Inspection Reports for
Orchard Rehabilitation & Nursing Center
600 Bates Road, Medina, NY, 14103
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Inspection Report — Sep 2, 2025
Complaint Investigation State
Date: Sep 2, 2025
Visit Reason
State-compiled facility profile showing 21 inspections from 2022 to 2026 with citation and enforcement history.
Complaint Details
The facility received 139 complaints with 26 on-site inspections conducted. Two citations resulted from those complaints.
Findings
Across 21 inspections, 19 had no citations and 2 resulted in 9 total citations, mostly minor potential harm. The facility had 139 complaints with 26 on-site inspections and 2 formal enforcement actions totaling $32,000 in fines.
Citations (9)
Standard Health Citation — Nutritive Value/appear, Palatable/prefer Temp: Quality of care issue noted with nutritive value and food temperature on September 2, 2025 inspection.
Standard Health Citation — Sufficient Nursing Staff: Insufficient nursing staff documented on September 2, 2025 inspection.
Standard Health Citation — Binding Arbitration Agreements: Issues with binding arbitration agreements found on April 16, 2024 inspection.
Standard Health Citation — Facility Hiring And Use Of Nurse Aide: Deficiencies in nurse aide hiring and use noted on April 16, 2024 inspection.
Standard Health Citation — Food Procurement,store/prepare/serve-sanitary: Sanitary issues in food procurement and preparation found on April 16, 2024 inspection.
Standard Health Citation — Free Of Accident Hazards/supervision/devices: Accident hazards and supervision deficiencies noted on April 16, 2024 inspection.
Standard Health Citation — Nutritive Value/appear, Palatable/prefer Temp: Quality of care issue repeated regarding nutritive value and food temperature on April 16, 2024 inspection.
Life Safety Code Citation — Electrical Systems - Essential Electric System: Electrical system deficiencies noted on April 16, 2024 inspection.
Life Safety Code Citation — Fire Alarm System - Testing And Maintenance: Fire alarm system testing and maintenance deficiencies found on April 16, 2024 inspection.
Report Facts
Inspections on page: 21
Total violations/deficiencies cited: 9
Inspections with violations: 2
Inspections without violations: 19
Total complaints: 139
On-site complaint inspections: 26
Total enforcement actions: 2
Total fines: 32000
Inspection Report — Sep 2, 2025
Complaint Investigation CMS
Date: Sep 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding insufficient nursing staff and suboptimal food and drink temperatures at the facility.
Complaint Details
The complaint investigation (NY00358687-745392) substantiated issues with insufficient nursing staff and unsafe food temperatures. Residents reported long wait times for assistance and medication delays. Interviews with staff confirmed staffing shortages and challenges in meeting care standards.
Findings
The facility failed to maintain sufficient nursing staff to meet residents' individualized care needs, resulting in delayed assistance and medication administration. Additionally, food and beverages were served at unsafe and unappetizing temperatures, posing a risk to resident health.
Citations (2)
F 0725: The facility did not provide enough nursing staff daily to meet resident needs and did not have a licensed nurse in charge on each shift. Staffing levels were below required minimums, causing delays in resident care and medication administration.
F 0804: The facility did not ensure food and drink were served at safe and appetizing temperatures. Observations showed hot foods and beverages were lukewarm or warm, and cold items were not kept sufficiently cold, risking bacterial growth.
Report Facts
Licensed nurse hours per resident per day: 0.8
Certified Nurse Aide hours per resident per day: 1.58
Food temperature: 118
Food temperature: 115
Drink temperature: 64.2
Drink temperature: 56.5
Drink temperature: 119.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Reported being responsible for 14 residents and unable to complete all care tasks per plans of care. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Reported responsibility for 40 residents and frequent late medication administration. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Reported inability to provide adequate care when responsible for 40 residents and medication delays. |
| Director of Nursing | Director of Nursing | Acknowledged ongoing recruitment efforts and awareness of staffing shortages. |
| Administrator | Administrator | Acknowledged staffing shortages and ongoing recruitment efforts. |
| Food Service Director | Food Service Director | Conducted food temperature testing and confirmed food and drink were served outside safe temperature ranges. |
| Director of Human Resources | Director of Human Resources/Scheduler | Responsible for creating nursing schedules and stated minimum staffing requirements. |
Inspection Report — Apr 16, 2024
Routine CMS
Date: Apr 16, 2024
Visit Reason
The inspection was a standard survey conducted to assess compliance with regulatory requirements related to resident safety, staff training, food service, and arbitration agreements.
Findings
The facility was found deficient in implementing smoking policies for residents, ensuring nurse aides were properly certified, maintaining safe and palatable food temperatures, proper food storage and sanitation in kitchens and nourishment refrigerators, and providing a neutral arbitration process in agreements.
Citations (5)
10 NYCRR 415.12(h)(1) The facility failed to implement smoking policy by not completing comprehensive quarterly assessments or developing a care plan for a resident who smoked independently.
