Below 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 The Villages Of Orleans Health And Rehab Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of elopement risk had their wander guard discontinued without additional care plan interventions or increased monitoring. Despite ongoing exit-seeking behavior, no new safety measures were implemented, and the resident was later taken out of the facility by a housekeeper without proper authorization or sign-out, resulting in the resident being transported to their responsible party's home.
The facility failed to maintain a safe and comfortable environment, with temperatures in the Orchard View unit and [NAME] View South shower room consistently below the required range. Residents and staff reported feeling cold, and the [NAME] View North nurse's station was in disrepair, with broken doors and damaged furniture. Staff expressed dissatisfaction with the environment, noting it was not homelike or sanitary.
The facility failed to maintain a safe environment and provide adequate supervision, leading to potential hazards from hot electric fireplaces, an elopement incident involving a cognitively impaired resident, and improper use of safety devices for residents. Staff were not adequately trained on the risks associated with these issues, and care plans were not consistently followed, resulting in multiple deficiencies.
A resident with severe cognitive impairment received a COVID-19 vaccine despite their representative's verbal declination. The error occurred due to a miscommunication and procedural oversight, where the Assistant Director of Nursing mistakenly added the resident to a list for vaccination, which was used by an RN to administer the vaccine without verifying consent. Facility staff acknowledged the mistake, confirming the resident's rights were not honored.
A resident with cognitive impairments was subjected to a position change alarm without proper assessment or documented rationale. Observations showed frequent alarm activation without unsafe movements. Staff interviews revealed a lack of awareness of alternative interventions and no documentation of assessment for the alarm's use, leading to a deficiency in compliance with facility policy.
A resident reported an allegation of sexual abuse by a male aide, which was not reported to the Department of Health within the required timeframe. The Director of Nursing was informed but did not report the incident, citing insufficient evidence. Interviews with staff revealed a lack of adherence to the facility's abuse reporting policy.
The facility failed to conduct thorough investigations into allegations of abuse and an unexplained injury for two residents. A resident reported sexual abuse by a male aide, but the investigation lacked documentation and interviews. Another resident sustained a femur fracture, but not all staff were interviewed, and inconsistencies were found in statements. The facility did not meet regulatory requirements for investigating these incidents.
The facility failed to provide permanently affixed compartments for controlled drugs in two medication rooms. Controlled drugs were stored in a locked metal box inside a refrigerator that was not affixed to the wall or countertop, involving several residents. The lack of proper storage increased the risk for diversion, as acknowledged by LPNs and the Pharmacy Manager. The Director of Nursing was aware of the issue, but it had not been previously identified during pharmacy visits.
The facility was cited for deficiencies in food storage and preparation, including unlabeled and outdated food, improper storage of coffee mugs, and staff not wearing proper beard guards. Additionally, the facility failed to follow manufacturer's directions for preparing a texture-modified bread mix, resulting in a gritty texture for pureed hot dogs served to residents requiring a pureed diet.
The facility failed to implement Enhanced Barrier Precautions for two residents, one with a sacral pressure ulcer and another with a foley catheter. Staff did not use appropriate PPE during care activities, despite the presence of drainage and the need for infection control. Interviews revealed inconsistencies in understanding and applying EBP protocols.
The facility did not conduct annual performance reviews for CNAs, as required. Three CNAs, employed for over a year, lacked documented evaluations. The DON and Administrator acknowledged the absence of a structured process for these reviews, and the facility could not provide a relevant policy.
The facility did not consistently post daily nursing staff information, failing to update the current resident census and staff hours for four out of five days reviewed. Observations showed outdated or missing postings, and interviews revealed lapses in responsibility for updating the information, which should have been accessible to residents and visitors.
