Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Orchard Park Rehab & Living Center during CMS and state inspections, most recent first.
Surveyors identified widespread environmental and housekeeping deficiencies across three units, the therapy room, a common area, and the laundry room. Cooking dishes were stored under a therapy room sink near the drainpipe. Multiple resident rooms had privacy curtains in disrepair, rusty and chipped baseboard heaters, damaged bathroom doors with exposed unsealed wood, and a rusty toilet water line escutcheon. Hallways on two units had numerous chipped and broken floor tiles, and a whirlpool room had damaged walls, ripped and missing linoleum, rusty ceiling components, and a dirty, stained, and cracked whirlpool tub with soiled jets and intake screen. Additional findings included a damaged bathroom ceiling tile around a sprinkler head, cracked floor tiles and chipped paint in a shower room, stained ceiling near a nurse’s station, a broken ramp handrail, and laundry equipment and carts held together with Velcro and duct tape. These conditions were confirmed by the DON, Maintenance Director, and Director of Environmental Services.
Care plans were not developed or implemented to reflect the current needs of two residents. One resident had a pacemaker documented in the chart, with nursing notes showing attempted device checks and communication with the clinic, but no care plan goals or interventions for pacemaker monitoring. Another resident had recurrent GI issues, including intestinal obstruction, abdominal pain, distention, loose stools, ER transfer, and a recent SBO, yet the care plan lacked goals and interventions for the GI concerns.
A resident bathroom toilet was observed loose and not secured to the floor, and the DON confirmed it was an accident hazard. In addition, hazardous chemicals including germicidal wipes, disinfectant cleaner, and WD40 were found stored in an unlocked therapy room cabinet with resident access to the sink; the COTA and DON confirmed the chemicals were accessible to residents.
Improper Storage of Respiratory Equipment: The facility failed to maintain sanitary respiratory care equipment for 3 residents. A resident’s oxygen tubing was found on the floor, and two other residents had nebulizer tubing and masks left unbagged and exposed on a bedside table and shelf. The DON confirmed two of the findings, and an LPN confirmed the third. Facility policy required unused nasal cannulas to be bagged and nebulizer parts to be rinsed, air dried, and stored in a respiratory set up bag.
Kitchen sanitation and food storage deficiencies were observed during a surveyor tour. The wall AC unit was dusty and dirty, debris was on the floor under equipment, and a coffee pot table shelf had chipped paint creating an uncleanable surface. Food storage issues included an unlabeled package of crackers, an opened and unsealed supplement powder, and a thickened cranberry cocktail concentrate past its use-by date. The ice machine drain lines were also installed without the required 1-inch air gap, and the Administrator confirmed the findings.
Failure to Provide Required Dementia Training for CNAs: The facility failed to ensure 5 of 5 sampled CNAs had required dementia management training. Record review showed no evidence of dementia training for the CNAs, including contracted staff, and the BOM confirmed the staff had not received the training. The facility assessment stated the facility commonly cares for residents with Alzheimer’s disease and non-Alzheimer’s dementia, with 12 residents identified with dementia, while dementia management training was not scheduled until later.
The facility failed to show that an IDT reviewed and revised a resident’s care plan after an MDS quarterly assessment. The record lacked evidence of an IDT meeting within 7 days of the assessment, and when surveyors asked for documentation, the LSW and DON could not provide meeting notes or other proof that the meeting occurred.
Two residents were transferred multiple times to acute care hospitals, including ED visits and an admission for an intestinal blockage, without documented written transfer/discharge notices or bed-hold notices, including cost of care, being provided to their legal representatives. Clinical records and nursing notes confirmed the transfers and hospital admissions, but lacked evidence of the required written notifications. The LSW later acknowledged that there was no documentation of these notices and indicated that one ED transfer was viewed as a scheduled appointment, and thus she believed notices were not required.
Failure to Post Daily Nurse Staffing Information: Surveyors observed that the posted nurse staffing sheet was several days old instead of being updated daily. The Administrator said the Scheduler or clinical team was responsible for posting staffing, and the Scheduler stated she normally posts it on weekdays while nursing posts it on weekends, but it was overlooked for 6 days.
Single resident rooms 116 and 118 did not meet the required 100 sq ft minimum. Surveyors observed residents in the rooms and confirmed each room measured 93 sq ft, while facility records also documented 93 sq ft. The Administrator confirmed there was no waiver or variance for the rooms.
