The Vardell Report.Orchard Hill Rehabilitation and Healthcare Center

Across 6 inspections from June 2021 to April 2026, state surveyors documented 99 findings at Orchard Hill Rehabilitation and Healthcare Center; 99 have a recorded correction; CMS lists 2 enforcement actions in the window.

Inspections

6

2021–2026, standard and complaint

Findings

99

Deficiencies cited by state inspectors

Corrected

99

Of 99 findings, with a recorded correction date

Penalties

2

2 fines; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Apr 232026

   Standard health inspection

   18 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Mar 6, 2026
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Jun 25, 2026
   • F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Jun 25, 2026
   • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Jun 25, 2026
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 25, 2026
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Jun 25, 2026
   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Jun 25, 2026
   • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Jun 25, 2026
   • F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level DNo actual harm, potential for moreCorrected Jun 25, 2026
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jun 25, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jun 25, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jun 25, 2026
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jun 25, 2026
   • F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Level DNo actual harm, potential for moreCorrected Jun 25, 2026
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Jun 25, 2026
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Jun 25, 2026
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jun 25, 2026
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level DNo actual harm, potential for moreCorrected Jun 25, 2026

   Enforcement Action

   Civil money penalty, $22,225 imposed April 23, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of April 23, 2026, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Jan 212026

   Complaint investigation

   4 findings

   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Feb 19, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Feb 19, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Feb 19, 2026
   • F840Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.Level DNo actual harm, potential for moreCorrected Feb 19, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Oct 172025

   Complaint investigation

   12 findings

   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Dec 22, 2025
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Dec 22, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Dec 22, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Dec 22, 2025
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Dec 22, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Dec 22, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Dec 22, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 22, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Dec 22, 2025
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Dec 22, 2025
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Dec 22, 2025
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Dec 22, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Mar 182025

   Standard health inspection

   19 findings

   The same visit included a complaint investigation.

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Apr 28, 2025
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Apr 28, 2025
   • F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Apr 28, 2025
   • F578Honor 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.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F584Honor 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.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F732Post nurse staffing information every day.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F790Provide routine and 24-hour emergency dental care for each resident.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F840Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F881Implement a program that monitors antibiotic use.Level DNo actual harm, potential for moreCorrected Apr 28, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Oct 222024

   Complaint investigation

   14 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Nov 13, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jan 13, 2025
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Nov 30, 2024
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Nov 30, 2024
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Nov 30, 2024
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Nov 30, 2024
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jan 13, 2025
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Nov 30, 2024
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Nov 30, 2024
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Nov 30, 2024
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Nov 30, 2024
   • F840Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.Level DNo actual harm, potential for moreCorrected Nov 30, 2024
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Nov 30, 2024
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Nov 30, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Jun 302021

   Standard health inspection

   32 findings

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Aug 10, 2021
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level ENo actual harm, potential for moreCorrected Aug 10, 2021
   • F570Assure the security of all personal funds of residents deposited with the facility.Level ENo actual harm, potential for moreCorrected Aug 10, 2021
   • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level ENo actual harm, potential for moreCorrected Aug 10, 2021
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Aug 10, 2021
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Aug 10, 2021
   • F692Provide enough food/fluids to maintain a resident's health.Level ENo actual harm, potential for moreCorrected Aug 10, 2021
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level ENo actual harm, potential for moreCorrected Aug 10, 2021
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Aug 10, 2021
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Aug 10, 2021
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F584Honor 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.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F624Prepare residents for a safe transfer or discharge from the nursing home.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Aug 10, 2021
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Aug 10, 2021

   Enforcement Action

   Civil money penalty, $50,122 imposed October 22, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 30, 2021, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Telling Families About Changes, Cited in Four Inspections

   Inspectors cited F580 in June 2021, October 2024, March 2025 and October 2025. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212425252626F580 across all 6 inspections, oldest to newest
2. 2

