Inspection Reports for
Fox Run at Orchard Park
One Fox Run Lane, Orchard Park, NY, 14127
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Inspection Report — Mar 7, 2025
Routine CMS
Date: Mar 7, 2025
Visit Reason
The inspection was a standard survey conducted to assess compliance with psychotropic medication regulations, specifically focusing on the appropriate use and documentation of as needed (PRN) psychotropic drug orders.
Findings
The facility failed to ensure that as needed orders for psychotropic medications were limited to 14 days unless a documented rationale for extension was provided. Specifically, Resident #24 had an as needed psychotropic antianxiety medication ordered for longer than 14 days without documented physician rationale or duration.
Citations (1)
10 NYCRR 415.12(l)(2): The facility did not ensure that as needed psychotropic medication orders were limited to 14 days unless the attending physician documented a rationale and duration for extension. Resident #24 had an as needed Ativan order exceeding 14 days without documented reevaluation or rationale.
Report Facts
Residents affected: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #1 | Provided interview regarding Resident #24's medication orders and mental health status | |
| Consultant Pharmacist | Interviewed about psychotropic medication orders and pharmacy practices | |
| Medical Director | Interviewed about Resident #24's medication and clinical status | |
| Register Nurse Supervisor #1 | Interviewed about Resident #24's behavior and medication orders | |
| Registered Nurse Supervisor #2 | Interviewed about medication order entry and pharmacy integration | |
| Social Worker | Interviewed about behavioral modification reviews and medication orders | |
| Director of Nursing | Interviewed about expectations for as needed medication orders and Resident #24's status |
Inspection Report — Mar 7, 2025
Original Licensing State
Date: Mar 7, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2022 to 2025 with deficiency history and enforcement actions.
Findings
Across 4 inspections in the reporting period, the facility received 10 citations including standard health and Life Safety Code violations, mostly Level 2 severity indicating minor potential harm. One enforcement action with fines totaling $10,000 was recorded.
Citations (10)
Standard Health Citation — quality of care: Free From Unnec Psychotropic Meds/prn Use.
Life Safety Code Citation — NFPA requirements: Fire Drills.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrie.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste.
Life Safety Code Citation — NFPA requirements: Exit Signage.
Life Safety Code Citation — NFPA requirements: Stairways And Smokeproof Enclosures.
Standard Health Citation — quality of care: Reporting - National Health Safety Network.
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents.
Standard Health Citation — quality of care: Infection Control.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure.
Report Facts
Inspections on page: 4
Total violations/deficiencies cited: 10
Inspections with violations: 4
Inspections without violations: 0
Enforcement actions: 1
Total fines: 10000
Inspection Report — Oct 27, 2023
Annual Inspection CMS
Date: Oct 27, 2023
Visit Reason
Annual inspection survey of the nursing home facility Fox Run at Orchard Park.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Jul 1, 2022
Routine CMS
Date: Jul 1, 2022
Visit Reason
The inspection was a standard survey conducted to assess compliance with care standards related to activities of daily living and hygiene for residents.
Findings
The facility failed to ensure that Resident #31 received complete incontinence care, specifically failing to retract the foreskin during cleaning and not performing proper hand hygiene after fecal incontinence care. Staff interviews confirmed these lapses in care and hygiene practices.
Citations (1)
F 0677: The facility did not ensure that staff retracted the foreskin to clean Resident #31 during incontinence care and failed to change gloves and perform hand hygiene after fecal incontinence care before applying clean briefs and clothing.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Named in deficiency for not retracting foreskin and not performing hand hygiene. |
| CNA #1 | Certified Nurse Aide | Observed and interviewed regarding care deficiencies. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding proper care procedures and hygiene. |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for care and hygiene practices. |
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