A resident was found seated in a wheelchair with a sheet tied around their waist and johnny pants applied backwards, both secured in double knots, to prevent access to their brief. These actions, performed by a CNA without inclusion in the care plan, were determined to be abuse and use of a restraint, violating the resident's rights to dignity and respect.
A resident was found with a sheet tied around their waist and johnny pants applied backwards, both double knotted, restricting their ability to access their brief. A CNA implemented these measures, which were not part of the care plan, to prevent the resident from removing their brief. The CNA had received training on abuse and restraints but did not recognize the actions as inappropriate. The facility determined these actions constituted abuse and the use of a restraint, violating the resident's rights.
A resident was found with a sheet tied around the waist and johnny pants applied backwards, both secured in double knots, restricting movement and access to personal care items. A CNA performed these actions without including them in the care plan, intending to prevent the resident from removing their brief. The facility's policy defines such practices as physical restraint, and the CNA had previously received training on restraint use and resident rights.
The facility did not implement a policy to ensure staff received education on the COVID-19 vaccine, including its benefits and risks. The Infection Preventionist confirmed the absence of such education since the previous year, and the new employee packet lacked COVID-19 information. Interviews with the Maintenance Director, an LPN, and a facility clerk revealed they had not received education on the COVID Spikevax in the past year.
The facility failed to maintain a safe and clean environment, with issues such as broken fixtures, inadequate water temperatures, and non-operational dryers. A resident's room had a persistent urine odor due to a leaking foley bag, and wash basins were improperly stored on the bathroom floor. These deficiencies were confirmed by facility staff.
The facility failed to implement baseline care plans within 48 hours of admission for four residents, as required by policy. A resident with COPD and respiratory failure lacked a care plan addressing respiratory needs, while another with sleep apnea had no interventions for respiratory care. A resident with dementia had no care plan for behavioral needs, and another with multiple chronic conditions had no baseline care plan initiated. These deficiencies were confirmed by staff interviews.
A resident with severe cognitive impairment reported an unwitnessed fall, but the facility failed to complete a fall incident report, post-fall observation tool, or continued monitoring as required by policy. The resident's medical record lacked evidence of necessary documentation and monitoring for further injuries or neurological changes.
The facility failed to secure hazardous chemicals in an unlocked utility room, posing a risk to vulnerable residents. Despite the presence of Safety Data Sheets outlining potential harm, chemicals like disinfectants and hand sanitizers were observed unsecured on multiple survey days. The Acting DON and Infection Preventionist confirmed the unsafe storage, acknowledging the risk to confused and compromised residents.
The facility failed to maintain sanitary conditions and follow provider orders for respiratory care for three residents. A resident's nebulizer was left unbagged, and their oxygen concentrator was set below the prescribed rate. Another resident received oxygen at a lower rate than ordered, and a third resident's CPAP mask was improperly stored. These issues were confirmed by facility staff during observations.
The facility's kitchen was found to be unsanitary, with dusty and dirty hood system filters, wall air conditioning units, and walls. The ceiling grid hangers were rusty and stained, the floor fan was dusty, and the grease trap lid had chipped paint, creating an uncleanable surface. These issues were confirmed by the Food Service Director.
The facility failed to implement its Antibiotic Stewardship Program, as outlined in its policy, which aims to improve antibiotic use and prevent resistance. The Infection Preventionist did not have a system to monitor antibiotic use effectively, and the facility's quarterly reports lacked evidence of a review of antibiotic use. This deficiency could affect all residents receiving antibiotics.
A resident with severe cognitive impairment and a history of fractures fell while using a walker. The facility delayed notifying the medical provider by 20 hours and failed to promptly inform the resident's representative. The incident report and nursing documentation lacked necessary details and notifications.
The facility failed to provide adequate dental care and maintain personal hygiene for two residents with dementia, leading to deficiencies in their activities of daily living. A resident with severe cognitive impairment was not receiving proper mouth care, resulting in significant tartar buildup. Another resident was observed in dirty clothes, highlighting a failure to maintain personal hygiene and dignity. These issues were confirmed by staff and a Quality Improvement Specialist.
