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Deficiency Records for Orchard Park Health Care and Rehab Center

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.

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?
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-07-11 2024-08-08 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-07-11 2024-08-08 Y
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 2024-07-11 2024-08-08 Y
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 2024-06-07 2024-06-28 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-06-07 2024-06-24 Y
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 2024-05-20 2024-06-12 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-04-02 2024-04-23 Y
Respond appropriately to all alleged violations. Health 2024-04-02 2024-04-23 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-04-02 2024-04-23 Y
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
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

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