Deficiency Records for Orchard Park Health Care and Rehab Center
Updated as of July 01, 2021
This is not the most recent data for Orchard Park Health Care and Rehab Center. For the most recent information, click here.
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 and implement an infection prevention and control program. | Health | 2020-12-17 | 2021-01-11 | 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 |
| 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 |
| 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 |
| Respond appropriately to all alleged violations. | Health | 2020-01-21 | 2020-02-25 | Y |
| 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 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-12-11 | 2019-01-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-11 | 2019-01-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-11 | 2019-01-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-12-11 | 2019-01-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-11 | 2019-01-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-11 | 2019-01-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-12-11 | 2019-01-15 | N |
| Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2018-12-11 | 2019-01-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-12-11 | 2019-01-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-11 | 2019-01-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-12-11 | 2019-01-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-12-11 | 2019-01-15 | 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 | 2018-12-05 | 2019-01-10 | 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 | 2018-12-05 | 2019-01-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-05 | 2019-01-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-05 | 2019-01-10 | 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 | 2018-12-05 | 2019-01-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-12-05 | 2019-01-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-12-05 | 2019-01-10 | 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 | 2018-12-05 | 2019-01-10 | 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 | 2018-12-05 | 2019-01-10 | 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 | 2018-12-05 | 2019-01-10 | N |
| Provide or obtain dental services for each resident. | Health | 2018-12-05 | 2019-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-05 | 2019-01-10 | 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 | 2017-12-15 | 2018-01-23 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2017-12-15 | 2018-01-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2017-12-15 | 2018-01-23 | N |
| Respond appropriately to all alleged violations. | Health | 2017-12-15 | 2018-01-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2017-12-15 | 2018-01-23 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2017-12-15 | 2018-01-23 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2017-12-15 | 2018-01-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-15 | 2018-01-23 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-12-15 | 2018-01-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2017-12-15 | 2018-01-23 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2017-12-15 | 2018-01-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2017-12-15 | 2018-01-23 | N |
| Keep all essential equipment working safely. | Health | 2017-12-15 | 2018-01-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2017-12-13 | 2018-01-17 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2017-12-13 | 2018-01-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-12-13 | 2018-01-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-12-13 | 2018-01-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-12-13 | 2018-01-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-12-13 | 2017-12-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-12-13 | 2017-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-12-13 | 2017-12-15 | N |