A resident with type 2 Diabetes Mellitus received Novolog insulin doses outside of physician orders, which specified administration only for blood sugar levels above 110. Despite this, nursing staff administered insulin on several occasions when the resident's blood sugar was below 110, contrary to the care plan aimed at preventing diabetes complications. This was confirmed by Quality Improvement Specialists.
The facility's Quality Assurance Committee failed to ensure the effectiveness of corrective actions for previously identified deficiencies. During a follow-up survey, deficiencies F684 and F757 were cited again. F684 involved a failure to document and monitor a resident after an unwitnessed fall, while F757 involved a failure to ensure a resident's drug regimen was free from unnecessary medications. These issues were confirmed with the President of Quality Improvement and Nursing Services and the DON.
An LPN failed to maintain sanitary conditions during a lunch meal on the Cortland Unit by not sanitizing hands between resident contacts. The LPN handled a lunch tray, removed trash with bare hands, and touched a resident and a side table without using hand sanitizer, despite passing a sanitizer station. The DON confirmed the expectation for hand sanitization before and after resident contact.
Environmental and Housekeeping Deficiencies Across Multiple Units and Service Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, sanitary, and comfortable environment across multiple units and service areas. Surveyors observed multiple cooking dishes stored under the therapy room sink next to and below the drainpipe; this was confirmed by a COTA and the DON. During an environmental tour, surveyors, accompanied by the Maintenance Director and Director of Environmental Services, identified resident rooms on Cortland and Northern Spy units with privacy curtains missing hooks, hanging down, and in disrepair. In one Cortland resident room, the bathroom baseboard heater and room baseboard heater had chipped/missing paint and rust, creating uncleanable surfaces; the bathroom door’s protective surface was pulled away on both sides, and the bottom of the door was chipped/gouged with exposed unsealed wood. The same bathroom contained a wash basin on the floor under the sink and a toilet water fill line with a rusty escutcheon. Additional environmental issues were found throughout the facility. On Cortland, the hallway floor had seven chipped/broken tiles, and the whirlpool room had walls with chipped/missing paint and damaged sheetrock, ripped/missing linoleum at the wall corner and sink cabinet, ripped/missing flooring around the floor drain, split seams in the middle of the floor, a rusty ceiling light and ceiling grid, and a whirlpool tub that was dirty, yellow-stained, cracked, with soiled and stained water intake screen and jets. On Northern Spy, one resident room had a bathroom ceiling tile around a sprinkler head that was bubbled and bent, and the hallway floor had 32 chipped/broken tiles. On the [NAME] unit, six cracked/broken floor tiles and a shower room with chipped and missing paint on the walls were observed. In common areas, the ceiling near the nurse’s station had large brown stains, and a ramp handrail going downstairs was broken. In the laundry room, the left clothes dryer had Velcro tape holding the bottom lint door and tape on the door glass, and a three-shelf laundry cart had ripped and hanging duct tape on the bottom shelf. The Maintenance Director and Director of Environmental Services confirmed these findings.
Care plans did not reflect pacemaker monitoring or recurrent GI concerns
Penalty
Summary
The facility failed to ensure that care plans were developed and implemented to reflect the current needs of 2 of 14 residents reviewed. One resident had a cardiac pacemaker documented in the clinical record, including a provider progress note listing the pacemaker as an active diagnosis and a nursing note stating staff attempted a pacemaker check but could not transfer data to the clinic. The resident’s care plan did not include goals or interventions for the pacemaker. During interviews, an RN stated the resident’s pacemaker was monitored through a wireless device in the room and that the facility received reports from the cardiology clinic, and the DON and QIS later confirmed the care plan had not been developed or implemented for the pacemaker. The second resident had diagnoses including intestinal obstruction, nausea with vomiting, and multiple abdominal surgeries. The record showed physician orders for ambulation four times daily to promote bowel function and Senna with Docusate Sodium twice daily for intestinal obstruction. Nursing notes documented abdominal pain, loose watery stools, hypoactive bowel sounds, transfer to the ER, return to the facility after a small bowel obstruction, a firm and distended abdomen, pain rated 5/10, and abdominal girth measurements. A provider history and physical noted a recurrent small bowel obstruction that had been managed conservatively, that the resident was feeling better but not at baseline, and that the facility was to schedule GI follow-up and resume the bowel program. The resident’s care plan lacked goals and interventions for the GI concerns, and the DON confirmed this during interview.
