The Villages of Orleans Health and Rehabilitation

Inspectors wroteBased on observation, interview, and record review conducted during an Abbreviated survey (#2604865) the facility did not ensure each resident receives adequate supervision to prevent elopement for one (1) (Resident #1) of three (3) residents reviewed for elopement. Specifically, the facility discontinued Resident #1's wander guard on 08/20/2025, the facility did not implement additional care plan interventions after the removal of a wander guard (device that alarms if the resident leaves a designated area). The resident did not have a physicians order to go out on pass and left the faciity on [DATE] with a staff member, Housekeeper #1. The finding is:The policy titled Elopement/Missing Resident dated 07/2024 documented patients/residents identified at risk to elope will have an individualized interdisciplinary plan of care. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Recertification survey completed 1/31/25, the facility did not provide a safe, clean, comfortable and homelike environment; and did not maintain comfortable temperatures levels between 71 degrees Fahrenheit to 81 degrees Fahrenheit for three (Orchard View, [NAME] View South, and [NAME] View North) of five resident units. Specifically, air temperatures were not maintained above 71 degrees Fahrenheit in resident common areas (Orchard View) and a resident shower room ([NAME] View South). Additionally, the [NAME] View North nurse's station structure/area that was visible and used by to residents had broken hinged doors, chipped laminate countertops, scratched and chipped paint; recliner chairs and straight back chairs that were in disrepair; and a 2-person sofa that was visibly soiled.

Inspectors wroteBased on observations, interviews, and record review conducted during a Complaint (Complaint #NY00349205, #NY00338010) investigation during the Standard survey completed on 1/31/25, the facility did not ensure that the resident environment remained as free from accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for six (Orchard View lounge area, Canal View lounge area, [NAME] View South lounge area, Main Lobby , Villages Dining Room, Garden View lounge area) of seven resident areas and three (Resident #s 11, 115 and 320) of five residents reviewed for accidents. [...]

Inspectors wroteBased on interview and record review conducted during a Complaint investigation (#NY00357991) during a Standard survey completed on 1/31/25, the facility did not ensure that a resident has the right to refuse treatment for one (1) (Resident #69) of five (5) residents reviewed for immunizations. Specifically, Resident #69's Representative did not give consent for a COVID-19 vaccine, and the resident received it. The finding is: The policy and procedure titled COVID-19 Vaccination for Residents, with a revised date of 12/2024 documented to obtain a verbal and/or written consent and/or declination from recipient or qualified representative and note in the immunization tab of the medical record prior to administration of the COVID-19 vaccination. The policy documented the administering nurse would verify consent prior to administering the vaccine. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 1/31/2025, the facility did not ensure residents were free from physical restraints imposed for purposes of discipline or convenience that were not required to treat the resident's medical symptoms, used for the least amount of time and document ongoing re-evaluation of the need for restraints for one (Resident #370) of three residents reviewed for physical restraints. Specifically, Resident #370 had no assessment/evaluation for the initiation of the use of a position change alarm. Additionally, there was no documented evidence to address the reason that warranted the use of the device. The finding is: [...]

Inspectors wroteBased on interview and record review conducted during a Standard Survey completed 1/31/25, the facility did not ensure that all alleged violations including abuse were reported immediately, but not later than two hours after the allegation was made to the State Survey Agency for one (Resident #70) of seven residents reviewed. Specifically, the Director of Nursing was notified of an allegation of resident sexual abuse, and it was not reported to the New York State Department of Health as required. The finding is: The policy and procedure titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last revised 10/19 documented the facility prohibits abuse. Abuse: Shall mean, inappropriate physical contact with a resident. Inappropriate physical contact includes but is not limited to sexual molestation. When to report: In response to allegations of abuse the facility must: [...]

Inspectors wroteBased on interview and record review conducted during a Complaint Investigation (#NY00338010) conducted during the Standard survey completed on 1/31/25, the facility did not ensure that all alleged allegations of abuse, neglect, or mistreatment were thoroughly investigated for two (Resident #70 and #320) of seven residents reviewed. Specifically, there was a lack of evidence thorough investigations were completed into an allegation of sexual abuse (#70) and a femur fracture of unknown origin (#320).

