Cycle 1
Health 2025-03-07 · Fire 2025-03-07
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Orchard Park, NY
Fox Run At Orchard Park
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
One Fox Run Lane, Orchard Park, NY
(716) 662-5001
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-02-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.02
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.66
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.50
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
4.18
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.24
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.11
CMS adjusted RN staffing hours
Adjusted total hours
4.90
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
254
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
75.53
Composite VBP score used to determine payment impact.
Payment multiplier
1.0246
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
10
Baseline 18.37% · Performance 22.00% · Measure score 10 · Achievement 10 · Improvement 0
Adjusted total nurse staffing
5.11
Baseline 4.56 hours · Performance 4.53 hours · Measure score 5.11 · Achievement 5.11 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.24% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 3.45% · Lower 95% interval 5.9% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.55 |
1.02
0.5 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 13.01% |
8.2%
4.8 pts better
|
Numerator 16 · Denominator 123 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
91.2%
2.7 pts better
|
93.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 91.1% · Q3 95.7% · Q4 95.7% · 4Q avg 93.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.0%
0.3 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.2% · Q3 4.3% · Q4 4.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
18.5%
16.6 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 9.2% |
6.1%
3.1 pts worse
|
5.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.9% · Q3 11.6% · Q4 10.0% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.4% |
13.5%
7.9 pts worse
|
19.6%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 21.4% · Q3 23.9% · Q4 19.0% · 4Q avg 21.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.4% |
14.8%
8.4 pts better
|
16.7%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 8.6% · Q3 2.9% · Q4 2.6% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 47.4% |
15.1%
32.3 pts worse
|
16.3%
31.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 47.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.0% |
15.5%
13.5 pts worse
|
14.9%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 37.1% · Q3 29.3% · Q4 16.7% · 4Q avg 29.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.4% |
0.6%
3.8 pts worse
|
1.0%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 6.6% · Q3 1.7% · Q4 1.4% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.6% |
1.4%
4.2 pts worse
|
1.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 2.2% · Q3 8.5% · Q4 4.3% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.7% |
20.8%
8.1 pts better
|
19.8%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 15.3% · Q3 12.8% · Q4 4.6% · 4Q avg 12.7% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
6.9%
1.6 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 11.7% · Q3 4.1% · Q4 6.0% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
76.7%
12.8 pts better
|
81.7%
7.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.6% · Q2 89.1% · Q3 95.5% · Q4 91.4% · 4Q avg 89.5% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.6% |
78.8%
14.8 pts better
|
79.7%
13.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-27 · Fire 2023-10-27
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-07-01 · Fire 2022-07-01
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-03-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-21
E · Potential for more than minimal harm
2023-10-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-14
D · Potential for more than minimal harm
2023-10-27
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-11-14
E · Potential for more than minimal harm
2022-07-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-07-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-02
D · Potential for more than minimal harm
2022-07-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-07-25
Penalties and ownership
What sits behind the stars
Ownership
Kueker, Michael
Operational/Managerial Control · Individual
Manufacturers & Traders Trust Company
Operational/Managerial Control · Organization
Morrison Management Specialists Inc
Operational/Managerial Control · Organization
Olsen, Allysa
Operational/Managerial Control · Individual
Szalach, Jill
Corporate Officer · Individual
Thoman, Patricia
Operational/Managerial Control · Individual
Wlodarczyk, William
Corporate Officer · Individual
Nearby options
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Father Baker Manor
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5-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Elderwood At Hamburg
Hamburg, NY
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Autumn View Health Care Facility L L C
Hamburg, NY
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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