Unsecured Toilet and Accessible Chemicals
Penalty
Summary
The facility failed to ensure that a resident bathroom environment was free of accident hazards when a toilet in a resident room bathroom was observed loose and not secured to the floor. During the observation, the Director of Nursing confirmed that the toilet was not secure to the floor and identified it as an accident hazard. The facility also failed to ensure that hazardous chemicals were properly secured in a therapy room kitchenette. Two surveyors observed two 1.13-ounce containers of Super Sani-Cloth Germicidal wipes, one 25-ounce bottle of Rapid Multi-Surface Disinfectant Cleaner, and one 8-ounce container of WD40 Multi-Use Product Aerosol stored in an unlocked cabinet with a sink in the therapy room kitchenette. The Certified Occupational Therapy Aide confirmed that the chemicals were stored in the unlocked cabinet and that residents had access to the sink, and the DON later confirmed that the unlocked cabinet contained hazardous chemicals accessible to residents.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care for 3 of 3 residents reviewed. Resident #1 had oxygen tubing dated 11/19/25 observed laying on the floor on 1/20/26 and again on 1/21/26. Resident #27 had unlabeled and unbagged nebulizer tubing and a mask observed on the bedside table on 1/20/26 and again on 1/21/26. Resident #8 had an unbagged nebulizer mask and tubing observed lying on a shelf in the room on 1/20/26 and again on 1/21/26. The DON observed and confirmed the findings for Residents #1 and #27, and an LPN observed and confirmed the finding for Resident #8. Facility policy stated that nasal cannulas not in use should be placed in a plastic bag to avoid contamination and that nebulizer parts should be rinsed, air dried, and then placed in a respiratory set up bag once dried.
Kitchen Sanitation, Food Storage, and Ice Machine Plumbing Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner during an initial kitchen tour. A surveyor observed the wall air conditioning unit by the three-bay pot sink was dusty and dirty, dirt, trash, and food debris were present on the floor underneath equipment, and the bottom shelf of the coffee pot table had chipped and missing paint that created an uncleanable surface. The facility also failed to ensure food items were properly labeled, dated, sealed, and discarded when past their use-by date. In the small storage room by the walk-in refrigerator, one package of crackers was not labeled and dated, and a previously opened package of vanilla shake supplement powder was open to air and not sealed. In another storage room, a container of thickened cranberry cocktail concentrate had a use-by date of 12/11/25. In addition, the drain lines for the ice machine were installed down into the drainpipe without the required 1-inch air gap, and the Administrator later confirmed the findings during interview.
Failure to Provide Required Dementia Training for CNAs
Penalty
Summary
The facility failed to develop, implement, and maintain an effective in-service training program by not ensuring that 5 of 5 randomly sampled CNAs had required dementia management training. The Comprehensive Facility Assessment, updated August 2025, stated the 38-bed facility commonly provides care to individuals with Alzheimer's Disease and Non-Alzheimer's Dementia and identified 12 residents with dementia. On 1/22/26, review of the employee files for CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5 showed no evidence of dementia training. CNA #1 was hired on 1/7/25, CNA #2 on 1/14/25, CNA #3 on 12/12/25, CNA #4 on 7/23/25, and CNA #5 was contracted staff with an initial start date of 3/29/25 and a most recently renewed contract start date of 12/9/25. During an interview on 1/22/26 at 11:59 a.m. in the presence of 2 surveyors, the Business Office Manager confirmed that the CNAs had not received dementia training and provided the facility's Mandatory Education Calendar showing Dementia Management training was not scheduled until August 2026.
Failure to Document IDT Care Plan Review After MDS Assessment
Penalty
Summary
The facility failed to review and revise the care plan by an interdisciplinary team after a Minimum Data Set quarterly assessment for Resident #28. Review of the resident’s clinical record showed that the MDS quarterly assessment was completed on 12/17/25, but there was no evidence in the record that an IDT meeting was held within 7 days after that assessment. During an interview on 1/22/26, the Social Services Director stated that Resident #28’s IDT meeting had been held on 12/19/25, but when the surveyor requested documentation of the meeting, the LSW said she was off at the time and would request the meeting notes from the DON. In a follow-up interview later that day, the LSW confirmed that the facility did not have meeting notes or other evidence that an IDT meeting was held for the 12/17/25 assessment.
