Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Orchard Park Health Care Center during CMS and state inspections, most recent first.
Medication storage and labeling were deficient in multiple med carts and med storage areas. Surveyors found opened ophthalmic drops, an opened insulin vial, and an opened lorazepam vial without date-opened labels, along with loose pills left in cart drawers without containers or labels. An LPN, RN, and DON stated nurses were responsible for cleaning carts, labeling opened meds, and removing dropped pills from drawers.
Improper Hot Food Holding During Meal Service: During dinner meal service, a cook checked steam table food and found pureed beef and hamburger patties at 127 degrees F, below the required hot holding temperature. The cooks then served the food without reheating it, and meal plates were assembled with the food still at the inappropriate temperature.
Inaccurate Bathing Documentation and Missing Refusal Notes: A resident with paraplegia, MS, and a colostomy was dependent on staff for bathing, but the care plan did not reflect her bathing preferences or refusals. Shower records showed repeated gaps on scheduled bed bath days, and the resident reported she was not consistently receiving her ordered baths. CNAs and the DON said refusals should be re-approached and documented, but the missing entries were not explained.
A resident with severe cognitive impairment and physical limitations was injured after using a complex bed controller unsafely, resulting in fractures to her left lower leg. Staff had previously observed unsafe use of the bed controller but the care plan did not address this risk, and the facility failed to implement effective interventions to prevent injury.
A resident with severe cognitive impairment sustained a fractured lower leg of unknown origin, requiring hospitalization and surgery. The facility's investigation was incomplete, with conflicting staff accounts, unclear timelines, and discrepancies between video surveillance and witness statements. Interviews with other residents were generic and did not address the specific incident, and language barriers further hindered clear communication during the investigation.
A resident with severe cognitive impairment experienced a lower leg fracture and was found in distress with swelling and pain. LPNs assessed the resident, administered pain medication, and arranged for a STAT X-ray, but did not notify the RN on duty or ensure an RN assessment was completed as required by professional standards and facility policy. The DON, who was off-site, did not instruct staff to involve the RN, and documentation showed no evidence of an RN assessment prior to the resident's transfer to the hospital.
The facility failed to serve food that was palatable, attractive, and at appropriate temperatures. Multiple residents reported issues such as missing items, cold food, and poor taste. Observations confirmed these complaints, and staff interviews acknowledged the deficiencies.
The facility failed to ensure that two residents received proper fingernail care and assistance with ADLs. One resident with dementia had long, chipped, and cracked fingernails despite receiving showers twice a week. Another resident with diabetes and reduced mobility did not receive showers or nail care, resulting in long, dirty fingernails and dry, flaky skin. Staff cited a lack of clarity and consistency in providing these services, as well as staff shortages.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in three of seven medication carts and two of three medication storage rooms. Surveyors found that opened ophthalmic solutions, including Artificial Tears and Pataday, were present without labels showing the date they were opened. An opened vial of Humalog insulin was also found without a date opened label in a medication cart. Surveyors additionally found loose medications in medication cart drawers. In one medication cart, seven loose pills were found at the bottom of the second drawer with no container or label identifying the pills. In another medication cart, one loose pill was found at the bottom of the second drawer, also without a container or label. In a third medication cart, eight loose pills were found at the bottom of the second drawer without identification. In the Columbine medication storage room, surveyors found one opened vial of lorazepam in the refrigerator without a label showing the date it was opened. Staff interviewed stated that nurses were responsible for cleaning medication carts, labeling medications with open dates, and picking up dropped medications from cart drawers. The DON stated that medications should be dated when opened to prevent administration of expired medications to residents.
Improper Hot Food Holding During Meal Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen by not ensuring hot food was held at the correct temperature. During a continuous observation of dinner meal service, the cook checked food on the steam table at 4:05 p.m. and recorded the pureed beef at 127 degrees F and the hamburger patties at 127 degrees F. These temperatures were below the required hot holding temperature referenced in the report, which stated hot food must be maintained at 135 degrees F or above except under specific cooling conditions. At 4:22 p.m., without reheating the food, the cooks began serving the hamburger patties, pureed beef, and banana pudding. The cook assembled meal plates with the hamburger patties and pureed beef while they were still at 127 degrees F. In interviews, the cooks and dietary manager stated that temperatures were checked during cooking, after cooking, and before meal service, and that food not held at an appropriate temperature should be discarded or replaced, but the observed meal service proceeded with the food at the lower temperature.
