The Villages of Orleans Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at The Villages of Orleans Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Jan 12, 2024

  Based 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. […]

• Actual harm, isolatedF689Aug 21, 2026

  Based on interviews and record review conducted during survey, the facility failed toensure that a resident's environment remains as free of accidents as possible and receives adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents. Specifically, on 05/03/2026, Certified Nurse Aide #1 failed to follow Resident #1's care plan to use two person assist for bed mobility, resulting in Resident #1 falling to the floor and sustaining a head injury. Resident #1 later had a change in their condition and required transfer to the emergency room for an evaluation where they were diagnosed with post-concussive syndrome (mild traumatic brain injury caused by impact to the head). […]

• No harm, potential for more than minimal, widespreadF895Aug 10, 2023

  Based on interview and record review conducted during an Abbreviated survey completed on 8/10/23 the facility did not develop, implement and maintain an effective compliance and ethics program. Specifically, at a minimum the facility did not establish written compliance and ethics standards, policies, and procedures to follow that are reasonable capable of reducing the prospect of criminal, civil, and administrative violations under the Act. and promote quality of care, which include, but are not limited to, the designation of an appropriate compliance and ethics program contact to which individuals may report suspected violations, as well as an alternate method of reporting suspected violations anonymously without fear of retribution; and disciplinary standards that set out the… […]

• No harm, potential for more than minimal, patternF584Jan 31, 2025

  Based 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). […]

• No harm, potential for more than minimal, patternF689Jan 31, 2025

  Based 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. […]