Failure to Provide Required Written Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer/discharge and bed-hold notices, including cost of care information, to residents and/or their legal representatives when residents were transferred to an acute care hospital. For one resident admitted in January 2024, the clinical record showed that the resident was transported to an acute care hospital on a specified date, but there was no documentation that the resident or the resident’s representative received a written transfer/discharge notice or a written bed-hold notice for that transfer. For another resident admitted in October 2022, the clinical record showed multiple transfers to an acute care hospital on several dates, including an Emergency Department visit followed by an admission for an intestinal blockage. Nursing progress notes documented communication with a gastroenterologist, the decision by the team to send the resident to an alternate ED, and the subsequent hospital admission. Additional record review showed another hospital transfer and admission on a later date. However, the record lacked evidence that the resident’s representative received written transfer/discharge notices and written bed-hold notices for any of these transfers. During an interview, the LSW confirmed there was no evidence of such notices for the identified transfers and stated that one ED transfer was considered a scheduled appointment, and therefore she believed notices were not required.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information on a daily basis for 1 of 3 days of survey. On 1/20/26 at 8:00 a.m., four surveyors observed that the posted nurse staffing sheet was dated 1/14/26, which was 6 days old. On 1/22/26 at 8:22 a.m., the Administrator stated that the Scheduler or the clinical team was responsible for posting the nurse staffing daily. Later that day, at 9:47 a.m., the Scheduler stated that since starting in August, she posts the nurse staffing information each weekday and nursing posts the staffing on weekends, and acknowledged that it was overlooked for those 6 days.
Single Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that all single resident rooms measured at least 100 square feet for 2 of 6 single resident rooms, identified as rooms 116 and 118. On 1/20/26 at 8:30 a.m., two surveyors observed the rooms with a resident occupying each room. A review of the Orchard Park Resident List (Census) showed Resident #2 residing in one of the single resident rooms. At 9:30 a.m., facility documentation stated that each room measured 93 square feet, and a surveyor measured the rooms and confirmed they were 93 square feet. The surveyor requested documentation showing the facility had a variance for the rooms. At 9:40 a.m., the surveyor observed the facility license and found no waiver stated on the license. On 1/21/26 at 9:50 a.m., the Administrator confirmed that the facility did not have variances for rooms 116 and 118 for not meeting the required 100 square feet for a single resident room.
Resident Restrained with Improper Use of Sheet and Clothing, Violating Dignity and Rights
Penalty
Summary
A deficiency occurred when a certified nurse's assistant (CNA) applied a sheet around a resident's waist and secured it in a double knot while the resident was seated in a wheelchair. Additionally, the CNA put johnny pants on the resident backwards, with the ties positioned in the back and also secured in a double knot. These actions were taken to prevent the resident from accessing and removing their brief, as the CNA could not locate a belt. The CNA confirmed that these interventions were not part of the resident's care plan and acknowledged having received prior training on abuse, neglect, restraints, and resident rights. The facility's internal investigation determined that the CNA's actions constituted abuse and the use of a restraint, as they restricted the resident's ability to access their brief and were not authorized in the care plan. The investigation also found that the resident's rights to dignity and respect were violated by being inappropriately tied with a sheet and having clothing applied in a manner that restrained movement. The CNA did not recognize these actions as inappropriate, despite previous training and orientation on proper care and resident rights.
Resident Restrained with Improper Use of Sheet and Clothing
Penalty
Summary
A resident was found seated in a wheelchair with a sheet tied around their waist and secured in a double knot, as well as wearing johnny pants that had been applied backwards with the ties positioned in the back and also double knotted. These actions were performed by a Certified Nurse's Assistant (CNA) who stated that the interventions were intended to deter the resident from accessing and removing their brief, as the resident was known to shred and remove it. The CNA admitted to not being able to locate a belt and therefore used the sheet and johnny pants as alternatives. These interventions were not part of the resident's care plan. The CNA confirmed during an interview that they had received training on abuse, neglect, restraints, and resident rights, but did not recognize their actions as inappropriate or as a form of restraint. The facility's investigation determined that the use of the sheet and backwards johnny pants, both double knotted, constituted a restraint and violated the resident's rights, amounting to abuse. The facility's policy clearly prohibits such actions, defining them as unreasonable confinement and restraint, and requires that residents be free from abuse, neglect, and harm.