Inaccurate Bathing Documentation and Missing Care Plan Refusal Information
Penalty
Summary
The facility failed to maintain accurately documented medical records for Resident #13, a cognitively intact resident with paraplegia, multiple sclerosis, and a colostomy who was dependent on staff for bathing and other ADLs. The resident’s comprehensive care plan did not include documentation of bathing preferences or indicate that she sometimes refused bed baths, even though the shower schedule showed she was to receive bed baths three times per week. Record review of the resident’s shower sheets showed multiple instances where bed baths were documented as provided or refused, but several scheduled bathing dates had no documentation showing whether the resident was offered a bed bath or refused one. In February 2026, March 2026, and April 2026, there were repeated gaps in the shower records on scheduled bath days. The resident told surveyors she was not receiving her regularly scheduled bed baths, said she had only been bathed once or twice a week instead of three times, and stated she had refused care only on two occasions, including once when she was in pain and once when staff attempted to bathe her at midnight. Staff interviews confirmed that CNAs were expected to re-approach residents who refused showers and document refusals, and the unit manager stated Resident #13 was scheduled for bed baths on Tuesdays, Thursdays, and Saturdays. The unit manager and DON were unable to explain the missing documentation for the scheduled bed baths, and the additional documentation provided did not account for the dates with no record of whether the resident received or refused her bath.
Failure to Prevent Accident Hazard Related to Bed Controls for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with severe cognitive impairment, dementia, and significant physical limitations. The resident was dependent on two staff members for transfers and positioning, had poor safety awareness, and was unable to safely operate the bed controls. Despite staff being aware of the resident's unsafe use of the bed controller and concerns about potential injury, the facility did not identify or address the risk associated with the resident's inability to use the bed controls safely. On the day of the incident, the resident was found in distress, holding the bed controller, and reaching toward the bed, possibly attempting to self-transfer from her wheelchair. She was noted to have swelling and pain in her left lower leg, and a STAT X-ray revealed fractures of the tibia and fibula. The facility's investigation concluded that the likely cause of injury was the resident unknowingly lowering the bedframe onto her legs due to her confusion and inability to operate the bed controls appropriately. The care plan did not address the risk of injury related to the bed controls, despite the resident's known cognitive and physical limitations. Staff interviews confirmed that the resident had previously been observed using the bed controller unsafely, and some staff had even hidden the controller from her. The facility's policies required evaluation and implementation of safety interventions for residents at risk of falls or injury, but these were not updated to reflect the specific hazard posed by the bed controls. The manufacturer's manual for the bed also warned of increased risk for users with cognitive impairment, emphasizing the need for frequent monitoring, which was not adequately implemented in this case.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of an injury of unknown origin involving a resident who sustained a fractured tibia and fibula, requiring hospitalization and surgical intervention. The facility's policy required immediate reporting and thorough investigation of all injuries of unknown origin, but the investigation into this incident was incomplete and contained several discrepancies. The resident, who had severe cognitive impairment and required substantial assistance for transfers and activities of daily living, was found in her wheelchair complaining of leg pain, and was later diagnosed with significant fractures. The investigation relied on staff interviews and video surveillance, but the video did not capture the inside of the resident's room, and the timeline established by the facility was inconsistent with staff statements. Staff provided conflicting accounts regarding who assisted the resident into bed after the injury, and their descriptions of the incident changed after a reenactment conducted several days later. The facility did not clarify these discrepancies or document how the final conclusion about the cause of injury was reached, especially as the initial and reenacted scenarios differed significantly. Additionally, the facility failed to conduct thorough and relevant interviews with other residents, including the resident's cognitively intact suitemate, who may have witnessed or overheard the incident. The interviews conducted were generic and did not address specific concerns about the care provided by the staff involved in the incident. Language barriers between the DON and the staff involved further contributed to unclear communication and possible misunderstandings during the investigation, which were not adequately addressed or clarified in the documentation.
