Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Orchards At Warren during CMS and state inspections, most recent first.
A resident with impaired cognition and existing Stage 3 pressure ulcers to the sacral region and left hip had a physician order for daily-shift wound care, including cleansing with NS, application of Medihoney gel, and a dry dressing. Review of the TAR showed four consecutive days where the ordered treatment was left blank, indicating it was not completed, and there was no documentation explaining the missed care. In interview, the DON could not explain the lack of charting and stated an expectation that all treatments be documented, despite a facility policy committing to prevention of skin breakdown.
A resident with vascular dementia, intact cognition, and independent mobility repeatedly expressed intent to leave, contacted outside parties to assist with discharge, and had previously attempted to move toward an exit, leading staff to apply a wander alert device and mark the resident as an elopement risk, though this device was not documented in the care plan and the resident was still scored as low elopement risk. On a later occasion, the resident removed screws from a window designed to limit its opening, climbed out unnoticed, and was found walking outside by a housekeeping supervisor, who, along with additional staff, spent about 15 minutes coaxing the resident back inside. Staff confirmed they were unaware the resident had left the building, the NHA noted the resident’s preference for a closed door complicated supervision, and the DON acknowledged there was no documentation policy for nurses and CNAs.
Staff failed to provide timely incontinence care, appropriate meal positioning, and regular repositioning for three dependent residents. One resident, cognitively impaired and care-planned for q2h incontinence checks, remained in bed through the morning and was later found soiled with loose stool, with no prior incontinence care observed. Another resident with severe cognitive impairment and multiple comorbidities was left in bed with a breakfast tray positioned at mouth and nose level, a urine odor present, and bed controls out of reach; when care was finally provided, the brief was visibly urine-soiled, and the CNA stated this was the first incontinence care since the start of the shift. A third resident with paralysis, stroke, and malnutrition, care-planned as totally dependent for repositioning at least every two hours, was observed multiple times over several hours with no change in body position, including with the head off the pillow. The DON later acknowledged that aides may prioritize care timing and reported rounds had been done, but the residents’ positions had not changed.
The facility failed to keep AEDs and crash carts in a ready-to-use condition, including during a code blue for a resident with full code status when the nearest AED lacked pads and staff had to retrieve another device from a different unit. Surveyors later found an AED case cracked open with no visible status light, an empty wall-mounted AED box above a crash cart that was documented as checked, and a dining room crash cart with soiled towels on top and no inventory form. On multiple units, AEDs were stored with batteries removed, contrary to the manufacturer’s instructions that they be stored with pads and battery installed to allow daily self-tests. A unit manager was unable to complete the AED self-test as outlined in the manual, and the administrator confirmed there were no facility policies governing AEDs or crash carts.
A facility failed to notify a resident's family of a change in condition, despite multiple nursing notes documenting the resident's decline in ability to transfer and toilet independently. The resident, with severe cognitive impairment and multiple diagnoses, was not able to communicate the change, and the family only became aware during a visit. Staff interviews revealed a lack of communication and documentation, and the facility's policy did not address notifying the resident's representative.
A resident with dysphagia, diabetes, and dementia was admitted with a pureed diet order and experienced weight loss. Despite requiring extensive eating assistance and showing decreased oral intake and appetite, the facility failed to complete a comprehensive nutritional assessment in a timely manner. The RD acknowledged the oversight, and the DON could not provide the policy on assessment timeliness.
The facility failed to serve food in a palatable manner and at the preferred temperature, leading to dissatisfaction among residents. Observations showed meals were served cold, with missing items and inadequate portions. A resident with congestive heart failure and type 2 diabetes expressed dissatisfaction with the food quality. A test tray revealed food temperatures below the preferred level, contrary to the facility's policy on food palatability.
The facility failed to maintain an effective pest control program in the kitchen, with standing water and gnats observed in multiple areas. The Dietary Manager was unable to explain the presence of standing water, which was noted as a breeding ground for gnats. Pest control reports indicated ongoing issues with gnats.
The facility failed to ensure proper medication storage, with four residents found with medications at their bedsides without assessments or physician orders for self-administration. This included inhalers and pills, with staff confirming the lack of authorization for bedside storage.
A resident with a history of kidney stones and chronic kidney disease requested a hospital transfer due to severe pain, but the facility failed to honor this request. The resident was informed that they would need to sign out AMA and cover transportation costs, leaving them in pain without the desired medical intervention. This incident highlights a violation of the resident's right to self-determination.
