Albion, NY

The Villages Of Orleans Health And Rehab Center

1-star overall rating with 1-star inspections with $71,112 in total fines with 12 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle

14012 Route 31, Albion, NY

(585) 589-5637

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

119

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1967-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.25

Registered nurse staffing

LPN hours / resident day

0.98

Licensed practical nurse staffing

Aide hours / resident day

2.15

Nurse aide staffing

Weekend hours

3.03

Weekend nurse staffing

RN turnover

80%

Annual RN turnover

Total nurse turnover

75%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.7	1.7 About the same	1.9 0.2 pts better	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	1.2	1.3 0.1 pts better	1.8 0.6 pts better	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	96.7%	91.2% 5.5 pts better	93.4% 3.3 pts better	Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents experiencing one or more falls with major injury	5.3%	3.0% 2.3 pts worse	3.3% 2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	1.4%	18.5% 17.1 pts better	11.4% 10 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	7.0%	6.1% 0.9 pts worse	5.4% 1.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.8%	13.5% 2.3 pts worse	19.6% 3.8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	27.0%	14.8% 12.2 pts worse	16.7% 10.3 pts worse	Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened	10.9%	15.1% 4.2 pts better	16.3% 5.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	14.4%	15.5% 1.1 pts better	14.9% 0.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.5%	0.6% 0.1 pts better	1.0% 0.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	1.4%	1.4% About the same	1.7% 0.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	25.3%	20.8% 4.5 pts worse	19.8% 5.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	7.8%	6.9% 0.9 pts worse	5.1% 2.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	55.7%	76.7% 21 pts worse	81.7% 26 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	17.5%	9.7% 7.8 pts worse	12.0% 5.5 pts worse	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	3.3%	1.2% 2.1 pts worse	1.6% 1.7 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	80.6%	78.8% 1.8 pts better	79.7% 0.9 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.6%	20.6% About the same	23.9% 3.3 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-31 · Fire 2025-01-31

12 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

12 fire-safety deficiencies

Top issue: Smoke (7 deficiencies)

Cycle 2 Health 2023-07-21 · Fire 2023-07-21

7 health deficiencies

Top issue: Nutrition and Dietary (4 deficiencies)

15 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 3 Health 2021-10-25 · Fire 2021-10-25

7 health deficiencies

Top issue: Resident Rights (3 deficiencies)

12 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-01-31

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2025-03-14

E · Potential for more than minimal harm 2025-01-31

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2025-03-14

E · Potential for more than minimal harm 2025-01-31

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-03-14

E · Potential for more than minimal harm 2025-01-31

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 2025-03-14

E · Potential for more than minimal harm 2025-01-31

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-03-14

E · Potential for more than minimal harm 2025-01-31

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2025-03-14

E · Potential for more than minimal harm 2025-01-31

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-04-11

E · Potential for more than minimal harm 2025-01-31

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-03-14

E · Potential for more than minimal harm 2025-01-31

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-03-14

E · Potential for more than minimal harm 2025-01-31

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-03-14

E · Potential for more than minimal harm 2025-01-31

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-03-14

E · Potential for more than minimal harm 2025-01-31

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2025-03-14

E · Potential for more than minimal harm 2023-07-21

K111 · Construction Deficiencies

Fire Safety

Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

Corrected 2023-09-08

E · Potential for more than minimal harm 2023-07-21

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-09-08

E · Potential for more than minimal harm 2023-07-21

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2023-09-08

E · Potential for more than minimal harm 2023-07-21

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2023-09-08

E · Potential for more than minimal harm 2023-07-21

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-09-08

E · Potential for more than minimal harm 2023-07-21

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 2023-09-08

E · Potential for more than minimal harm 2023-07-21

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2023-09-08

E · Potential for more than minimal harm 2023-07-21

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2023-09-08

E · Potential for more than minimal harm 2023-07-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-09-08

E · Potential for more than minimal harm 2023-07-21

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-09-08

E · Potential for more than minimal harm 2023-07-21

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-09-08

E · Potential for more than minimal harm 2023-07-21

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-10-15

E · Potential for more than minimal harm 2023-07-21

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-07-21

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-09-08

C · Minimal harm 2023-07-21

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2023-09-08

E · Potential for more than minimal harm 2021-10-25

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2021-12-24

E · Potential for more than minimal harm 2021-10-25

K111 · Construction Deficiencies

Fire Safety

Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

Corrected 2021-12-24

E · Potential for more than minimal harm 2021-10-25

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 2021-12-24

E · Potential for more than minimal harm 2021-10-25

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-12-24

E · Potential for more than minimal harm 2021-10-25

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2021-12-24

E · Potential for more than minimal harm 2021-10-25

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2021-12-24

E · Potential for more than minimal harm 2021-10-25

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2021-12-24

E · Potential for more than minimal harm 2021-10-25

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2021-12-24

E · Potential for more than minimal harm 2021-10-25

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2021-12-24

E · Potential for more than minimal harm 2021-10-25

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2021-12-24

D · Potential for more than minimal harm 2021-10-25

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2021-12-24

D · Potential for more than minimal harm 2021-10-25

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2021-12-24

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-11-17

F689 · Quality of Life and Care Deficiencies

Health

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

Not marked corrected

E · Potential for more than minimal harm 2025-01-31

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2025-03-14

E · Potential for more than minimal harm 2025-01-31

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-01-31

F578 · Resident Rights Deficiencies

Health

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.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-01-31

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-01-31

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-01-31

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-01-31

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-01-31

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-01-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-14

C · Minimal harm 2025-01-31

F730 · Nursing and Physician Services Deficiencies

Health

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

Corrected 2025-03-14

B · Minimal harm 2025-01-31

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-03-14

J · Immediate jeopardy 2024-01-12

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-12

F622 · Resident Rights Deficiencies

Health

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.

Corrected 2024-02-09

D · Potential for more than minimal harm 2023-10-18

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2023-11-16

F · Potential for more than minimal harm 2023-08-10

F895 · Administration Deficiencies

Health

Have a Compliance and Ethics Program.

Corrected 2023-09-15

D · Potential for more than minimal harm 2023-08-10

F578 · Resident Rights Deficiencies

Health

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.

Corrected 2023-09-15

E · Potential for more than minimal harm 2023-07-21

F801 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2023-09-08

E · Potential for more than minimal harm 2023-07-21

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2023-09-08

E · Potential for more than minimal harm 2023-07-21

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-07-21

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-07-21

F661 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-07-21

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-07-21

F803 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2023-09-08

D · Potential for more than minimal harm 2021-10-25

F578 · Resident Rights Deficiencies

Health

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.

Corrected 2021-12-24

D · Potential for more than minimal harm 2021-10-25