Resident Restrained with Improper Use of Sheet and Clothing
Penalty
Summary
A deficiency occurred when a resident was found seated in a wheelchair with a sheet tied around their waist and secured in a double knot, and wearing johnny pants applied backwards with the ties also secured in a double knot. These actions were performed by a Certified Nurse's Assistant (CNA) who stated that the interventions were intended to deter the resident from accessing and removing their brief, as the resident had a history of shredding and removing it. The CNA admitted to tying the sheet and securing the clothing in this manner because a belt was not available, and confirmed that these interventions were not part of the resident's care plan. The facility's restraint use policy prohibits the use of physical restraints for discipline or convenience and specifies that fastening fabric or clothing to restrict a resident's movement meets the definition of a physical restraint. The CNA acknowledged having received training on abuse, neglect, restraints, and resident rights, but did not recognize the actions as inappropriate. The facility's internal investigation determined that the resident's rights were violated, and the actions constituted both the use of a restraint and resident abuse.
Lack of COVID-19 Vaccine Education for Staff
Penalty
Summary
The facility failed to develop and implement a policy and procedure to ensure all staff were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine or information on obtaining the vaccine. The Infection Control Immunizations policy and the Employee Immunization/Vaccination Requirements policy did not include procedures for staff education on the COVID-19 vaccine. During interviews, the Infection Preventionist confirmed that staff had not been provided education on the COVID-19 vaccine since the previous year, and there was no information about COVID-19 in the new employee packet. Additionally, the Maintenance Director, a Licensed Practical Nurse, and a facility clerk all reported not receiving education on the COVID Spikevax within the past year.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment across multiple units and areas, as observed during an environmental tour. Deficiencies included missing ceiling tiles, broken and dirty fixtures, and inadequate water temperatures in resident rooms. The whirlpool room had torn flooring and damaged cabinets, while several resident rooms had issues with baseboard heaters, dirty floors, and broken fixtures. The laundry room was also found to be in disrepair, with two out of three dryers non-operational, one of which had been out of order for over two years. These issues were confirmed by the Administrator, Maintenance Director, and Housekeeping Account Manager. Additionally, a strong urine odor was detected in a resident's room, attributed to a frequently leaking foley bag that had potentially absorbed into the flooring. Despite daily cleaning efforts, the odor persisted. Furthermore, two wash basins were observed on the bathroom floor under the sink, indicating a lack of proper storage or maintenance. These findings were confirmed with the Director of Nursing, highlighting ongoing issues with facility maintenance and cleanliness.
Failure to Implement Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for four residents, as required by their policy. Resident #180, who was admitted with chronic obstructive pulmonary disease (COPD) and respiratory failure, had active orders for Trelegy Ellipta and continuous oxygen therapy. However, the care plan initiated on 11/20/24 did not include goals and interventions for the resident's respiratory needs. Similarly, Resident #80, admitted with sleep apnea, had orders for CPAP and PRN oxygen, but the baseline care plan initiated on 11/22/24 lacked evidence of goals and interventions for respiratory needs. Interviews with the Infection Preventionist and Quality Improvement Specialist confirmed these deficiencies. Resident #23, admitted with dementia and behavioral disturbances, had a care plan initiated on 10/10/24 that did not address goals and interventions for dementia needs. Additionally, Resident #27, admitted with chronic heart failure, respiratory failure, hypertension, and COPD, did not have a baseline care plan initiated at all. These findings were confirmed through interviews with facility staff, including the President of Clinical Operations and the Quality Improvement Specialist, highlighting a systemic issue in the facility's adherence to its baseline care plan policy.
Failure to Monitor Resident After Unwitnessed Fall
Penalty
Summary
The facility failed to adequately monitor a resident after an unwitnessed fall, which was identified as a deficiency during a review. According to the facility's Fall Management Policy, a fall incident report should be completed after any fall, whether witnessed or not, and a post-fall observation tool should be used to identify potential causes of the fall. Additionally, documentation must be completed in the nurse's notes on each shift for three shifts following the fall. However, for Resident #5, who self-reported a fall in the bathroom, there was no evidence of a fall incident report, post-fall observation tool, or continued monitoring for further injuries or neurological changes. Resident #5, who has a diagnosis of dementia and a Brief Interview of Mental Status (BIMS) score of 4 indicating severe cognitive impairment, reported the fall to the nursing staff. Despite the resident's report of mild pain in the left knee, the medical record lacked the required documentation and monitoring as per the facility's policies. The Quality Improvement Specialists confirmed the facility's failure to complete the necessary documentation and monitoring for the resident's unwitnessed fall.