A resident with severe cognitive impairment and a history of stroke was not provided with an assistive communication device, such as a communication board, despite being non-verbal and dependent on staff for most activities of daily living. Staff interviews revealed a lack of awareness about the availability of a communication board, and observations confirmed its absence, contrary to facility policy.
A resident with impaired vision was observed wearing broken glasses, with one lens missing and the other dirty. Despite being seen by an eye doctor, the issue was not resolved, and the resident was told to obtain new glasses independently. Facility staff were unaware of the problem until informed, and the Director of Nursing acknowledged that the situation should have been addressed immediately, as per the facility's policy on emergency services.
A resident with COPD and acute respiratory failure was observed using oxygen without a physician order, contrary to facility policy. Staff interviews confirmed the oversight, acknowledging the necessity of a physician order for oxygen administration.
A resident with cognitive impairment requested their medications to be crushed, and an LPN complied without verifying physician orders. This included Duloxetine, a delayed-release medication that should not be crushed. The facility's DON was informed post-administration, and it was confirmed that the medication was altered inappropriately, violating professional standards.
A resident with cerebral infarction and left hemiplegia was not using a prescribed hand splint, which was observed unused in their room. The resident reported occasional pain and acknowledged the need for the splint. Staff were unaware of any instructions to use the splint, and there was no documentation supporting its discontinuation. A new splint was ordered but delayed, and the facility's policy on splints was not provided.
Failure to Provide and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide and document ordered pressure ulcer treatment for a resident with existing Stage 3 pressure ulcers to the sacral region and left hip. The resident was admitted with these wounds, had impaired cognition with a BIMS score of 3/15, and required staff assistance with bed mobility and transfers. The Treatment Administration Record (TAR) contained an order, starting 7/9/2025, to cleanse the coccyx with normal saline, apply Medihoney gel, and cover with a dry dressing every day shift. Review of the July 2025 TAR showed that on four consecutive days (July 10th–13th) the treatment entries were left blank, indicating the ordered wound care was not completed, and there was no additional documentation in the medical record explaining why the treatments were not done. In an interview, the DON stated they were unsure why the treatment was not charted and reported an expectation that all treatments be documented as completed, while facility policy stated a commitment to providing care and services to prevent skin breakdown.
Failure to Adequately Supervise and Prevent Elopement of an Identified Elopement-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for one resident identified as an elopement risk. The resident was admitted with vascular dementia and had a BIMS score of 15/15, indicating intact cognition, and was independent with ambulation and most ADLs. In the weeks prior to the incident, the resident repeatedly verbalized plans to leave, including stating they would discharge the next day, calling a moving company and their church for assistance, and telling staff they would call the police. On one occasion, the resident moved quickly toward an exit when discussing discharge and had to be redirected; at that time, a wander alert device was applied, and the care plan was updated to reflect elopement risk, but the care plan did not document that a wander alert device had been applied. An elopement risk assessment subsequently scored the resident as low risk despite the multiple expressed intentions to leave. The incident under review occurred when the resident exited the building without staff knowledge by removing screws from the inside window casing that were intended to limit the window opening to 2–3 inches, allowing the window to open wide enough for the resident to climb out. The resident was later observed outside, walking on the driveway near the building by a housekeeping supervisor, who attempted unsuccessfully to coax the resident back inside while the resident repeatedly stated they were leaving and not returning. Additional staff were called, and after about 15 minutes the resident returned to the building. Staff confirmed they had not been aware the resident was out of the building. The Nursing Home Administrator stated that the resident preferred to keep their door closed at all times, making it difficult to balance privacy with increased supervision. The DON reported there was no policy for documentation for nurses and CNAs when documentation policy was requested.