   Accurate Assessments, Cited in Four Inspections

   Inspectors cited F641 in June 2021, October 2024, October 2025 and April 2026. This citation covers whether each resident’s assessment correctly records their condition. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212425252626F641 across all 6 inspections, oldest to newest
3. 3

   Care Plan Timing and Review, Cited in Four Inspections

   Inspectors cited F657 in June 2021, October 2024, March 2025 and April 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212425252626F657 across all 6 inspections, oldest to newest
4. 4

   Quality of Care, Cited in Four Inspections

   Inspectors cited F684 in June 2021, October 2024, March 2025 and October 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212425252626F684 across all 6 inspections, oldest to newest
5. 5

   Pressure Injury Care, Cited in Four Inspections

   Inspectors cited F686 in June 2021, October 2024, October 2025 and April 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212425252626F686 across all 6 inspections, oldest to newest
6. 6

   Accident Hazards and Supervision, Cited in Four Inspections

   Inspectors cited F689 in June 2021, October 2024, March 2025 and April 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212425252626F689 across all 6 inspections, oldest to newest
7. 7

   Medical Records, Cited in Four Inspections

   Inspectors cited F842 in June 2021, October 2024, October 2025 and April 2026. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212425252626F842 across all 6 inspections, oldest to newest
8. 8

   Reporting Suspected Abuse, Cited in Three Inspections

   Inspectors cited F609 in June 2021, October 2024 and October 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212425252626F609 across all 6 inspections, oldest to newest
9. 9

   Help With Daily Living, Cited in Three Inspections

   Inspectors cited F677 in June 2021, October 2025 and January 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212425252626F677 across all 6 inspections, oldest to newest
10. 10

    Nutrition and Hydration, Cited in Three Inspections

    Inspectors cited F692 in June 2021, March 2025 and April 2026. This citation covers whether residents get enough food and fluids to stay healthy. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212425252626F692 across all 6 inspections, oldest to newest
11. 11

    Post nurse staffing information every day, Cited in Three Inspections

    Inspectors cited F732 in June 2021, March 2025 and October 2025. The agency describes it this way: Post nurse staffing information every day. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212425252626F732 across all 6 inspections, oldest to newest
12. 12

    Citation F757, Cited in Three Inspections

    Inspectors cited F757 in June 2021, October 2024 and April 2026. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212425252626F757 across all 6 inspections, oldest to newest
13. 13

    Medication Labeling and Storage, Cited in Three Inspections

    Inspectors cited F761 in March 2025, October 2025 and April 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212425252626F761 across all 6 inspections, oldest to newest
14. 14

    Citation F840, Cited in Three Inspections

    Inspectors cited F840 in October 2024, March 2025 and January 2026. The agency describes it this way: Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212425252626F840 across all 6 inspections, oldest to newest
15. 15

    A Clean, Homelike Setting, Cited in Two Inspections

    Inspectors cited F584 in June 2021 and March 2025. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212425252626F584 across all 6 inspections, oldest to newest
16. 16

    Investigating Alleged Violations, Cited in Two Inspections

    Inspectors cited F610 in October 2024 and January 2026. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212425252626F610 across all 6 inspections, oldest to newest
17. 17

    Citation F637, Cited in Two Inspections

    Inspectors cited F637 in March 2025 and April 2026. The agency describes it this way: Assess the resident when there is a significant change in condition. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212425252626F637 across all 6 inspections, oldest to newest
18. 18

    Care Plans, Cited in Two Inspections

    Inspectors cited F656 in June 2021 and April 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212425252626F656 across all 6 inspections, oldest to newest
19. 19

    Professional Standards, Cited in Two Inspections

    Inspectors cited F658 in June 2021 and October 2025. This citation covers whether the home’s services meet professional standards of quality. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212425252626F658 across all 6 inspections, oldest to newest
20. 20

    Respiratory Care, Cited in Two Inspections

    Inspectors cited F695 in October 2024 and January 2026. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212425252626F695 across all 6 inspections, oldest to newest
21. 21