Inspectors wroteBased on observation, interview, and record review conducted during a Standard Survey completed on 1/31/25, the facility did not provide separately locked, permanently affixed compartments for the storage of controlled drugs for two (2) (Garden View and [NAME] View North) of three (3) medication rooms observed. Specifically, in both medication rooms, controlled drugs were stored in a locked metal box, inside a locked small 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.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 1/31/25, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues with foods being unlabeled or outdated in the refrigerators; stained, worn ceiling tiles, lack of [NAME] #2 wearing a beard guard in food preparation areas. Additionally, during the puree observation texture modified bread mix was not prepared and used in accordance with the manufacturer's directions.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 1/31/25 the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infection for two (Resident #42 and Resident #89) of five residents reviewed for Enhanced Barrier Precautions. Specifically, Enhanced Barrier Precautions were not initiated for Resident #42 who had a sacral pressure ulcer and staff did not wear appropriate personal protective equipment (PPE) during pressure ulcer care. [...]

Inspectors wroteBased on record review and interview conducted during the Standard survey completed on 1/31/25, the facility did not ensure Certified Nurse Aide performance reviews were completed once every 12 months per year for three (Certified Nurse Aides #7, #8, #9) of five reviewed. Specifically, there was no evidence Certified Nurse Aide #7, #8, and #9 who had worked for the facility more than 12 months had performance reviews completed at least once every 12 months. Additionally, the facility did not have a process/system in place to conduct annual performance evaluations for certified nurse aides. The finding is: Review of Certified Nurse Aide #7 employee file revealed they were hired on 11/24/17 and there was no evidence that an annual performance review had been completed. [...]

Inspectors wroteBased on observation and interviews conducted during the Standard survey completed on 1/31/25, the facility did not ensure the nursing staff information was posted on a daily basis and contained the required information. Specifically, the facility did not post daily the current resident census and the total number, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift in a prominent place readily accessible to residents and visitors for 4 of 5 days reviewed. The undated policy and procedure titled BIPA Staff Posting documented the nursing supervisor or designee will post the facilities staffing at the beginning of their shift. The 3:00 PM -11:00 PM and 11:00 AM -7:00 AM nursing supervisor/designee will update this information for their shift. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Partial Extended Abbreviated survey (Complaint #NY00331042) started on 1/10/24 and completed on 1/12/24, the facility failed to ensure that residents were free from significant medication errors for one (Resident #1) of three residents reviewed. Specifically, on 1/4/24 Licensed Practical Nurse #1 dispensed Resident #2's 5:00 PM medications and directed Licensed Practical Nurse #2 to administer the medications to Resident #2. Licensed Practical Nurse #2 did not verify the medications and dosages. Neither Nurse verified the resident, and Licensed Practical Nurse #2 erroneously administered Resident #2's medications to Resident #1. Subsequently, Resident #1 had a change in condition, became confused and had incoherent speech. Resident #1 was transferred to the hospital on 1/4/24 at 8:15 PM via ambulance and admitted . [...]

Inspectors wroteBased on interview and record review conducted during a Partial Extended Abbreviated survey (Complaint #NY00331388) completed on [DATE], the facility did not ensure that required documentation was sent to the receiving provider in a hospital transfer for one (Resident #1) of three residents reviewed. Specifically, on [DATE] Resident #1 was transferred to the hospital emergently, after a significant medication error. Licensed Practical Nurse #6 did not provide the hospital provider with the correct Medical Orders for Life-Sustaining Treatment (advanced directives) form which resulted in a delay of treatment for Resident #1. The finding is: Resident #1 had diagnoses of metabolic encephalopathy (neurological disorder), dysphagia (difficulty swallowing), hypertension (high blood pressure), and traumatic brain injury. [...]

Inspectors wroteBased on interview and record review conducted during an Abbreviated survey (Complaint # NY00325970) completed on 10/18/23, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to appropriate officials (including the State Survey Agency) for one (Resident #1) of four residents reviewed. Specifically, facility staff did not report alleged physical and verbal abuse of a resident to the Director of Nursing (DON) or the Administrator which resulted in the alleged abuse not getting reported to the appropriate officials including the New York State (NYS) Department of Health (DOH) as required. This finding is: [...]

