Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ORCHARD MANOR
LANCASTER, WI · 74 certified beds · Last Life Safety survey December 16, 2025
CMS Certification Number 525290 · first certified July 1978
Ownership
Independently operated (no chain recorded by CMS) · Government - County
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WI
19 citations — more than 54% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 9 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens January 2027 — about 4 months from now. This facility’s last Life Safety survey was December 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 19 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 19 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 17, 2023 | 4 |
| August 15, 2024 | 6 |
| December 16, 2025 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2025-12-16 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2025-12-16 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-08-15 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2025-12-16 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-12-16 |
| K-0912 | Have power receptacles that are properly grounded. | 1 | 2025-12-16 |
| K-0331 | Construct fire resistant interior walls. | 1 | 2025-12-16 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-12-16 |
What the citations cover
- Smoke Deficiencies 11
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Egress Deficiencies 2
- Miscellaneous Deficiencies 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Egress Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 16, 2025 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (January 23, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 23, 2026) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (January 23, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 23, 2026) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (January 23, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (January 23, 2026) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (January 23, 2026) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (January 23, 2026) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (January 23, 2026) |
August 15, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (September 12, 2024) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (September 12, 2024) |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Deficient, Provider has date of correction (September 12, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (September 12, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 12, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 12, 2024) |
May 17, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (June 16, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (July 10, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 16, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 16, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.