    Nursing Staff Levels, Cited in Two Inspections

    Inspectors cited F725 in June 2021 and October 2025. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212425252626F725 across all 6 inspections, oldest to newest
22. 22

    Citation F756, Cited in Two Inspections

    Inspectors cited F756 in June 2021 and April 2026. The agency describes it this way: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212425252626F756 across all 6 inspections, oldest to newest
23. 23

    Kitchen and Food Safety, Cited in Two Inspections

    Inspectors cited F812 in June 2021 and March 2025. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212425252626F812 across all 6 inspections, oldest to newest
24. 24

    Infection Control, Cited in Two Inspections

    Inspectors cited F880 in June 2021 and April 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212425252626F880 across all 6 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How quickly will we hear about a fall, an injury or a change in condition, and from whom?

   Telling Families About Changes: cited in four inspections, most seriously at level D.

2. 02

   Who completes resident assessments, and how are they checked for accuracy?

   Accurate Assessments: cited in four inspections, most seriously at level D.

3. 03

   How often are care plans revised, and who takes part in the review?

   Care Plan Timing and Review: cited in four inspections, most seriously at level E.

4. 04

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in four inspections, most seriously at level E.

5. 05

   How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

   Pressure Injury Care: cited in four inspections, most seriously at level D.

6. 06

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in four inspections, most seriously at level G.

7. 07

   How can a family request a resident’s records, and how are they kept accurate?

   Medical Records: cited in four inspections, most seriously at level E.

8. 08

   How are staff trained to report suspected abuse or neglect, and who reports it to the state?

   Reporting Suspected Abuse: cited in three inspections, most seriously at level D.

9. 09

   How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

   Help With Daily Living: cited in three inspections, most seriously at level D.

10. 10

    How are weight and fluid intake tracked, and what happens when a resident starts losing weight?

    Nutrition and Hydration: cited in three inspections, most seriously at level E.

11. 11

    What changed after F732 was cited, and how do you check it now?

    Post nurse staffing information every day: cited in three inspections, most seriously at level D.

12. 12

    What changed after F757 was cited, and how do you check it now?

    Citation F757: cited in three inspections, most seriously at level D.

13. 13

    How are medications stored and secured, and who checks the medication carts?

    Medication Labeling and Storage: cited in three inspections, most seriously at level E.

14. 14

    What changed after F840 was cited, and how do you check it now?

    Citation F840: cited in three inspections, most seriously at level D.

15. 15

    What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

    A Clean, Homelike Setting: cited in two inspections, most seriously at level D.

16. 16

    When an allegation is made, who investigates it, and how are residents protected in the meantime?

    Investigating Alleged Violations: cited in two inspections, most seriously at level D.

17. 17

    What changed after F637 was cited, and how do you check it now?

    Citation F637: cited in two inspections, most seriously at level D.

18. 18

    How is a care plan written and reviewed here, and how do families take part in it?

    Care Plans: cited in two inspections, most seriously at level D.

19. 19

    How do you check that nurses and aides follow professional standards, and what happens when they do not?

    Professional Standards: cited in two inspections, most seriously at level D.

20. 20

    Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

    Respiratory Care: cited in two inspections, most seriously at level D.

21. 21

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Nursing Staff Levels: cited in two inspections, most seriously at level E.

22. 22

    What changed after F756 was cited, and how do you check it now?

    Citation F756: cited in two inspections, most seriously at level E.

23. 23

    May we see the kitchen, and what do your own sanitation checks look like week to week?

    Kitchen and Food Safety: cited in two inspections, most seriously at level F.

24. 24

    Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

    Infection Control: cited in two inspections, most seriously at level E.

25. 25

    What led to the 2026 fine, and has it been paid?

    A $22,225 civil money penalty was imposed April 23, 2026. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Maryland state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Jun 30, 2021 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Oct 22, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Mar 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Oct 17, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Jan 21, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Apr 23, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 215069

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.