and jagged finger and toe nails. At that time, the resident stated, They haven't helped me trim my nails in a while. On July 25, 2024, at 12:49 p.m., the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to assess bladder incontinence and provide services to restore as much bladder function as possible for two of 24 sampled residents. (Residents 57, 60) Findings include: Review of the facility policy entitled, Urinary Continence and Incontinence - Assessment and Management, last reviewed January 16, 2024, revealed that facility staff was to complete a urinary incontinence assessment periodically and when there was a change in voiding. Staff would define each resident's level of continence and identify the type of incontinence. Clinical record review revealed that Resident 57 was admitted to the facility on [DATE], with diagnoses that included anxiety and hemiplegia. A Bowel and Bladder Program Screener was completed on April 3, 2024, and May 1, 2024, and indicated that the resident was a candidate for a scheduled toileting program. According to the Minimum Data Set (MDS) assessment, dated June, 24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to offer non-pharmacological interventions prior to the administration of as needed anti-anxiety medications for one of 24 sampled residents. (Resident 57) Findings include: Clinical record review revealed that Resident 57 had diagnoses that included schizophrenia and anxiety. On June 10 and 24, 2024, and July 8 and 22, 2024, the physician ordered an anti-anxiety medication, alprazolam, be given every eight hours as needed for 14 days. Review of the medication administration records for June and July 2024, revealed that staff had administered the as needed alprazolam 30 times. There was no documented evidence that staff attempted non-pharmacological interventions prior to the administration of the as needed anti-anxiety medication. In an interview on July 26, 2024, at 10:05 a.m., the Director of Nursing confirmed that there was no documented evidence that staff attempted non-pharmacological interventions prior to the administration of the as needed anti-anxiety medication. 28 Pa. code…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, observation, and resident interview, it was determined that the facility failed to ensure that a resident's preference at meal times had been accommodated for one of 24 sampled residents. (Resident 27) Findings include: Clinical record review revealed that Resident 27 had diagnoses that included diabetes mellitus and congestive heart failure. A Minimum Data Set assessment dated [DATE], indicated that the resident was alert and able to make his needs known. Resident 27's ongoing care plan revealed he had the potential to be at nutritional risk and an intervention was to honor his food preferences. On July 23, 2024, at 10:55 a.m., Resident 27 stated that he frequently received items he disliked on his meal trays. On July 23, 2024, at 12:40 p.m., Resident 27's lunch tray was observed and he received rice as a side dish. Review of Resident 27's meal ticket at that time revealed that rice was listed as a food the resident disliked. In an interview at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide adaptive equipment to assist with eating meals for one of 24 sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included dysphagia and aphasia. On March 19, 2024, the physician ordered that staff provide the resident a two handled cup at all meals. Review of an occupational therapy note dated July 17, 2024, revealed that it was recommended for the resident to continue to use a two handled mug or regular mug/cup with a lid and straw to aid independence. On July 23, 2024, from 12:40 p.m. through 12:55 p.m., and on July 25, 2024, from 12:40 p.m. through 12:55 p.m., Resident 1 was observed in the dining room without a two handled cup or regular mug/cup with a lid and straw for her beverages. In an interview on July 26, 2024, at 10:20 a.m., Registered Nurse 1 confirmed that the resident should have received her drink in a two handled cup at all meals. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, observations, and interviews, it was determined that the facility failed to follow policy related transmissions-based precautions and use of personal protective equipment for one of 24 sampled residents. (Resident 47) Findings include: Review of the facility policy entitled, Isolation- Categories of Transmission-Based Precautions, last reviewed on January 16, 2024, revealed that transmission-based precautions (TBP) were additional measures to protect staff, visitors, and other residents from becoming infected when a resident was diagnosed with specific pathogens. A sign was hung on the room entrance door so that staff and visitors were aware of the need for precautions. Clinical record review revealed that Resident 47 was admitted to the facility on [DATE], with a diagnoses that included dementia, pneumonia, and methicillin-resistant staphylococcus aureus (a drug resistant infection) in the sputum. On May 13, 2024, a physician ordered that staff use TBP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 23 sampled residents. (Resident 3) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included paraplegia (loss of feeling or movement in part of the body), anxiety, depression, and chronic pain. A physician's order dated June 21, 2023, directed staff to administer Percocet (a pain medication) every four hours as needed for severe pain of eight to 10 on the pain scale. Review of the June, July, and August 2023, medication administration records revealed that staff administered the medication when the resident's pain was rated below eight on the pain scale eight times in June, 19 times in July, and one time in August. In an interview on August 4, 2023, at 9:45 a.m., Quality Regulatory Consultant 1 confirmed that staff had administered the Percocet when the resident's pain was below the established parameters. CFR 483.25 Quality of Care Previously cited 10/6/22 28 Pa. Code 211.12(d)(1)(5) Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to implement treatment and services to prevent a further decrease in range of motion for one of six sampled residents with limited range of motion. (Resident 46) Findings include: Clinical record review revealed that Resident 46 had diagnoses that included quadriplegia (the inability to be able to move any muscles from the neck down), muscle spasm, and traumatic brain injury. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired, dependent on staff for activities of daily living, and had a limitation in range of motion on both sides of the upper extremities. On March 8, 2022, the occupational therapist (OT) recommended a restorative nursing program (RNP) for range of motion for both shoulders and the right elbow. A physician's order dated March 9, 2022, directed staff to provide the RNP and provide a prolonged stretch for both shoulders and also to extend the right elbow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.