Failure to Implement Elopement Interventions After Removal of Wander Guard
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident identified as an elopement risk. The resident, who had diagnoses including diabetes mellitus, vascular dementia, and schizoaffective disorder bipolar type, was assessed as moderately cognitively impaired and required supervision or assistance with transfers and ambulation. The care plan identified the resident as an elopement risk due to a history of attempts to leave the facility and poor safety awareness, with interventions including the use of a wander guard bracelet. On 08/20/2025, the wander guard was discontinued after the resident repeatedly removed it, but no additional interventions or increased monitoring were implemented despite the resident remaining at risk for elopement. Following the removal of the wander guard, the resident continued to express a desire to leave the facility, as noted by staff who reported daily statements from the resident about wanting to leave or be discharged. However, there was no documentation of increased monitoring or alternative safety measures after the device was discontinued. The resident did not have a physician's order to go out on pass, and the care plan was not updated with new interventions to address the ongoing elopement risk. On 08/29/2025, the resident left the facility with a housekeeper, who was unaware of the policy prohibiting staff from taking residents out without proper authorization. The resident was transported approximately 45 minutes away to their responsible party's home without the required sign-out process or provider order. The responsible party was not expecting the resident and contacted facility staff to arrange for the resident's return. Interviews with staff and the housekeeper confirmed a lack of awareness and adherence to facility policies regarding elopement risk and resident outings.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by the inability to maintain ambient temperatures within the required range of 71-81 degrees Fahrenheit in several areas. Specifically, the Orchard View unit and [NAME] View South shower room were consistently below the minimum temperature, with readings as low as 67.5 degrees Fahrenheit in common areas and 62.2 degrees Fahrenheit in the shower room. Residents and staff reported feeling cold, and some residents were observed wearing additional clothing to stay warm. The Director of Maintenance acknowledged the difficulty in maintaining temperatures in common areas due to open doors and stated that the shower room likely needed resealing. Additionally, the [NAME] View North nurse's station and surrounding furniture were in disrepair, with broken hinged doors, chipped laminate countertops, and visibly soiled and damaged recliner chairs. Observations noted that the nurse's station was highly visible to residents and visitors, yet it presented a worn and unkempt appearance. Staff and residents expressed dissatisfaction with the condition of the furniture and the overall environment, noting that it was not homelike or sanitary. Interviews with staff, including the Director of Nursing and the Administrator, revealed a lack of awareness regarding the specific temperature requirements and the extent of the environmental issues. The Director of Maintenance and other staff members acknowledged the need for improvements, but there was no indication of immediate corrective actions being taken to address the deficiencies. The facility's failure to maintain a homelike environment and comfortable temperatures compromised the residents' right to a safe and comfortable living space.
Failure to Ensure Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. Specifically, the facility installed electric fireplaces in resident-accessible areas without adequate safety measures. These fireplaces, which were hot to the touch, posed a burn risk to residents, particularly those with cognitive impairments or loss of sensation. Staff members were not adequately trained on the safety risks associated with these fireplaces, and there were no clear guidelines on maintaining a safe distance for residents. A cognitively impaired resident with exit-seeking behaviors managed to elope from the facility undetected. Despite previous incidents indicating the resident's potential to wander, the facility did not update the resident's wandering risk assessment in a timely manner or increase supervision. The resident was found in the facility's parking lot, having exited through an unlocked door and gate. The facility's policies on elopement and wandering risk were not adequately followed, leading to the resident's unsupervised departure. Another resident did not have the necessary safety devices, such as bilateral foot pedals and a calf protector/footboard, in place as care planned. This oversight occurred despite the resident's care plan clearly indicating the need for these devices to prevent injury. Staff members were unaware of the care plan requirements, and the resident was observed multiple times without the necessary equipment. Additionally, a resident was transferred by a staff member and an untrained family member, contrary to the care plan that required a two-person assist due to the resident's combativeness.
Failure to Honor Resident's Right to Refuse COVID-19 Vaccine
Penalty
Summary
The facility failed to honor a resident's right to refuse treatment, specifically regarding the administration of a COVID-19 vaccine. Resident #69, who had severe cognitive impairment and was sometimes understood and sometimes understands, had a representative who verbally declined the COVID-19 vaccination on their behalf. Despite this, the resident received the vaccine, as documented in the facility's records and the New York State Immunization Information System. The error occurred due to a miscommunication and procedural oversight. The Assistant Director of Nursing mistakenly added Resident #69 to a list of residents scheduled to receive the COVID-19 booster, which was then used by Registered Nurse #4 to administer the vaccine. The nurse did not have access to the actual consent/declination forms at the time of administration, relying solely on the list provided. This oversight led to the resident receiving a vaccination against the representative's explicit instructions. Interviews with facility staff, including the Director of Nursing, Assistant Director of Nursing, and Registered Nurse #4, confirmed the miscommunication and procedural errors. The staff acknowledged that the resident's rights and wishes were not honored due to the mistake in the vaccination process. The facility's policy required obtaining and verifying consent before administering vaccines, which was not followed in this instance, resulting in the deficiency.
