Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before 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 Orwigsburg Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple sclerosis, who had declined consent for photography, had personal care items photographed by a nurse aide. The photograph was then shown to another aide, despite facility policy prohibiting such actions and the resident's explicit refusal of consent.
Staff did not consistently follow physician orders for medication administration and oxygen therapy for four residents. This included administering blood pressure medications outside of ordered parameters and failing to provide ordered oxygen therapy to a resident with chronic respiratory failure.
A resident with diagnoses of anxiety, depression, and atrial fibrillation was inaccurately documented as having a tracheostomy on the MDS assessment, despite no supporting clinical record or care plan. The Administrator confirmed the inaccuracy during staff interview.
Two residents with histories of substance abuse and other medical conditions were able to obtain and use methamphetamine within the facility, with one resident selling the substance to another. Staff failed to ensure all areas were searched for additional hazards, resulting in an Immediate Jeopardy situation.
The facility failed to provide adequate grooming and personal hygiene for several residents, who were observed with long, jagged fingernails despite needing assistance with ADLs. Residents expressed dissatisfaction with the lack of nail care, and a group interview confirmed that routine nail care was not consistently provided. The DON stated that nail care should occur during showers, but this was not being followed.
The facility failed to assess and implement scheduled toileting programs for two residents, despite indications from Bowel and Bladder Program Screeners that they were candidates for such programs. Both residents required assistance for toileting and were frequently incontinent, yet there was no documented evidence of a toileting program being implemented, as confirmed by the DON.
A facility failed to offer non-pharmacological interventions before administering PRN anti-anxiety medication to a resident with schizophrenia and anxiety. The resident received alprazolam 30 times over two months without documented attempts of alternative interventions. The DON confirmed the lack of documentation.
A resident with diabetes and congestive heart failure, who was alert and able to communicate, had a care plan to honor his food preferences due to nutritional risk. However, he frequently received disliked items on his meal trays. During an observation, rice was served despite being listed as a disliked food, and the resident confirmed he would not eat it.
A resident with dysphagia and aphasia was not provided with the prescribed adaptive equipment, such as a two-handled cup, during meals. Despite a physician's order and occupational therapy recommendations, the resident was observed without the necessary equipment on multiple occasions. A nurse confirmed the oversight, highlighting a failure to comply with care directives.
A facility failed to follow its transmission-based precautions policy for a resident with MRSA. Despite a posted sign requiring gowns and gloves, a nurse aide and a visitor were observed in the resident's room without gowns. The Infection Preventionist confirmed the policy breach.
Unauthorized Photography Violates Resident Privacy
Penalty
Summary
The facility failed to protect a resident's right to privacy and confidentiality by allowing unauthorized photography of personal care items. According to facility policy, resident privacy and security must be maintained, and clinical records showed that the resident, who had multiple sclerosis and no cognitive impairment, had explicitly declined authorization for any images to be taken or used. Despite this, documentation revealed that a nurse aide took a photograph of the resident's waste products and showed it to another nurse aide, who confirmed that similar photographs had been shown in the past. The Nursing Home Administrator acknowledged that this action was against facility policy.
Failure to Follow Physician Orders for Medications and Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders for four residents with significant medical conditions. For one resident with chronic kidney failure, congestive heart failure, and diabetes, staff administered isosorbide mononitrate on multiple occasions when the resident's systolic blood pressure (SBP) was below the physician-ordered threshold of 115 mmHg. Similarly, another resident with hypertension received losartan potassium three times when their SBP was below the ordered hold parameter of 110 mmHg, and a third resident with hypertension was given metoprolol tartrate six times when their SBP was also below 110 mmHg, contrary to physician instructions. These actions were confirmed through medication administration record reviews and staff interviews. Additionally, a resident with partial paralysis following a stroke and chronic respiratory failure with hypoxia was observed without the ordered oxygen therapy. The resident was found in a hallway with an empty oxygen tank and no nasal cannula, despite a physician's order for continuous oxygen administration at two liters per minute. Staff confirmed that the oxygen was not administered as ordered. These findings demonstrate that the facility did not consistently implement physician orders for medication and oxygen therapy for multiple residents.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one of 25 sampled residents. Clinical record review showed that the resident had diagnoses of anxiety, depression, and atrial fibrillation. However, the MDS assessment incorrectly indicated that the resident had a tracheostomy, despite no supporting physician's orders or care plan documentation in the clinical record. During an interview, the Administrator confirmed that the MDS was inaccurate and that the resident did not have a tracheostomy. This deficiency was identified through clinical record review and staff interview, which revealed a discrepancy between the resident's documented medical conditions and the information recorded on the MDS assessment.
Failure to Prevent Resident Access to Illegal Substances Creates Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards by not preventing access to illegal substances for two residents. One resident, with a history of alcoholic cirrhosis, major depressive disorder, and diabetes, and another resident, with chronic pain, alcohol abuse, and psychoactive substance abuse, were both able to obtain and use methamphetamine within the facility. The first resident was identified as the source of the substance, selling it to the second resident, who then kept it in his room. Both residents were independently ambulatory, and one had mild cognitive impairment while the other had no cognitive impairment. The presence and use of methamphetamine were confirmed through interviews, clinical record review, and drug testing. The facility's failure extended beyond these two residents, as staff only searched the unit and common areas where the incident was discovered, neglecting to search other resident areas and common spaces on another nursing unit and the first floor. This incomplete response left other areas potentially unsafe and did not ensure that all residents were protected from similar hazards. The deficiency was identified through clinical record review, facility documentation, and interviews with residents and staff, resulting in an Immediate Jeopardy situation.
