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🔎 The Villages Of Orleans Health And Rehab Center

Inspection Results


Inspection Overview

The Villages Of Orleans Health And Rehab Center has been cited for a total of 41 deficiencies since we began saving each survey.

In New York, the average facility has **24.69 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2025-01-31
Correction Date: 2025-03-14
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2025-01-31
Correction Date: 2025-03-14
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2025-01-31
Correction Date: 2025-03-14
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: C

Observe each nurse aide's job performance and give regular training.

Survey Date: 2025-01-31
Correction Date: 2025-03-14
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: B

Post nurse staffing information every day.

Survey Date: 2025-01-31
Correction Date: 2025-03-14
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2025-01-31
Correction Date: 2025-03-14
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2025-01-31
Correction Date: 2025-03-14
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2025-01-31
Correction Date: 2025-03-14
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2025-01-31
Correction Date: 2025-03-14
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2025-01-31
Correction Date: 2025-03-14
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2025-01-31
Correction Date: 2025-03-14
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Survey Date: 2024-01-12
Correction Date: 2024-02-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure that residents are free from significant medication errors.

Survey Date: 2024-01-12
Correction Date: 2024-02-09
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2023-10-18
Correction Date: 2023-11-16
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2023-08-10
Correction Date: 2023-09-15
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: F

Have a Compliance and Ethics Program.

Survey Date: 2023-08-10
Correction Date: 2023-09-15
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-07-21
Correction Date: 2023-09-08
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Survey Date: 2023-07-21
Correction Date: 2023-09-08
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2023-07-21
Correction Date: 2023-09-08
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2023-07-21
Correction Date: 2023-09-08
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-07-21
Correction Date: 2023-09-08
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2023-07-21
Correction Date: 2023-09-08
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Survey Date: 2023-07-21
Correction Date: 2023-09-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2022-12-01
Correction Date: 2023-01-27
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2022-11-30
Correction Date: 2023-01-27
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2022-02-08
Correction Date: 2022-02-25
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2022-02-04
Correction Date: 2022-02-25
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2021-10-25
Correction Date: 2021-12-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-10-25
Correction Date: 2021-12-24
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2021-04-26
Correction Date: 2021-06-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2021-04-26
Correction Date: 2021-06-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Survey Date: 2021-04-26
Correction Date: 2021-06-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: C

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Survey Date: 2021-04-26
Correction Date: 2021-06-24
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-04-26
Correction Date: 2021-06-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2021-04-26
Correction Date: 2021-06-24
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-12-17
Correction Date: 2021-01-22
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Perform COVID19 testing on residents and staff.

Survey Date: 2020-12-17
Correction Date: 2021-01-22
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Assist a resident in gaining access to vision and hearing services.

Survey Date: 2020-09-14
Correction Date: 2020-10-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-09-14
Correction Date: 2020-10-05
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2020-08-13
Correction Date: 2020-09-21
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2020-08-13
Correction Date: 2020-09-21
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**