Failure to Assess and Document Use of Personal Alarm
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints that were not required to treat medical symptoms. Specifically, Resident #370 was subjected to a position change alarm without a proper assessment or documented rationale for its use. The facility's policy required a comprehensive assessment to determine the need for personal alarms, but this was not conducted for Resident #370. The resident, who had diagnoses including depression, dementia, and compression fractures of the spine, was severely cognitively impaired and required assistance for ambulation and transfers. Observations revealed that Resident #370 was frequently in a wheelchair with a personal alarm, which activated when the resident leaned forward. Despite the alarm's frequent activation, there was no evidence of unsafe movements or attempts to self-transfer. Interviews with staff indicated a lack of awareness regarding the necessity of the alarm and alternative interventions. Certified Nurse Aide #2 and Licensed Practical Nurse #1 were unsure of any other fall prevention measures besides the alarm, and there was no documentation of an assessment for its use. The Assistant Director of Nursing and the Director of Nursing both acknowledged the lack of documentation and assessment for the alarm's use. The Director of Nursing mentioned that less restrictive interventions could have been considered, but there was no evidence that these were tried before implementing the alarm. The facility's failure to document and assess the need for the alarm led to the deficiency, as it did not comply with the policy and procedure for the use of personal alarms.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the New York State Department of Health within the required timeframe. The incident involved a resident who was cognitively intact and had diagnoses including congestive heart failure, type 2 diabetes mellitus, and unspecified schizophrenia. The resident reported to a Physical Therapy Assistant that a male certified nurse aide had inappropriately touched their breasts. This information was relayed to the Director of Nursing, who did not report the allegation to the Department of Health, citing a lack of evidence to support the claim. Interviews with various staff members, including the Director of Nursing, Assistant Director of Nursing, and Licensed Practical Nurses, revealed a lack of adherence to the facility's policy on reporting abuse allegations. The Director of Nursing acknowledged being informed of the allegation but chose not to report it, despite being aware of the two-hour reporting requirement. The facility's policy mandates immediate reporting of abuse allegations, yet this protocol was not followed, resulting in a deficiency citation.
Inadequate Investigation of Abuse Allegations and Unexplained Injury
Penalty
Summary
The facility failed to ensure thorough investigations into allegations of abuse and injuries of unknown origin for two residents. Resident #70, who was cognitively intact and had diagnoses including congestive heart failure and schizophrenia, reported an incident of sexual abuse by a male certified nurse aide. Despite the report, there was no evidence of a comprehensive investigation, as the facility did not document interviews with staff or other residents, nor was there an investigation summary ruling out the abuse. Interviews with staff revealed that the allegation was known but not adequately documented or investigated, and the Director of Nursing admitted to not notifying the medical provider or emergency contact. Resident #320, who had severe cognitive impairment and a history of falls, sustained a femur fracture of unknown origin. The facility's investigation was incomplete, as not all staff who had contact with the resident were interviewed, and there were inconsistencies in the employee statements. The Director of Nursing acknowledged that the investigation should have included interviews with all staff who interacted with the resident 48 hours prior to the injury being noted, but this was not done. The Administrator expressed expectations for thorough investigations in both cases, including obtaining detailed staff statements and documenting all interviews. However, the facility's failure to conduct comprehensive investigations into these incidents resulted in deficiencies in addressing the allegations of abuse and the unexplained injury, as required by state and federal regulations.
Improper Storage of Controlled Drugs in Medication Rooms
Penalty
Summary
The facility failed to provide separately locked, permanently affixed compartments for the storage of controlled drugs in two of the three medication rooms observed. In both the Garden View and [NAME] View North medication rooms, controlled drugs were stored in a locked metal box inside a locked refrigerator that was not permanently affixed to the wall or countertop. Additionally, the Garden View medication refrigerator housed a locked metal box containing emergency narcotics that was not permanently affixed to the refrigerator. This involved Residents #6, 8, 40, and 82. The facility's policy required controlled substances requiring refrigeration to be kept double locked in the med room refrigerator within a metal locked box, but this was not adhered to. During observations and interviews, it was noted that the refrigerators were not secured, and the emergency narcotics box was not affixed, increasing the risk for diversion. Licensed Practical Nurses and the Pharmacy Manager acknowledged the lack of permanent affixation and the potential risk it posed. The Director of Nursing was aware of the situation but stated that it had not been identified as an issue during pharmacy visits. The report highlights the facility's failure to ensure proper storage of controlled substances, as required by regulations, which could lead to potential diversion of medications.
Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility was found to have several deficiencies in food storage, preparation, and service during a standard survey. Observations revealed that the kitchen had open and undated packages of sliced corned beef and turkey in the refrigerator, and premade sandwiches and canned fruit in the walk-in cooler that were past their use-by dates. Additionally, plastic coffee mugs were improperly stored right side up and uncovered, and the kitchen had stained ceiling tiles and a soiled floor beneath the coffee station. The survey also identified issues with staff not adhering to food safety protocols. A staff member with facial hair was observed in the kitchen without a proper beard guard, and there was confusion about whether a surgical mask could serve as an adequate substitute. The Food Service Director and Registered Dietitian both acknowledged that staff with facial hair should wear beard guards at all times in the kitchen, but there was uncertainty about the adequacy of surgical masks as a substitute. Furthermore, the facility failed to follow the manufacturer's directions for preparing a texture-modified bread mix during the preparation of pureed hot dogs for residents requiring a pureed diet. The staff member responsible for the preparation did not review the manufacturer's instructions and added the bread mix directly to the pureed hot dogs without proper mixing, resulting in a gritty texture. The Registered Dietitian confirmed that the directions should be followed, and the bread mix should not be added directly from the box into food.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for two residents. Resident #42, who had a stage 3 sacral pressure ulcer, was not placed on EBP despite having a draining wound. Observations revealed that there was no EBP signage or personal protective equipment (PPE) available in Resident #42's room, and staff did not wear appropriate PPE during wound care. Interviews with staff indicated a misunderstanding of the criteria for implementing EBP, as they believed it was unnecessary if the wound culture was clear, despite the presence of drainage. Resident #89, who had an indwelling foley catheter, was also not properly managed under EBP. Although the resident's care plan and room signage indicated the need for gown and gloves during high-contact activities, staff were observed emptying the urinary catheter bag without wearing a gown. This action was contrary to the facility's policy and the posted EBP requirements, which were intended to prevent the spread of infection through potential contact with urine. Interviews with the facility's nursing staff, including the Assistant Director of Nursing and the Director of Nursing/Infection Preventionist, revealed inconsistencies in the understanding and implementation of EBP. Staff acknowledged the importance of using PPE to protect against infection transmission but failed to consistently apply these precautions. The lack of adherence to EBP protocols for residents with open wounds and indwelling devices highlights a deficiency in the facility's infection control practices.
Lack of Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received performance reviews at least once every 12 months, as required. This deficiency was identified during a standard survey, which revealed that three CNAs, who had been employed for over a year, did not have documented performance reviews. Specifically, CNA #7, hired in November 2017, CNA #8, hired in July 2023, and CNA #9, hired in November 2020, all lacked evidence of annual performance evaluations in their employee files. Interviews conducted during the survey further highlighted the absence of a structured process for conducting these evaluations. The Director of Nursing acknowledged that the facility did not perform annual performance reviews for CNAs and lacked a system to track when these evaluations were due. The Administrator confirmed the historical absence of performance evaluations and recognized the importance of assessing CNAs' competencies to ensure quality care. The facility was also unable to provide a policy or procedure for conducting annual performance evaluations.
Failure to Post Daily Nursing Staff Information
Penalty
Summary
The facility failed to ensure that the nursing staff information was posted daily and contained the required information, as observed during a standard survey. Specifically, the facility did not post the current resident census and the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift in a prominent place accessible to residents and visitors for four out of five days reviewed. Observations on various dates revealed that the Daily Staffing form was either outdated or not posted at all on the bulletin board located in the front entrance hallway. Interviews with the Human Resource Manager and the Director of Nursing revealed that the responsibility for posting the Daily Staffing form was not consistently fulfilled. The Human Resource Manager admitted to not posting the forms for several days and acknowledged the importance of having the information available for families. The Director of Nursing was unaware of the lapse in posting and stated that the form should be accessible to visitors, families, and residents. The facility's policy required the nursing supervisor or designee to update the staffing information at the beginning of each shift, but this was not consistently done.
What surveyors are citing around you — mapped
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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 43 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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 Albion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orchard Rehabilitation & Nursing Center | 3.6 mi | ★★★★★ | 2 | 0 |
| Medina Memorial Hospital Snf | 4.9 mi | ★★★★★ | 0 | 0 |
| Absolut Center For Nursing And Rehabilitation At G | 14 mi | ★★★★★ | 1 | 1 |
| Western New York State Veterans Home | 15.8 mi | ★★★★★ | 0 | 0 |
| The Grand Rehabilitation And Nursing At Batavia | 16 mi | ★★★★★ | 1 | 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.