Orchard Park Health Care & Rehab Center

In the surveyor’s words

From the most serious findings on record at Orchard Park Health Care & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 31, 2023

  Based on observation, interview and record review, the facility failed to ensure the safety of four of four sample residents who smoked (Residents 8, 9, 10 and 11) by failing to assess residents' ability to safely smoke without supervision; and by allowing, and assisting, residents to convene in a known resident smoking area on the facility property, unsupervised by staff, while oxygen was in use by one resident (Resident 8). In addition, the facility's designated smoking area did not have safety items readily available, as outlined in the facility policy. […]

• Actual harm, patternF689Jun 12, 2025

  <Elopement> Review of a facility's policy titled, Elopements (when a resident identified as wandering leaves the facility without staff knowledge or authorization) - Resident Behavior and Facility Practices, dated 02/21/2025 showed when a resident who exhibited wandering behavior and/or were at risk for elopement received adequate supervision to prevent accidents, and received care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement. Review showed monitoring and managing residents at risk for elopement and unsafe wandering showed the effectiveness of interventions would be evaluated and changes made as needed. […]

• Actual harm, isolatedF684Aug 19, 2026

  Based on observation, interview, and record review, the facility failed to ensure 2 of 3 residents (Residents 1 & 4) reviewed, received the necessary care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to ensure Resident 1, and Resident 4 had wheelchairs which fit properly and were in good repair. These failures placed Resident 1 and Resident 4 at risk skin breakdown, accidents/hazards, uncomfortable positioning, and diminished quality of life. […]

• Actual harm, isolatedF689Aug 19, 2026

  Based on interview and record review, the facility failed to provide the required care planned supervision to prevent accidents for 2 of 4 sample residents (Resident 2 & 5) reviewed for accidents/hazards. The facility failed to assess safety risks, provide adequate resident supervision, and implement fall and elopement care plans (CP). Resident 2, who had a history of falling, experienced harm when they fell out of bed and fractured their nose, requiring hospitalization, due to fall prevention interventions not being implemented. These failures placed the residents at a potential risk of harm related to avoidable incidents. Findings included .Review of the facility's Fall Management policy, dated 05/26/2021 showed residents would be assessed for fall risk upon admission to the facility. […]

• Actual harm, isolatedF550Aug 5, 2026

  Based on observation, interview and record review, the facility failed to provide care and services in a manner that maintained and promoted dignity for 10 of 10 sampled Residents (Resident 12, 8, 13, 1, 5, 4, 3, 7, 17 & 21) reviewed for resident rights. The facility failed to ensure staff spoke in the English language in common areas and while providing personal care for 8 of 10 sampled residents (Residents 12, 8, 13, 7, 5, 4, 3, & 21) and failed to answer call lights timely for 5 of 10 sampled residents (Residents 1, 17, 8, 12 & 13). […]