Failure to Provide Timely Incontinence Care and Repositioning for Dependent Residents
Penalty
Summary
The deficiency involves staff failure to timely provide incontinence care, toileting-related ADL assistance, and repositioning for three dependent residents. One resident, admitted with diagnoses including hypertension and pain and assessed as moderately cognitively impaired, required substantial/maximal assistance with toileting hygiene, personal hygiene, bathing, and meal setup, and had a care plan directing incontinence checks at least every two hours during the day. This resident was observed in bed from early morning through mid-morning without evidence of incontinence checks; at 10:50 AM, staff found the resident soiled with loose stool covering the pubic area. The resident’s fingernails were noted to have soil underneath, and there was no prior observed incontinence care before that time. Another resident, with diagnoses including adult failure to thrive, heart disease, and Alzheimer’s disease, and severely impaired cognition, required substantial/maximal assistance for toileting hygiene and was dependent for bathing, dressing, and personal hygiene, with partial assistance needed for bed mobility and meal setup. This resident was observed in bed with the breakfast tray positioned at mouth and nose level, unable to respond meaningfully, with a urine odor present; the bed controls were out of reach, and the LPN did not adjust the resident’s position when questioned. Later, staff found a visibly urine-soiled brief, and the CNA reported this was the first incontinence care provided to these residents since the start of the 7 AM shift. A third resident, admitted with diagnoses including left-sided paralysis, stroke, and malnutrition, had a care plan indicating incontinence of bowel and bladder, need for assistance with ADLs, and total dependence on staff for repositioning in bed at least every two hours and as necessary. This resident was repeatedly observed supine in bed with the head of the bed elevated 30–45 degrees, eyes closed, and legs elevated with heel boots, from late morning through mid-afternoon. Across multiple observations, the resident’s position did not change, including when the head was noted to be off the right side of the pillow. The DON later stated that aides may prioritize timing of care based on resident needs and reported that rounds had been completed initially and between 9:00 and 9:30 AM, but the observed positions of the residents had not changed. Facility policy on toileting stated that when a resident indicates verbally or non-verbally a need to use the bathroom, staff should promptly assist, but the observations showed delays in incontinence care and lack of timely repositioning for these dependent residents.
Failure to Maintain AEDs and Crash Carts in Ready-to-Use Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure essential emergency equipment, specifically AEDs and crash carts, were maintained in a ready-to-use condition. A complaint intake reported that during a code blue for resident R904 on the [NAME] unit, staff could not use the closest AED because it did not have pads, and staff had to obtain another AED from a different unit. R904’s record showed the resident was cognitively intact, required staff assistance with activities of daily living, and had a full code status; after the code and a 911 call, the resident was transferred to a local hospital. During the survey, attempts to contact the nurse involved in the code were unsuccessful. Surveyors observed multiple issues with AEDs and crash carts throughout the facility. An AED in a red case on top of the crash cart outside reception was found cracked open with no visible status light. On the [NAME] unit, the crash cart log showed all items checked, but the wall-mounted AED box above it was empty. In the large dining room, the crash cart had soiled towels on top and no form to monitor its inventory. On the [NAME] unit and the Rose/Lavender unit, AEDs were stored with the batteries removed; the unit manager and the DON stated this was done to prevent beeping and preserve battery life. Review of the manufacturer’s manual, however, showed the AED must be stored with pads and battery installed so it can perform daily self-tests and remain ready for use. When asked to demonstrate the self-test, a unit manager inserted the battery and turned the AED on but did not complete the self-test, stating it would waste pads, and reported being unable to complete it without connecting pads. The administrator reported the facility had no policies addressing AEDs or crash carts.
Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition, which was identified during an interview and record review. The resident, who was admitted with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, Diabetes, Dementia, and Heart Failure, was severely cognitively impaired and required limited assistance for transfers and bed mobility. On multiple occasions, nursing notes documented a decline in the resident's ability to transfer and toilet independently, indicating a significant change in condition. Despite these observations, the resident's family was not informed of the change until a family member noticed the decline during a visit. Interviews with facility staff revealed that there was a lack of communication and documentation regarding the notification of the resident's family. A Licensed Practical Nurse (LPN) was informed of the change in condition but was not familiar with the resident and relied on the Unit Manager to contact the family. The Unit Manager claimed to have contacted the family but did not document the attempt. The Director of Nursing acknowledged that the family should have been notified. Additionally, the facility's Acute Change in Condition policy did not address the requirement to notify the resident's representative, contributing to the deficiency.
Failure to Complete Timely Nutritional Assessment
Penalty
Summary
The facility failed to complete a comprehensive nutritional assessment in a timely manner for a resident admitted with nutritional at-risk indicators. The resident, who had diagnoses including dysphagia, diabetes mellitus, and dementia, was admitted with a hospital transfer order for a pureed diet. The resident's weight decreased from 140 pounds to 131.7 pounds over a period of time, and the care plan indicated the need for extensive assistance with eating. Despite these indicators, a comprehensive nutritional assessment by the Registered Dietician (RD) was not completed. The RD confirmed during an interview that the assessment was missed, although a Minimum Data Set (MDS) nutrition assessment was completed, which is not a comprehensive dietary evaluation. The Director of Nursing (DON) was unable to provide the facility's policy on the timeliness of a full RD assessment, and the policy provided only addressed MDS assessments. The lack of a comprehensive assessment potentially delayed necessary care interventions for the resident, who exhibited multiple dietary-related indicators such as decreased oral intake, decreased appetite, and weight loss.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to serve food in a palatable manner and at the preferred temperature for one resident and a group of ten residents, leading to dissatisfaction during meals. Observations and interviews revealed that a resident's breakfast consisted of items like biscuits, pancakes, and cereal, with the only protein being a small carton of milk. The resident expressed dissatisfaction with the food, describing it negatively. A review of the resident's electronic medical record showed they had diagnoses including congestive heart failure and type 2 diabetes, with moderately impaired cognition. Notes from a Food Council Meeting indicated widespread dissatisfaction with the food, describing it as unseasoned, soggy, and cold. Further observations included a food cart with trays lacking plate warmers and open doors while meals were being served. A temperature test of a meal showed the food was below the preferred temperature, with items missing from the plate. The Dietary Manager confirmed the preferred temperature should be 100 degrees Fahrenheit or above. A test tray revealed a pork chop at 107 degrees Fahrenheit, which was lukewarm and fatty. The facility's policy on food palatability and temperature was reviewed, indicating that food should be palatable, attractive, and served at appetizing temperatures.
