Deficiency Records for Orchard Park Health Care and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Orchard Park Health Care and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-31 | 2024-03-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-27 | 2023-12-08 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-10-27 | 2023-12-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-10-27 | 2023-12-08 | N |
| 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. | Health | 2023-10-27 | 2023-12-08 | N |
| Notify 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. | Health | 2023-10-27 | 2023-12-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-27 | 2023-12-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-27 | 2023-12-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-27 | 2023-12-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-27 | 2023-12-08 | N |
| Provide activities to meet all resident's needs. | Health | 2023-10-27 | 2023-12-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-27 | 2023-12-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-27 | 2023-12-08 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-27 | 2023-12-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-27 | 2023-12-08 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-10-27 | 2023-12-08 | N |
| Post nurse staffing information every day. | Health | 2023-10-27 | 2023-12-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-10-27 | 2023-12-08 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-10-27 | 2023-12-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-27 | 2023-12-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-27 | 2023-12-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-27 | 2023-12-08 | N |
| 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. | Health | 2023-10-27 | 2023-12-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-27 | 2023-12-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-27 | 2023-12-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-27 | 2023-12-08 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-10-27 | 2023-12-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-27 | 2023-12-08 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-27 | 2023-12-08 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-27 | 2023-12-08 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-10-24 | 2023-12-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-10-24 | 2023-12-01 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-10-24 | 2023-12-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-10-24 | 2023-12-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-10-24 | 2023-12-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-24 | 2023-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-24 | 2023-12-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-24 | 2023-12-01 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-10-24 | 2023-12-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-19 | 2023-10-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-25 | 2023-06-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-18 | 2023-06-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-18 | 2023-06-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-11 | 2023-06-07 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-04-28 | 2023-05-31 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-28 | 2023-05-31 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-04-28 | 2023-05-31 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-28 | 2023-05-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-31 | 2023-02-16 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-08 | 2022-12-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-10 | 2022-12-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-10 | 2022-12-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-10 | 2022-12-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-10 | 2022-12-14 | N |
| 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. | Health | 2022-11-10 | 2022-12-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-10 | 2022-12-14 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2022-11-10 | 2022-12-14 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2022-11-10 | 2022-12-14 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-11-10 | 2022-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-10 | 2022-12-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-11-10 | 2022-12-14 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-11-10 | 2022-12-14 | N |
| Report COVID19 data to residents and families. | Health | 2022-11-10 | 2022-12-14 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-11-10 | 2022-12-14 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-11-08 | 2022-12-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-08 | 2022-12-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-08 | 2022-12-13 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-11-08 | 2022-12-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-08 | 2022-12-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-08 | 2022-12-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-08 | 2022-12-13 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-11-08 | 2022-12-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-08 | 2022-12-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-04 | 2022-11-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-04 | 2022-11-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-18 | 2022-06-27 | Y |
| Post nurse staffing information every day. | Health | 2022-03-08 | 2022-03-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-18 | 2021-12-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-30 | 2021-08-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-30 | 2021-08-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-30 | 2021-08-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-30 | 2021-08-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-30 | 2021-08-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-30 | 2021-08-10 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-06-30 | 2021-08-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-15 | 2021-08-10 | Y |
| Meet other general requirements that are deficient. | Fire Safety | 2020-01-09 | 2020-03-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-09 | 2020-03-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-09 | 2020-03-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-09 | 2020-03-03 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-01-09 | 2020-03-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-09 | 2020-03-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-09 | 2020-03-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-09 | 2020-03-03 | N |
| 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. | Health | 2020-01-21 | 2020-02-25 | N |
| Respond appropriately to all alleged violations. | Health | 2020-01-21 | 2020-02-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-01-21 | 2020-02-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-01-21 | 2020-02-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-21 | 2020-02-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-21 | 2020-02-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-21 | 2020-02-25 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-01-21 | 2020-02-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-21 | 2020-02-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-01-21 | 2020-02-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-01-21 | 2020-02-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-01-21 | 2020-02-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-21 | 2020-02-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-01-21 | 2020-02-25 | N |
| 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. | Health | 2020-01-21 | 2020-02-25 | N |
| Provide or obtain dental services for each resident. | Health | 2020-01-21 | 2020-02-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-21 | 2020-02-25 | N |
