Orchard Park Rehab & Living Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF887Dec 11, 2024

  Based on review of the facility's Infection Control Immunizations - Influenza, Pneumococcal, COVID and Employee Immunization/Vaccination Requirements policy and procedures and interviews the facility failed to develop and implement policy and procedure to ensure all staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine or information on obtaining COVID-19 vaccine. This has the potential to effect all employees. Findings: Review of the Infection Control Immunizations - Influenza, Pneumococcal, COVID policy, last revised on 12/24, and the Employee Immunization/Vaccination Requirements policy, last revised on 9/5/23 failed to include procedures relating to staff education regarding the benefits and potential risks associated with COVID-19… […]

• No harm, potential for more than minimal, widespreadF880Oct 12, 2023

  Based on interviews, and record review, the facility failed to assess and have measures in place to monitor and prevent the growth of Legionella and other opportunistic waterborne pathogens in the facility resulting in the potential for harm to all residents in the facility. Finding: On 10/12/23, the facility's Legionella Prevention Program policy developed July 2019 was reviewed. Under procedure - The following employees will be on the Water Management Team: The Administrator, the Infection Control Specialist, the Maintenance Director and the Corporate Plant Manager. The policy indicates to 1. Describe your building water systems. 2. Describe your building water systems using a flow diagram. 3. Identify areas where Legionella could grow & spread on the flow diagram. 4. […]

• No harm, potential for more than minimal, patternF842Jun 25, 2026

  Based on record reviews, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 sampled residents reviewed during a complaint investigation (Resident's #1).Findings: Review of facility policy CNA Documentation dated 1/19 states Resident care will be documents in an accurate and efficient manner by CNA's as a means of reviewing resident status and progress toward identified goals The CNA Daily flow sheet will be completed each shift by the CNA assigned to the resident. Using the codes provided on the form, the CNA is to indicate the care provided . […]

• No harm, potential for more than minimal, patternF584Jan 22, 2026

  Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 Units (Cortland, Northern Spy and [NAME]), the Therapy room, a common area, and the laundry room for 2 of 2 environmental tours (1/20/26 and 1/22/26).Findings: 1. On 1/20/26 at 10:56 a.m., 2 surveyors observed multiple cooking dishes stacked under the therapy room sink next to and below the drainpipe. At this time, in an interview with two surveyors present, a Certified Occupational Therapy Aide (COTA) confirmed the finding. […]

• No harm, potential for more than minimal, patternF656Jan 22, 2026

  Based on record reviews and interviews, the facility failed to ensure a resident's care plan was developed and implemented to reflect the current needs of the resident for 2 of 14 residents reviewed for care planning (Residents #25, #28).Findings:1. Resident #25 was admitted with diagnoses to include presence of cardiac pacemaker.Review of Resident #25's clinical record revealed a provider progress note dated 11/11/25 that indicated, under active diagnoses, the presence of a cardiac pacemaker. […]