Inspectors wroteBased on interview and record review conducted during a Standard survey completed 7/21/23, the facility did not employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Specifically, one of one facility reviewed for sufficient staffing did not have a full-time (working 35 or more hours a week) qualified Director of Food and Nutrition services. The finding is: Refer to F 802, F 803, and F 812 for related information. The undated policy titled Role of the Dining Services Director documented the Dining Services Director effectively manages the Dietary Department to assure that the food service is safe, appetizing, and nutritious. Qualifications include enrollment and/or completion of an approved educational program. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 7/21/23, the facility did not provide food and drink that was palatable, and at a safe and appetizing temperature for five ([NAME] View North and South, Canal View, Garden View, and the Villages Main Dining Room) of five test trays. Specifically, food and beverages during meals were served at suboptimal temperatures and were not palatable. Residents #37, #87, and #114 were involved.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 7/21/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues: undated or outdated food items, improper use of the dish machines heat booster causing low rinse temperatures with multiple blanks on the temperature log for July 2023, walk in freezer was not functioning correctly causing ice build around the door frame, ice buildup on the boxes under the condenser, and ice bubbles forming on the ceiling of the freezer. [...]

Inspectors wroteBased on interview and record review conducted during a complaint investigation (#NY00299607) completed on a Standard survey completed 7/21/23, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made to the appropriate officials (including the State Survey Agency). Specifically, two (#69 and #124) of two residents reviewed for alleged sexual abuse was not reported timely to the New York State (NYS) Department of Health (DOH) as required. The finding is: The policy and procedure (P&P) titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property with revision date of 10/19 documented that identified professionals are to report to the NYSDOH when they have reasonable cause to believe that abuse has occurred. [...]

Inspectors wroteBased on interview and record review conducted during a complaint investigation (Complaint #NY00310713) conducted during the Standard survey completed on 7/21/23, the facility did not ensure completion of the discharge summary to included but not limited to a recapitulation of the residents stay and any arrangements that have been made for the resident's follow up care and post-discharge medical and non-medical services for one (Resident #420) of four residents reviewed for discharge. Specifically, the resident was discharged to home without a recapitulation of the resident's stay, a final summary of the resident's status or a post discharge plan of care. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard Survey completed on 7/21/23, the facility did not provide adequate supervision and assistive devices to prevent accidents for two (Residents #31 & #32) of four residents reviewed for falls. Specifically, staff used the wrong size sling when Resident #31 was transferred from the wheelchair to the bed which resulted in the resident falling to the floor. In addition, during an observed mechanical lift transfer of Resident #32 from the bed to the Geri-chair, staff incorrectly attached the sling to the lift. The care plans for Resident's #31 & #32 did not include the size or type of transfer sling to use.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 7/21/23, the facility did not ensure developed and prepared menus to meet resident choices including their nutritional, religious, cultural, and ethnic needs were met. One of one kitchen did not provide correct food items as listed on residents' meal tickets. Specifically, Resident #20 on 7/20/23 had No Pork printed on the meal ticket and received a BBQ (barbequed) pork sandwich. Resident #86 on 7/17/23 was to receive a puree diet with honey thick liquids in bowls and received a regular texture diet with their honey-thick liquids in glasses. During additional meal observations both Resident #20 and #86 did not receive food items that were listed on their meal tickets.

Inspectors wroteBased on record review and interviews conducted during the Standard survey completed on 10/25/21, the facility did not honor the resident's right to formulate an advance directive for two (Resident #18, 24) of two residents reviewed. Specifically, Resident #18 and Resident 24 had Medical Orders for Life Sustaining Treatment (MOLST, a set of medical orders for advance directive status) that included the instructions for no weights and no laboratory (labs) testing (blood work); weights and laboratory tests were obtained for resident #18 and Resident #24.

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (Complaint # NY00278907) during the Standard survey completed on 10/25/21, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #27) of seven residents reviewed for accidents. Specifically, Resident (#27) with a history of a bruise of unknown origin, that the facility concluded occurred during a transfer, was observed to be transferred by staff without the use of a gait belt (assistive device used to help safely transfer a resident). The finding is: [...]