Deficiency Index

Fox Run at Orchard Park

Orchard Park, New York · CCN 335854

11 surveys since 2011, 2 of them producing a finding at harm level or worse.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
23
Surveys
11
Harm or worse
2
Immediate jeopardy
2
The record, 2011–2025
’11’15’20’25
No harm recordedHarm or worseNot surveyed
Immediate jeopardy2

Findings at the most serious level CMS records.

Beyond CMS’s monthly file9/11

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
60
Ownership
For profit - Corporation
Chain
Independent
County
Erie
Medicare-certified since
2008

CMS ratings

Overall
5
Health inspection
5
Staffing
5
Quality measures
4

CMS’s own Five-Star ratings.

Compared with similar facilities

Not shown for this facility: too few citations in window (n=3, floor 20).

Last survey on record

Mar 7, 2025

612 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day4.593.60
Registered-nurse hours per resident day0.95—
Annual nurse turnover29.3%48.7%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

No fines, payment denials or special-focus designation on the current CMS record.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD2100.0%E—F—
No harm, potential for minimalA—B—C—
CMS’s current file: 2 of the 23 citations on record.

In the surveyor’s words

From the most serious findings on record at Fox Run at Orchard Park, in the surveyor’s own words.

  • No harm, potential for more than minimal, patternF880Jan 13, 2021

    Based on interview and record review conducted during the Focused Infection Control COVID-19 survey completed on 1/13/21, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility did not ensure employees were screened for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks every 12 hours while on duty. […]

  • No harm, potential for more than minimal, isolatedF758Mar 7, 2025

    Based on observation, interview, and record review conducted during the Standard survey completed on 3/7/25, the facility did not ensure that as needed (PRN) orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the order to be extended beyond 14 days; they should document their rationale in the resident's medical record and indicate the duration for the as needed order. Specifically, for one (1) (Resident #24) of five (5) residents reviewed for unnecessary medications an as needed psychotropic antianxiety medication was ordered longer than 14 days. Additionally, there was no documented physician rationale to extend the duration of the order. […]

  • No harm, potential for more than minimal, isolatedF677Jul 1, 2022

    Based on observation, interview and record review completed during a Standard survey conducted from 6/27/22 through 7/1/22, the facility did not ensure that each resident who was unable to carry out activities of daily living (ADL's) receives the necessary services to maintain grooming and personal hygiene for one (Resident #31) of one resident reviewed for ADL's. Specifically, staff provided incomplete incontinence care, including retraction of the foreskin to Resident #31. Additionally, staff did not change their gloves and perform hand hygiene after they provided fecal incontinence care and prior to applying Resident #31's clean brief and clothing. […]

Read 20 findings in full →The most serious and the most recent: 20 of 23 on record.

Every survey on record

FindingsAt actual harm or above

  • Mar 7, 2025Standard1 finding
  • Jul 1, 2022Standard1 finding
  • Jan 13, 2021Infection control1 finding
  • Sep 28, 2018Standard1 finding
  • Aug 3, 2017Standard2 findings
  • Aug 24, 2016Standard3 findings
  • Aug 27, 2015Standard2 findings
  • Jan 29, 2015Standard and complaint5 findings
Show the 3 earlier surveys
  • Jun 6, 2014Standard and complaint4 findings · 2 harm
  • Oct 11, 2012—2 findings
  • Nov 15, 2011—1 finding

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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