Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Fox Run At Orchard Park during CMS and state inspections, most recent first.
Fire drills were not conducted on the second floor of a resident unit during the fourth quarter, as required by facility policy. The Facilities Supervisor and Director of Facilities, responsible for planning and conducting the drills, acknowledged the oversight. The Administrator was unaware of the missed drills until the survey and did not usually review the schedule with the responsible parties.
Smoke barrier walls on the second floor were found to be incomplete and improperly maintained, with open penetrations outside a resident's room and the DON's office. The Director of Facilities confirmed the lack of regular smoke barrier audits.
A facility failed to limit PRN orders for a psychotropic medication, Ativan, to 14 days for a resident with anxiety disorder and dementia. The resident received extended orders without documented rationale, contrary to facility policy. Staff interviews revealed a lack of oversight and awareness of the 14-day limitation, despite improvements in the resident's condition.
Missed Fire Drills on Second Floor
Penalty
Summary
During a Life Safety Code survey, it was found that fire drills were not conducted at least once per shift per quarter on the second floor of the resident unit. The facility's policy, dated 2010, requires fire drills to be conducted once per shift, per quarter at varying times. However, a review of fire drill reports from 2024 revealed that no fire drills were conducted during the fourth quarter. The Facilities Supervisor admitted that although fire drills were scheduled, they were not conducted due to an oversight. The Director of Facilities confirmed that both they and the Facilities Supervisor were responsible for planning and conducting the drills, and acknowledged the oversight. The Administrator stated they were unaware of the missed drills until the survey and did not typically review the fire drill schedule with the Director of Facilities or the Facilities Supervisor.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 K712 Fire Drills 1. The Facility will ensure fire drills are conducted in accordance with NFPA 101. 2. The Director of Facilities and Facilities Supervisor reviewed and revised the policy entitled Conducting Fire Drills. Inservice with Maintenance staff conducted reviewing policy and future schedule. The 2025 fire drill schedule was reviewed to ensure drills are planned for once on each shift per quarter. 3. The Director of Facilities will audit fire drills to ensure they are conducted once on each shift per quarter. 4. Fire drill audit will continue for 12 months and be brought to QA/QAPI meetings on a quarterly basis for review and need for continuance. 5. Overall responsibility to ensure action is implemented and maintained is with the Director of Facilities.
Smoke Barrier Wall Deficiencies on Second Floor
Penalty
Summary
During a Life Safety Code survey, it was observed that smoke barrier walls on the second floor of the facility were not properly maintained. Specifically, the smoke barrier walls were incomplete from floor to ceiling/roof deck, lacked a 30-minute fire resistance rating, and had open and unsealed penetrations that could allow the passage of smoke. One instance involved a piece of damaged drywall outside Resident Room 422, which was hanging loosely and required securing and re-caulking with fire-rated caulk. Another instance was found outside the Director of Nursing's Office, where a one-inch square penetration with a blue wire passing through it was observed. The Director of Facilities acknowledged the issues and noted that regular smoke barrier audits were not currently performed, although they had been conducted in the past during a construction project.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 K372 Subdivision of Building Spaces – Smoke Barrier Construction 1. Corrective Action a. The Maintenance Department immediately secured the drywall piece and sealed the penetration using fire caulk in the smoke barrier outside of room 422 and sealed the penetration through the smoke barrier outside of the Director of Nursing’s office using fire caulk. b. Maintenance Staff were inserviced on inspection and maintenance of smoke barriers. 2. Identification of other smoke barriers having the potential to be affected The Director of Facilities and Maintenance Staff conducted a 100% audit of smoke barriers to ensure there were not any unsealed penetrations. 3. Systematic Changes The Director of Facilities and/or Maintenance Staff will conduct monthly audits of smoke barriers to ensure compliance. 4. Monitor Performance The Director of Facilities/designee will monitor monthly smoke barrier audits for 12 months. All audits will be reviewed quarterly at QA/QAPI meeting, and need for continuance after 12 months. 5. The Director of Facilities will be responsible for overall completion of the plan with respect to K372.