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 21 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
9E
1F
Potential for minimal harm
0A
0B
0C
April 30, 2026Standard inspection · 5 citations
- E
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 a review of facility policy, observations, and staff interviews, it was determined that the facility failed to make sure that medical supplies and medications were properly stored and/or disposed of in one of two medication rooms (A/B Nursing Unit Medication Room).
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined the facility failed to make certain a resident had an updated, person-centered care plan individualized to each specific resident's needs for three of eight residents (Resident R12, R23, R99).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policy, clinical records, observations, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for two of eight sampled residents (Residents R53, and R133).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of five residents reviewed (Residents R56).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of policies and clinical records, as well as observations, it was determined that the facility failed to ensure that proper infection control practices were followed while providing medications to three of 32 residents reviewed (Resident R26, R31, and R119).
March 11, 2026Complaint inspection · 2 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on review of facility policy, facility records, resident and staff interviews, it was determined that the facility failed to make certain call lights were accessible and answered timely for six of thirteen residents as required (Resident R1, R2, R3, R4, R5, and R6).
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on facility policy, observation, and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for three of thirteen residents (Resident R1, R5 and R7).
January 15, 2026Complaint inspection · 2 citations
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents are free of significant medication errors for two of five residents reviewed (Residents R2 and R3).
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to notify the medical provider of a change in condition for one of four residents (Resident R1).
December 3, 2025Complaint inspection · 1 citation
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on review of facility policy, observation, and staff interviews it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of four medication carts (orchards unit).
September 3, 2025Complaint inspection · 1 citation
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on review of facility documents and resident interviews and observations, it was determined that the facility failed to ensure sufficient staffing to meet resident need for nine of thirteen residents (Resident R1. R2, R3, R4, R5, R6, R7, R8, and R9).
May 30, 2025Standard inspection, Complaint inspection · 2 citations
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on review of clinical record and staff interviews, it was determined that the facility failed to inform a resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for one of three residents (Resident R43).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of facility policies, clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of four residents (Resident R69) A review of the facility policy Administration Procedures For All Medications dated 4/1/25, indicated medications will be administered in a safe and effective manner and after administration document in the MAR (medication administration record) or TAR (treatment administration record) as necessary. A review of the clinical record indicated that Resident R69 was admitted to the facility on [DATE], with diagnoses that included heart disease, dementia, and asthma. A review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/13/25, indicated the diagnoses remained current. [...]
February 6, 2025Complaint inspection · 2 citations
- F
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on a review of facility policies, documents, observations and staff interviews it was determined that the facility failed to properly design, approve, and follow the Winter five week cycle menu and modifications of the cycle menu. (Winter menu Cycle weeks one, two, three, four and five).
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to maintain a homelike environment throughout the facility (resident rooms, dining room and hallways) as required. (resident rooms, dining room, and hallways)
June 7, 2024Standard inspection · 4 citations
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on review of resident group interview, Ombudsman interview, and observations it was determined that the facility failed to provide a private space for the resident group for ten of ten residents (GR100, GR101, GR102, GR103, GR104, GR105, GR106, GR107, GR108, and GR109).
- E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for four of five residents reviewed (Resident R23, R65, R84, and R87).
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for seven of 20 residents (Resident R9, R13, R17, R26, R36, R64, and R92).
- 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 review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications and medication supplies were properly stored and/or disposed of in one of two medication rooms (Orchards medication room).
May 19, 2024Complaint inspection · 1 citation
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observations and staff interview it was determined that the facility failed to maintain call light equipment for five of seven residents (Resident R1, R2, R3, R4, and R5).
April 2, 2024Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of five residents (Resident R1). This was identified as past non-compliance. Review of the facility policy Elopement of Resident dated 2/13/24, indicated residents will be evaluated for elopement risk upon admission, re-admission, quarterly, and with a change in condition as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce the risk and minimize injury. Review of the clinical record revealed Resident R1 was originally admitted to the facility on [DATE], and readmitted on [DATE]. [...]
Fire safety inspections
3 fire safety citations on file: 2 on May 30, 2025, 1 on June 7, 2024.
Every fire safety citation3 citations
- E
Provide properly protected cooking facilities.
K 324 · May 30, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 30, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · June 7, 2024 · Corrected (the home has a date of correction)