Failure to Ensure RN Assessment After Significant Change in Condition
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality when a resident experienced a significant change in condition involving a fracture of the left fibula and tibia. The resident, who had severe cognitive impairment, was found in distress with swelling and pain in her left lower leg. Certified nurse aides alerted LPNs, who assessed the resident, administered pain medication, and arranged for a STAT X-ray. However, there was no documentation that a registered nurse (RN) performed a comprehensive assessment following the change in condition, as required by professional standards and facility policy. Documentation in the electronic medical record and incident reports showed inconsistencies in the timing of events and lacked evidence of an RN assessment at the time of the injury. The LPNs involved did not notify the RN on duty to conduct an assessment, and the director of nursing (DON), who was off-site, did not instruct staff to ensure an RN assessment was completed. The DON and LPNs communicated about the incident and X-ray results, but the RN on duty never observed or assessed the resident after the injury or prior to hospital transfer. Staff interviews confirmed that the process for a change in condition was not followed, as the LPNs did not involve the RN on duty for assessment. The DON acknowledged that she did not assess the resident and relied on communication with the on-call LPN. The lack of RN assessment after a significant change in condition, specifically a suspected fracture, constituted a failure to meet professional standards of nursing care as outlined in both professional references and facility policy.
Failure to Ensure Palatable and Safe Food
Penalty
Summary
The facility failed to consistently serve food that was palatable, attractive, and at appropriate temperatures. Multiple residents reported issues with their meals, including missing items, cold food, and poor taste. One resident mentioned receiving a hamburger without lettuce and tomatoes, and another complained about hard rice and a meal consisting of mostly beans with a small piece of hotdog. Observations by surveyors confirmed these complaints, noting that meals were often unappetizing and not served at safe temperatures. For example, a test tray revealed that the chicken pot pie was too salty, the carrots were bland, and the cheesecake pudding pie was served warm instead of cold. The temperature of the cheesecake pudding pies was found to be above the acceptable range for safe and palatable food temperature, indicating a failure to maintain proper food storage and serving practices. Staff interviews further highlighted these deficiencies. The dietary managers acknowledged that the kitchen staff should have checked the temperature of the cheesecake before serving it to residents. They also noted that the chicken pot pie might have been overly salty due to the chicken base used and that the pureed carrots did not reach the proper texture, which could pose a risk of aspiration and weight loss for residents. The facility provided immediate education on proper pureed textures for all kitchen staff, but the report focuses on the initial failure to ensure food quality and safety.
Failure to Provide Adequate ADL Assistance and Fingernail Care
Penalty
Summary
The facility failed to ensure that two residents received proper fingernail care and assistance with activities of daily living (ADL). Resident #65, who has dementia, blindness, chronic pain, and muscle weakness, was observed multiple times with long, chipped, and cracked fingernails. Despite receiving showers twice a week, the certified nurse aides (CNA) did not cut and trim his fingernails. The care plan for Resident #65 did not include interventions for fingernail care, and the nursing staff were unsure of their responsibilities regarding nail care, leading to the resident's continued discomfort and potential health risks. Resident #69, who has diabetes, reduced mobility, and is cognitively intact, also did not receive adequate assistance with ADLs. The resident reported a preference for showers over bed baths but had not received a shower in over a week. Additionally, the resident's fingernails were long and dirty, and his skin was dry and flaky. The care plan for Resident #69 did not include interventions for maintaining fingernails or treating dry skin. The resident's electronic medical record lacked documentation on the assistance needed for nail care or the last time he received it. Interviews with the nursing staff revealed a lack of clarity and consistency in providing nail care and bathing assistance. CNA #1 admitted to noticing Resident #65's long nails but did not have clippers to cut them. LPN #1 and RN #2 acknowledged that Resident #69 should receive showers and nail care but cited staff shortages as a possible reason for the oversight. The director of nursing (DON) confirmed that the nursing staff were responsible for assisting residents with nail care and that showers or baths could help with skin issues and body odor control.
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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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Nursing homes near Littleton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Suites At Holly Creek Care Center, The | 0.6 mi | ★★★★★ | 0 | 0 |
| Suites At Someren Glen Care Center, The | 1 mi | ★★★★★ | 18 | 0 |
| Brookdale Greenwood Village | 2.2 mi | ★★★★★ | 25 | 0 |
| Cherrelyn Healthcare Center | 3.8 mi | ★★★★★ | 1 | 0 |
| Julia Temple Healthcare Center | 4.2 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 October 2026) and official state health department websites.