Improper Storage of Chemicals in Unlocked Utility Room
Penalty
Summary
The facility failed to ensure that the resident's environment was free of accident hazards due to improper storage of chemicals. During the survey, it was observed that various chemical products, including Rapid Multi Surface Disinfectant Cleaner, Enzymatic Foul Odor Digester, Germs Be Gone Hand Sanitizer Gel, and GelRite Instant Hand Sanitizer, were stored in an unlocked soiled utility room. These chemicals have specific first aid measures outlined in their Safety Data Sheets, indicating potential harm if they come into contact with eyes, skin, or if ingested or inhaled. The presence of these unsecured chemicals posed a risk, especially considering the facility had residents who were confused, compromised, and vulnerable, as confirmed by the Acting Director of Nursing and Infection Preventionist. On two separate days of the survey, the surveyor observed the same issue of unsecured chemicals in the soiled utility room. The Acting Director of Nursing and Infection Preventionist acknowledged that the chemicals were not stored safely behind a locked door. Additionally, the Quality Improvement Specialist confirmed the findings during an interview. The repeated observation of unsecured chemicals over multiple days highlights a failure in maintaining a safe environment for residents, particularly those who may be at risk of accessing these hazardous substances.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to maintain a sanitary environment and adhere to provider orders for respiratory care for three residents. Resident #180, diagnosed with COPD and respiratory failure, had a nebulizer left unbagged on the bedside table, contrary to facility policy requiring respiratory equipment to be stored in a clean bag. Additionally, Resident #180's oxygen concentrator was set at 1.5 liters per minute, despite an active order for 3 liters per minute. These observations were confirmed by the Acting Director of Nursing/Infection Preventionist and a Quality Improvement Specialist. Resident #14, with diagnoses including COPD and asthma, was observed receiving oxygen at 2.5 liters per minute, although the active order specified 3 liters per minute. Similarly, Resident #80, diagnosed with sleep apnea, had a CPAP face mask stored improperly in an open drawer instead of being bagged. These deficiencies were confirmed by the Acting Director of Nursing/Infection Preventionist during observations with surveyors.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a tour conducted with the Food Service Director. The inspection revealed several deficiencies, including dusty and dirty hood system filters, wall air conditioning units, and walls above and below these units. Additionally, the ceiling grid hangers were found to be rusty and stained a yellowish color throughout the kitchen. The floor fan was also noted to be dusty and dirty, and the grease trap lid had chipped or missing paint, creating an uncleanable surface. These findings were confirmed by the Food Service Director during the interview.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) as outlined in its policy, which aims to improve antibiotic use, reduce adverse events, prevent resistance, and lead to better outcomes for residents. The policy specifies that the Infection Preventionist is responsible for monitoring and supporting antibiotic activities, tracking antibiotic therapy, reviewing resistance patterns, and monitoring healthcare-acquired infections (HAIs) and multi-drug resistant organisms (MDROs). However, the facility did not have a system in place to monitor antibiotic use effectively, as evidenced by the lack of tracking systems to identify trends and antibiotic use, and the absence of a review of the monthly pharmacy antibiotic report by the Infection Preventionist. The facility's Quality Assurance & Performance Improvement Pharmacy quarterly reports for several quarters lacked a section on Antibiotic/Antimicrobial Stewardship Discussion, indicating that there was no evidence of a review of antibiotic use or the ASP during these meetings. Additionally, the Infection Preventionist and Acting Director of Nursing confirmed frequent urinary tract infections requiring antibiotics but admitted to not implementing any tracking systems for trends and antibiotic use. This deficiency has the potential to affect all residents receiving antibiotics, as the facility did not adhere to its policy and failed to monitor antibiotic use effectively.
