Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
0E
2F
Potential for minimal harm
0A
0B
0C
March 8, 2026Standard inspection · 8 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Food Service Policy and Procedure, the facility failed to ensure opened food items in the dry storage were properly stored, food items were properly labeled, dated, and discarded by expiration date, and failed to remove food items containing a gray thick fuzzy substance in the refrigerators for four of six kitchens (Main Kitchen, Rehabilitation Kitchen, Meadows Terrace Kitchen, and Garden View Kitchen). The facility also failed to ensure the filters were free from thick gray fuzzy substance for two of two ice machines in the Main Kitchen. Also, the facility failed to ensure staff members' personal belongings were not stored in the residents' dry storage, refrigerators and freezers for four of six kitchens (Rehabilitation Kitchen, Meadows Terrace Kitchen, Grove Terrace Kitchen, and Garden View Kitchen). [...]
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations and staff interview, the facility failed to ensure perishable waste was disposed properly and free from a leak to prevent infestation or spread of infection for one of two garbage dumpsters. This failure had the potential to affect all 154 facility residents.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled, Self-administered medications, treatments, the facility failed to ensure medications were not left at the bedside of three of 51 sampled residents (R) (R7, R124, and R57) who were not assessed for medication self-administration. This deficient practice had the potential to place R7, R124, and R57 at risk for the unsafe use of medications and for other residents, staff and visitors to have access to medication.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Psychotropic Medications, the facility failed to ensure a stop date was implemented, not to exceed 14 days, for psychotropic medications for one of 51 sampled residents (R) (R58).
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a comprehensive person-centered care plan was developed for two of 51 sampled residents (R) (R9 and R8). This deficient practice had the potential to place R9 and R8 at risk of not receiving care and services in accordance with their needs.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, resident and staff interviews, record review, and the facility policy titled, Storage and Replacement of Oxygen Equipment, the facility failed to ensure proper storage of oxygen equipment for one of 14 residents (R) (R124) reviewed with oxygen. This deficient practice had the potential to place the resident at risk for cross contamination and negatively impact the resident's quality of life. Review of the facility policy titled Storage and Replacement of Oxygen Equipment, documented under Policy: It is the policy of Orchard View to assure proper storage and replacement of oxygen equipment for those residents to whom oxygen therapy is prescribed by the physician. Under PROCEDURE: The procedure for accomplishing this includes, but is not limited to, the following. 2. [...]
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, staff interviews, and review of facility policy titled, Medication Storage in the Care Center, the facility failed to ensure that expired medications and /or biologicals were not available for resident use in one of five medication storage rooms and failed to ensure medications were secured on one of 9 medication carts on one of three medication carts reviewed.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policies titled, Infection Control Policy and Glucometer Disinfection, the facility failed to follow infection control procedures for one of 37 Rs (R154) receiving fingerstick glucose testing, to provide a safe and sanitary environment for one of 28 residents (R) (R2) receiving wound care, and one of nine Rs (R9) receiving catheter care. The deficient practices had the potential to increase the risk of infection transmission among residents and staff.
June 8, 2025Standard inspection, Complaint inspection · 2 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Assessment and Nursing Care Screening the facility failed to complete an accurate Minimum Data Set (MDS) assessment that indicated the use of an alarm for two of 15 residents (R) (R2) and (R108). This deficient practice had the potential to lead to several negative impacts on the residents physical and psychological well-being.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled [Name of Organization] Policy: Restraint Use, the facility failed to ensure two of 15 residents (R) (R2 and R108) had a physician order for restraint use.
February 15, 2024Standard inspection · 3 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Abuse Prevention, Intervention, Investigation, and Reporting, the facility failed to ensure an injury of unknown origin was reported to the proper authorities immediately, but no later than two hours for one Resident (R) 31. The sample size was 24.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on staff interviews, record review and review of the facility's policy titled, Abuse Prevention, Intervention, Investigation, and Reporting, the facility failed to investigate an allegation of injury of unknown origin for one Resident (R) (R31). This failure not to conduct an investigation had the potential to result in other residents not being identified as potential victims of injury of unknown origin. The sample size was 24. Findings Include: Review of the facility's policy titled, Abuse Prevention, Intervention, Investigation, and Reporting dated 2/15/2014 under the section titled, Investigation revealed, 1. Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, an investigation ensues. 3. Information gathering- The following information will be gathered: [...]
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Medication Storage in the Care Center, the facility failed to store medications in a locked compartment when unattended for one of five treatment carts. The facility census was 128.
Fire safety inspections
8 fire safety citations on file: 6 on March 8, 2026, 2 on February 15, 2024.
Every fire safety citation8 citations
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · March 8, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 8, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 8, 2026 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · March 8, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 8, 2026 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of highly flammable decorations.
K 753 · March 8, 2026 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · February 15, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 15, 2024 · Corrected (the home has a date of correction)