The Villages of Orleans Health and Rehabilitation Inspection Report, Violations & Safety Grade (ALBION, New York)

14012 ROUTE 31, ALBION, New York 14411

Phone: 5855895637

CMS Overall:1/5

Overview & Bed Count

Certified Beds

120

Avg Residents/Day

115.6

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Orleans

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall1/5

Health1/5

Staffing2/5

Quality2/5

Nurse Staffing Check

Metric	This Facility	New York Avg	Difference
RN Hours per Resident per Day	0.32	0.73	-0.41
Total Nurse Hours per Resident per Day	3.59	3.69	-0.10
CMS Staffing Rating	2/5	2.9/5	-
Nursing Staff Turnover	56.3%	40.3%	-

Health Citation History

26 health citations on record

Date	Category	Description	Severity
2026-08-21	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	G – Actual Harm
2026-08-21	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2025-11-17	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2025-01-31	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2025-01-31	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	E – Moderate Harm Potential
2025-01-31	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2025-01-31	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.	D – Moderate Harm Potential
2025-01-31	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	D – Moderate Harm Potential
2025-01-31	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	D – Moderate Harm Potential
2025-01-31	Pharmacy Service Deficiencies	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.	D – Moderate Harm Potential
2025-01-31	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	D – Moderate Harm Potential
2025-01-31	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2025-01-31	Nursing and Physician Services Deficiencies	Observe each nurse aide's job performance and give regular training.	C – Minimal Harm Potential
2025-01-31	Nursing and Physician Services Deficiencies	Post nurse staffing information every day.	B – Minimal Harm Potential
2024-01-12	Pharmacy Service Deficiencies	Ensure that residents are free from significant medication errors.	J – Immediate Jeopardy
2024-01-12	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2023-10-18	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	D – Moderate Harm Potential
2023-07-21	Nutrition and Dietary Deficiencies	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.	E – Moderate Harm Potential
2023-07-21	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	E – Moderate Harm Potential
2023-07-21	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2023-07-21	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	D – Moderate Harm Potential
2023-07-21	Resident Assessment and Care Planning Deficiencies	Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.	D – Moderate Harm Potential
2023-07-21	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2023-07-21	Nutrition and Dietary Deficiencies	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.	D – Moderate Harm Potential
2021-10-25	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2021-10-25	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential

Fire Safety Citation History

39 fire safety citations on record

Date	Category	Description	Severity
2025-01-31	Construction Deficiencies	Meet other general requirements.	E – Moderate Harm Potential
2025-01-31	Egress Deficiencies	Have exits that are accessible at all times.	E – Moderate Harm Potential
2025-01-31	Egress Deficiencies	Install emergency lighting that can last at least 1 1/2 hours.	E – Moderate Harm Potential
2025-01-31	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2025-01-31	Smoke Deficiencies	Provide properly protected cooking facilities.	E – Moderate Harm Potential
2025-01-31	Smoke Deficiencies	Have properly installed hallway dispensers for alcohol-based hand rub.	E – Moderate Harm Potential
2025-01-31	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	E – Moderate Harm Potential
2025-01-31	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2025-01-31	Smoke Deficiencies	Properly select, install, inspect, or maintain portable fire extinguishes.	E – Moderate Harm Potential
2025-01-31	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2025-01-31	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	E – Moderate Harm Potential
2025-01-31	Miscellaneous Deficiencies	Have restrictions on the use of portable space heaters.	E – Moderate Harm Potential
2023-07-21	Construction Deficiencies	Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.	E – Moderate Harm Potential
2023-07-21	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	E – Moderate Harm Potential
2023-07-21	Egress Deficiencies	Have exits that are accessible at all times.	E – Moderate Harm Potential
2023-07-21	Egress Deficiencies	Install proper backup exit lighting.	E – Moderate Harm Potential
2023-07-21	Egress Deficiencies	Have properly located and lighted "Exit" signs.	E – Moderate Harm Potential
2023-07-21	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2023-07-21	Smoke Deficiencies	Have properly installed hallway dispensers for alcohol-based hand rub.	E – Moderate Harm Potential
2023-07-21	Smoke Deficiencies	Properly provide smoke detection systems in areas open to corridors.	E – Moderate Harm Potential
2023-07-21	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2023-07-21	Smoke Deficiencies	Properly select, install, inspect, or maintain portable fire extinguishes.	E – Moderate Harm Potential
2023-07-21	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	E – Moderate Harm Potential
2023-07-21	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	E – Moderate Harm Potential
2023-07-21	Gas, Vacuum, and Electrical Systems Deficiencies	Have proper medical gas storage and administration areas.	E – Moderate Harm Potential
2023-07-21	Smoke Deficiencies	Install an approved automatic sprinkler system.	D – Moderate Harm Potential
2023-07-21	Emergency Preparedness Deficiencies	Establish staff and initial training requirements.	C – Minimal Harm Potential
2021-10-25	Construction Deficiencies	Meet other general requirements.	E – Moderate Harm Potential
2021-10-25	Construction Deficiencies	Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.	E – Moderate Harm Potential
2021-10-25	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2021-10-25	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2021-10-25	Smoke Deficiencies	Properly select, install, inspect, or maintain portable fire extinguishes.	E – Moderate Harm Potential
2021-10-25	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2021-10-25	Services Deficiencies	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	E – Moderate Harm Potential
2021-10-25	Gas, Vacuum, and Electrical Systems Deficiencies	Meet requirements for the installation and maintenance of electrical systems.	E – Moderate Harm Potential
2021-10-25	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	E – Moderate Harm Potential
2021-10-25	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	E – Moderate Harm Potential
2021-10-25	Egress Deficiencies	Have stairways and smokeproof enclosures used as exits that meet safety requirements.	D – Moderate Harm Potential
2021-10-25	Smoke Deficiencies	Provide properly protected cooking facilities.	D – Moderate Harm Potential

Total Penalties & Fines

$71,112

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2024-01-12	Fine	$71,112	-

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Need Help Finding Safe Care?

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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.