Failure to Timely Notify Medical Provider and Family After Resident Fall
Penalty
Summary
The facility failed to ensure timely notification of a medical provider and the resident's representative following a significant incident involving a resident. The resident, who has a history of lumbar vertebra fracture and bone density disorder, and severe cognitive impairment, experienced a fall on 2/2/25 at 5:00 p.m. The medical provider was not notified until 20 hours later, on 2/3/25 at 1 p.m. The incident report lacked a detailed description, resident assessment, or notification to the resident's representative. Additionally, the nursing documentation completed on 2/3/25 at 4:06 p.m. confirmed the fall occurred in the dining room while the resident was using a walker, but it also failed to document any notification to the resident's representative. The Director of Nursing stated that the family was notified the day after the fall.
Deficiencies in Oral Hygiene and Personal Care for Residents with Dementia
Penalty
Summary
The facility failed to provide adequate dental care and maintain personal hygiene for two residents with dementia, leading to deficiencies in their activities of daily living (ADL). Resident #10, who has a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment, was observed with significant food and tartar buildup on their teeth. Despite the care plan indicating the need for extensive assistance with self-care, the resident was not receiving mouth care twice a day as required. Interviews with CNAs revealed that although mouth care was part of the daily routine, it was not consistently performed, and the resident's teeth were not brushed, only rinsed. This lack of proper oral hygiene was confirmed by a Quality Improvement Specialist who noted that the resident could brush their teeth independently with minimal setup assistance. Resident #7, also diagnosed with dementia and having a BIMS score of 3, was observed wearing clothes with dried food particles, indicating a failure to maintain personal hygiene and dignity. The care plan for Resident #7 also required extensive assistance with self-care. Despite this, the resident was left in dirty clothes after breakfast and before being put to bed, which was acknowledged as a dignity issue by both a CNA and the Quality Improvement Specialist. These observations highlight the facility's failure to ensure residents' basic hygiene needs were met, impacting their dignity and quality of care.
Insulin Administered Outside Physician Orders
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by administering doses of insulin outside of the physician's order parameters. Specifically, a resident with type 2 Diabetes Mellitus and Diabetic Polyneuropathy had a physician's order for Novolog Insulin to be administered only if blood sugar levels were above 110. However, the Electronic Medication Administration Record (EMAR) showed that nursing staff administered 6 units of Novolog insulin on multiple occasions in October, November, and December 2024, despite the resident's blood sugar levels being below 110 on those dates. This action was contrary to the physician's orders and the resident's nutrition care plan, which aimed to prevent complications related to diabetes by adhering to prescribed medications and treatments. The Quality Improvement Specialists confirmed these findings during an interview, noting the failure to follow physician orders and the care plan.
Recurrent Deficiencies in Resident Monitoring and Medication Management
Penalty
Summary
The facility's Quality Assurance Committee failed to ensure the effectiveness of the Plan of Correction for deficiencies identified during the Annual Long Term Care Survey Process for Federal Recertification. Specifically, deficiencies F684 and F757 were cited again during a follow-up survey. F684 was cited due to the facility's failure to document and adequately monitor a resident after an unwitnessed fall. Additionally, F757 was cited for the facility's failure to ensure that a resident's drug regimen was free from unnecessary medications. These deficiencies were confirmed during an interview with the President of Quality Improvement and Nursing Services and the Director of Nursing.
Failure to Maintain Sanitary Conditions During Meal Service
Penalty
Summary
The facility failed to ensure food was served under sanitary conditions during a lunch meal on the Cortland Unit. An LPN was observed exiting a room with a lunch tray, removing trash from the tray with bare hands, and placing it on a kitchen utility cart. The LPN then walked past a hand sanitizer station without using it and entered another resident's room, where she placed her bare hands on a resident's shoulder and a side table. After exiting the room, the LPN proceeded to the lunch cart, opened it with her bare hand, and retrieved another lunch tray without sanitizing her hands between resident contacts. During an interview, the Acting Director of Nursing/Infection Preventionist confirmed that it was expected for staff to sanitize their hands before and after resident contact.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 115 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Farmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewood Rehab & Living Ctr | 0.7 mi | ★★★★★ | 42 | 0 |
| Sandy River Center | 3.5 mi | ★★★★★ | 21 | 0 |
| Maplecrest Rehab & Living Center | 15.8 mi | ★★★★★ | 0 | 0 |
| Pinnacle Health & Rehab Canton | 18.1 mi | ★★★★★ | 34 | 0 |
| Woodlawn Rehabilitation & Nursing Center | 21.7 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.