Failure to Provide Adequate Grooming and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate grooming and personal hygiene services for four residents, as observed and documented by surveyors. Resident 17, who had diabetes and a history of respiratory disease, became more dependent on staff for activities of daily living (ADLs) after a hospital stay. Despite this increased need, she was observed with long and jagged nails on multiple occasions, and she reported that staff had not assisted her with nail care. Similarly, Resident 31, who required substantial assistance for ADLs due to diabetes and hypertension, was observed with long, yellow, and jagged fingernails over several days, expressing a preference for short nails and a need for assistance. Resident 68, diagnosed with macular degeneration and anxiety, also required substantial assistance for ADLs and was observed with long, yellow, jagged fingernails with debris underneath. He expressed frustration over the lack of assistance with nail care. Resident 87, who had a history of stroke and osteoarthritis, was dependent on staff for personal hygiene and was observed with long, jagged fingernails, stating he could not cut them himself. A group interview with other residents revealed that routine nail care was not consistently provided as part of ADL assistance. The Director of Nursing indicated that nail care should be performed during residents' showers, but this was not being adequately implemented.
Failure to Implement Scheduled Toileting Programs
Penalty
Summary
The facility failed to assess bladder incontinence and provide services to restore bladder function for two residents. According to the facility's policy on urinary continence and incontinence, staff were required to complete a urinary incontinence assessment periodically and when there was a change in voiding. However, for one resident with diagnoses including anxiety and hemiplegia, the clinical record review showed that although a Bowel and Bladder Program Screener indicated the resident was a candidate for a scheduled toileting program, there was no documented evidence that such a program was implemented. The resident's type of urinary incontinence was not identified, and the Minimum Data Set (MDS) assessment indicated the resident was incontinent of urine and required staff assistance for toileting. Similarly, another resident with diabetes mellitus was identified as a candidate for a scheduled toileting program through multiple Bowel and Bladder Program Screeners. Despite this, the resident was frequently incontinent of urine and not on a toileting program, as confirmed by the MDS assessment. The type of urinary incontinence was not identified, and there was no documentation of a scheduled toileting program being implemented. The Director of Nursing confirmed the lack of documented evidence for the assessment and implementation of toileting programs for these residents.
Failure to Implement Non-Pharmacological Interventions Before PRN Medication
Penalty
Summary
The facility failed to offer non-pharmacological interventions before administering as-needed anti-anxiety medication to one resident. The clinical record review showed that the resident, who had diagnoses of schizophrenia and anxiety, was prescribed alprazolam to be given every eight hours as needed over a period of 14 days. During June and July 2024, the medication was administered 30 times without documented evidence of attempts to use non-pharmacological interventions first. In an interview, the Director of Nursing confirmed the absence of documentation regarding non-pharmacological interventions prior to the administration of the anti-anxiety medication. This deficiency was identified during a survey, as per the requirements of 28 Pa. code 211.12(d)(1)(5) Nursing services.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preferences, as evidenced by the case of a resident with diabetes mellitus and congestive heart failure. The resident was alert and able to communicate his needs, as indicated in a Minimum Data Set assessment. His care plan included an intervention to honor his food preferences due to his potential nutritional risk. However, on July 23, 2024, the resident reported frequently receiving disliked items on his meal trays. During an observation of his lunch tray, rice was served as a side dish, despite being listed as a disliked food on his meal ticket. The resident confirmed he did not want the rice and would not eat it.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive equipment to assist with eating meals for one of the residents. Resident 1, who had diagnoses of dysphagia and aphasia, was ordered by a physician on March 19, 2024, to be provided with a two-handled cup at all meals. An occupational therapy note dated July 17, 2024, recommended the continued use of a two-handled mug or a regular mug/cup with a lid and straw to aid the resident's independence. However, observations on July 23 and July 25, 2024, revealed that the resident was in the dining room without the prescribed adaptive equipment for her beverages. In an interview on July 26, 2024, a registered nurse confirmed that the resident should have received her drink in a two-handled cup at all meals, indicating a failure to comply with the physician's order and occupational therapy recommendations.
Failure to Follow Transmission-Based Precautions
Penalty
Summary
The facility failed to adhere to its policy on transmission-based precautions (TBP) and the use of personal protective equipment (PPE) for one resident. The policy, last reviewed on January 16, 2024, required additional measures to protect staff, visitors, and other residents from infections when a resident was diagnosed with specific pathogens. Resident 47, who was admitted with diagnoses including dementia, pneumonia, and methicillin-resistant Staphylococcus aureus (MRSA) in the sputum, was ordered by a physician on May 13, 2024, to be on TBP. On July 24, 2024, a sign was posted outside the resident's room indicating the need for TBP, including the use of gowns and gloves. However, observations revealed that a nurse aide provided care without wearing a gown, and a visitor was also seen in the room without a gown. The Infection Preventionist confirmed that the policy was not followed, as all staff and visitors should have worn appropriate protective equipment.
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orwigsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seton Manor Nursing And Rehabilitation Center | 0.9 mi | — | 6 | 0 |
| Rosewood Rehabilitation And Nursing Center | 3.5 mi | — | 1 | 0 |
| Edenbrook Of Greenwood Hill | 4.9 mi | — | 1 | 0 |
| Schuylkill Center | 5 mi | — | 4 | 0 |
| Gardens At York Terrace, The | 6.8 mi | — | 0 | 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.