Ineffective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program by not eliminating harborage conditions in the kitchen, which has the potential to affect all residents. During an observation, standing, stagnant, slimy water was found on the floor underneath the garbage grinder at the three-compartment sink, accompanied by cobwebs and numerous gnats. The Dietary Manager (DM) stated that the pipe for the garbage grinder was small and sometimes overflowed but did not explain why the standing water was not cleaned up to prevent a breeding ground for gnats. Additionally, standing water was observed between the coffee maker and the juice dispenser, with gnats flying in the area, and the DM was unsure of the water's source. Pest control service reports from previous dates noted the presence of gnats, indicating ongoing issues with pest control.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for four residents, leading to a deficiency in medication storage and administration. Resident 71 was observed with an inhaler on their bedside table on multiple occasions, without an assessment for self-administration of medications. The resident, who was moderately cognitively impaired, confirmed using the inhaler but there was no documentation supporting their ability to self-administer. Resident 63 was found with a medication cup containing pills on their bedside table, which they ingested upon inquiry, stating they were from the previous night. The resident was cognitively intact, yet there was no indication of an assessment or order for self-administration. A Licensed Practical Nurse (LPN) confirmed that the medications were not administered by them and identified the pills as Gabapentin and Buspar. Residents 22 and 44 were also observed with medications at their bedsides without proper authorization. Resident 22 had an albuterol inhaler on the dresser, and Resident 44 had nasal sprays, including a discontinued medication. Both residents did not have physician orders or assessments for self-administration. The facility's policy requires an interdisciplinary team assessment and a physician's order for residents to self-administer medications, which was not followed in these cases.
Failure to Honor Resident's Request for Hospital Transfer
Penalty
Summary
The facility failed to honor a resident's request for a higher level of care, specifically a transfer to the hospital, which is a violation of the resident's right to self-determination. The resident, identified as R33, reported experiencing severe pain due to a suspected kidney stone and requested to be transferred to the hospital. Despite this request, the resident was informed that the physician did not order a transfer and that they would need to sign out Against Medical Advice (AMA) and be responsible for the transportation costs if they chose to leave. This left the resident in excruciating pain without the desired medical intervention. The resident's medical record indicated a history of kidney stones, chronic kidney disease, and acute pyelonephritis, which substantiates their concern for needing hospital care. The nursing staff documented the resident's request and pain but did not facilitate the transfer. Interviews with the nursing staff and the Director of Nursing revealed a lack of communication and misunderstanding regarding the resident's rights to self-determination and hospital transfer. The facility's policy on resident rights supports the resident's ability to make significant choices about their care, which was not upheld in this instance.
Failure to Provide Assistive Communication Device
Penalty
Summary
The facility failed to provide an assistive communication device for a resident, resulting in limited communication between the resident and staff. The resident, who was admitted with diagnoses including a cerebral infarction and type 2 diabetes, was observed to have severely impaired cognition and was dependent on staff for all activities of daily living except eating. During observations and interviews, it was noted that the resident communicated primarily through gestures, such as giving a thumbs up, and did not have a communication board available, despite the facility's policy to provide such devices to non-verbal residents. Interviews with staff, including a CNA and an LPN, revealed that they were unaware of any communication board being used by the resident. The Rehabilitation Director initially stated that the resident had a communication board by their bed, but subsequent observations did not confirm its presence. The facility's administrator acknowledged the expectation for providing communication boards to non-verbal residents and indicated that alternative communication methods should be explored if a board is not usable. The lack of a communication board was not addressed in the resident's care plan, contributing to the deficiency.