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that as needed (PRN) orders for psychotropic drugs were limited to 14 days, as required by regulations. Specifically, for one resident, an as needed antianxiety medication, Ativan, was ordered for periods longer than 14 days without documented physician rationale to extend the duration of the order. The facility's policy on psychotropic medication use mandates that such medications are not prescribed on an as needed basis unless necessary for a diagnosed condition, and any extension beyond 14 days must be justified and documented by the prescriber. Resident #24, who had diagnoses including traumatic brain injury, anxiety disorder, and dementia, was cognitively intact and had no behavioral symptoms according to the Minimum Data Set. Despite this, the resident received multiple as needed orders for Ativan over an extended period without the required 14-day reevaluation and documentation of rationale for continuation. Observations and interviews with staff indicated that the resident's anxiety was stable, and there were no recent behavioral issues, suggesting that the extended use of Ativan may not have been necessary. Interviews with various staff members, including the Nurse Practitioner, Consultant Pharmacist, Medical Director, and Registered Nurse Supervisors, revealed a lack of awareness and oversight regarding the 14-day limitation for as needed psychotropic medications. The Consultant Pharmacist and Medical Director acknowledged the oversight, and the Social Worker confirmed that the as needed Ativan order was incorrectly set for 30 days instead of 14. The Director of Nursing and other staff noted improvements in the resident's condition, further questioning the need for prolonged use of the medication without proper documentation and review.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 758 483.45(e)(4) [MEDICAL CONDITION] Drugs 1. The facility currently has [MEDICAL CONDITION] Medication Use policy that ensures residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is deemed necessary to treat a diagnosed specific condition that is documented in the clinical record. Resident #24's chart was reviewed by the Medical provider and PRN [MEDICAL CONDITION] order was discontinued, and a corrected PRN [MEDICAL CONDITION] order was written immediately with stop date of 14 days. Two (2) separate audits by the Director of Nursing and Pharmacy Consultant on 3/19/25 were completed to ensure [MEDICAL CONDITION] medication use accuracy in all medical records. Audits will continue twice per month for the next 6 months. 2. Nursing Staff were educated immediately by the Director of Nursing with an in-service reviewing Policy and Procedure, Continuing education regarding [MEDICAL CONDITION] Medications and PRN Medication Administration. RN and LPN staff completed this in-service by 3/25/2025. The Director of Nursing, Pharmacist Consultant and Social Worker meet once monthly to review resident [MEDICAL CONDITION] use. All residents are reviewed monthly/quarterly and as needed. Residents that need GDRs are determined and reviewed by the Director of Nursing/designee and Medical Director. 3. The Director of Nursing reviewed all Resident Care plans for [MEDICAL CONDITION] drug use. As stated in our [MEDICAL CONDITION] Medication Use policy, residents will not receive [MEDICAL CONDITION] drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. 4. PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days except if the attending physician/designee believes that it is appropriate for the PRN order to be extended beyond 14 days. The Physician/designee will document any clinically contraindicated or specific conditions in clinical record along with their rationale and indicate the duration for the PRN order. 5. All (52) current resident’s medical records were audited to ensure all active PRN [MEDICAL CONDITION] medications have a 14-day stop date. If the order does not include the 14-day stop date, prescriber will be contacted and a corrected order will be issued. If the prescriber deems it appropriate to extend past 14 days, the prescriber will document rationale in the resident’s permanent medical record. An audit of the clinical record for PRN [MEDICAL CONDITION] Medications will continue twice monthly x 6 months by the DON/designee and/or Pharmacy Consultant. All audits will be reviewed quarterly for the next 6 months at QA/QAPI meetings. The Director of Nursing/designee will be responsible for the overall implementation of the plan of correction.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
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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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orchard Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Father Baker Manor | 2.3 mi | ★★★★★ | 1 | 1 |
| Elderwood At Hamburg | 4.8 mi | ★★★★★ | 3 | 0 |
| Autumn View Health Care Facility L L C | 5.1 mi | ★★★★★ | 3 | 0 |
| Seneca Health Care Center | 5.6 mi | ★★★★★ | 1 | 0 |
| Safire Rehabilitation Of Southtown, L L C | 5.8 mi | ★★★★★ | 16 | 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.