Failure to Address Resident's Broken Glasses
Penalty
Summary
The facility failed to address the issue of broken glasses for a resident, identified as R109, who was observed wearing glasses missing a section of the frame and the entire lens on the right side. The left lens was dirty and smeared with a greasy substance. R109 reported that the glasses had been broken for quite some time and that the facility had not assisted in obtaining new ones. Despite being seen by an eye doctor in August, the issue was not resolved, and the resident was told to get their own glasses. The resident's medical record indicated a diagnosis of sequelae of cerebral infarction and ataxia, with a care plan noting impaired visual function and the need for assistance with visual devices. Interviews with facility staff revealed a lack of awareness and action regarding the resident's broken glasses. The Unit Manager was unaware of the issue until informed and stated that social work would be notified. The Social Worker confirmed they had contacted the eye doctor but were awaiting a response. The Director of Nursing acknowledged that the situation was emergent and should have been addressed immediately, with optometry fixing or replacing the glasses during the resident's last visit. The facility's policy on appointments indicated that emergency services should be contacted immediately, but this was not followed in R109's case.
Failure to Obtain Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician order for oxygen for a resident, identified as R76, who was observed multiple times wearing oxygen at four liters per minute via nasal cannula. R76 was admitted with diagnoses including cerebral infarction, chronic obstructive pulmonary disease (COPD), and acute respiratory failure with hypoxia. Despite these conditions, a review of R76's medical records revealed no physician order for oxygen, although the care plan indicated oxygen settings of 2-3 liters via nasal cannula. Interviews with facility staff, including an LPN, the Unit Manager, the Director of Nursing, and the Nursing Home Administrator, confirmed the absence of a physician order for oxygen. The staff acknowledged that a physician order is required for residents on oxygen. The facility's policy on oxygen administration also stipulates that oxygen should be administered per physician orders and facility protocol, which was not adhered to in this case.
Failure to Follow Medication Administration Standards
Penalty
Summary
The facility failed to adhere to professional standards of practice for medication administration when an LPN crushed an extended-release medication for a resident without a physician's order. The incident involved a resident with a history of paraplegia, schizophrenia, and seizure disorder, who was dependent on self-care and had moderate cognitive impairment. The resident requested their medications to be crushed, and the LPN complied without verifying the physician's orders, which did not include instructions to crush the medications. During the medication administration, the LPN crushed several medications, including Duloxetine, which is a delayed-release medication that should not be crushed. The facility's Director of Nursing (DON) was informed of the incident after the medications were administered. Upon review, it was confirmed that Duloxetine should not have been crushed as it is designed to release the active ingredient after ingestion. The facility's policy requires medications to be administered according to the physician's written orders, which was not followed in this case. The DON contacted the facility pharmacist to verify if any of the medications were on the 'DO NOT CRUSH' list. Although the pharmacist initially reported that none of the medications were on the list, further review of the drug manufacturer's literature confirmed that Duloxetine should not be crushed. The facility's failure to follow proper medication administration procedures led to the inappropriate alteration of a resident's medication without a physician's directive.
Failure to Maintain Splinting Program for Resident
Penalty
Summary
The facility failed to maintain a splinting program for a resident, identified as R68, who was observed not using a prescribed hand splint. The splint was repeatedly seen laying on the heat register in the resident's room over several days. R68, who has a history of cerebral infarction with left hemiplegia and muscle wasting, reported that the splint was for their left hand but stated it was never put on anymore. The resident expressed occasional pain in the left hand and acknowledged that the splint should probably be used. Despite the resident's condition and the previous recommendation for a splint to prevent further contracture and pain, there was no recent occupational therapy evaluation or documentation supporting the discontinuation of the current splint. Interviews with staff, including CNAs and the Director of Rehab (DOR), revealed a lack of awareness and documentation regarding the use of the splint. The DOR mentioned that a new splint was ordered but delayed due to the resident's payor source and authorization process. However, no documentation was provided to indicate that the current splint was contraindicated or deemed inappropriate. The facility's policy on splints and orthotics was requested but not provided by the conclusion of the survey, and there was no clear documentation expectation from the facility's administration regarding the discontinuation of the splint.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Warren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Woods Residential Health | 0.4 mi | — | 2 | 0 |
| Windemere Park Health And Rehabilitation Center | 2 mi | — | 2 | 0 |
| Father Murray, A Villa Center | 2.1 mi | — | 5 | 0 |
| Harmony Village Of Warren | 2.1 mi | — | 0 | 0 |
| The Villa At City Center | 2.1 mi | — | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.