10 NYCRR 415.26(d)(2) A nurse aide worked more than four months without certification and failed multiple certification exams, yet performed duties independently without proper supervision.
10 NYCRR 415.14(d)(1)(2) Food and drink were served at unsafe and unappetizing temperatures, with hot foods below 140°F and cold foods above 40°F, affecting multiple residents.
10 NYCRR 415.14(h) The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including undated and expired food in nourishment refrigerators, unsanitary kitchen conditions, and improper food handling by staff.
10 NYCRR 415.30 The Binding Arbitration Agreement did not provide for selection of a neutral arbitrator agreed upon by both parties or a venue convenient to both parties.
Report Facts
Residents affected: 1
Residents affected: 5
Residents affected: 3
Nurse aides reviewed: 5
Test trays: 4
Peanut butter and jelly sandwiches: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Assistant #1 | Nurse Aide Trainee | Worked more than 4 months without certification, failed certification exams, performed CNA duties independently |
| Licensed Practical Nurse #2 | Stated Resident #116 smokes and goes outside to smoke | |
| Director of Activities | Reported Resident #116 was not on smoking list and had seen resident smoking outside | |
| Director of Nursing | Acknowledged Resident #116 should have been assessed and care planned for smoking | |
| Administrator | Acknowledged Resident #116 should have been assessed and care planned for smoking; discussed arbitration agreement | |
| Food Service Director #1 | Conducted food temperature testing and observed improper food handling | |
| Dietary Aide #1 | Conducted food temperature testing | |
| Infection Preventionist #1 | Stated gloves should be changed and food served with utensils | |
| Licensed Practical Nurse Unit Manager #6 | Reported on unlabeled and expired food in nourishment refrigerators | |
| Licensed Practical Nurse Unit Manager #3 | Reported on unlabeled and expired food in nourishment refrigerators | |
| Licensed Practical Nurse Unit Manager #7 | Reported on unlabeled and expired food in nourishment refrigerators |
Inspection Report — Apr 25, 2022
Routine CMS
Date: Apr 25, 2022
Visit Reason
The inspection was a standard survey conducted to assess compliance with regulatory requirements related to resident care and facility operations.
Findings
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, did not ensure proper use of adaptive devices, and failed to provide appropriate pressure ulcer care for one resident, resulting in minimal harm or potential for harm.
Citations (2)
F 0656: The facility did not develop and implement a comprehensive care plan for anticoagulant use for Resident #41, failed to ensure Resident #22 wore a right-hand palm guard as ordered, and did not supervise Resident #53 in common areas per the care plan.
F 0686: The facility did not ensure Resident #41's right heel pressure ulcer was properly off-loaded in bed as recommended by the Wound Consultant, contributing to wound deterioration.
Report Facts
Residents reviewed: 25
Residents affected: 3
Wound measurements: 1.5
Wound measurements: 3.5
Medication dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Unit Manager | Stated Resident #41 was on anticoagulant and care plan should address it |
| Director of Nursing | DON | Expected care plans to address anticoagulant use and supervise residents per care plan |
| CNA #3 | Certified Nursing Assistant | Reported Resident #22 was to wear right-hand palm guard but had not seen it |
| CNA #4 | Certified Nursing Assistant | Aware Resident #22 was to wear palm guard but did not see it and did not report |
| LPN #3 | Licensed Practical Nurse, Unit Manager | Unaware if Resident #22 had palm guard and expected staff to notify if missing |
| Occupational Therapist | OT | Stated Resident #22 wears palm guard due to contractures and moisture |
| CNA #5 | Certified Nursing Assistant | Stated Resident #53 was allowed to independently propel wheelchair but should be supervised |
| LPN #5 | Licensed Practical Nurse, Unit Manager | Reviewed Resident #53's care plan and stated supervision was required but not followed |
| LPN #6 | Licensed Practical Nurse | Observed providing wound care to Resident #41's right heel |
| Wound Consultant | Reported wound deterioration due to lack of heel off-loading | |
| Physician #1 | Expected facility to follow wound consultant's recommendations |
Inspection Report — Jun 21, 2019
Routine CMS
Date: Jun 21, 2019
Visit Reason
Routine standard survey inspection of Orchard Rehabilitation & Nursing Center to assess compliance with regulatory requirements related to resident care, medication management, and facility operations.
Findings
The facility had multiple deficiencies including failure to thoroughly investigate alleged resident-to-resident abuse, inadequate personal hygiene care, lack of hospice care plan for a resident, missing blood sugar monitoring orders for a diabetic resident, failure to act on optometry recommendations, improper oxygen therapy administration, lack of pharmacist recommendations for psychotropic medication dose reduction, expired and unlabeled medications on medication carts, and serving food at unsafe temperatures.
Citations (9)
F 0610: The facility failed to ensure a thorough investigation of alleged resident-to-resident abuse when Resident #34 threw water on another resident and no Accident/Incident report or follow-up investigation was completed.
F 0677: Resident #111 dependent on staff for activities of daily living had long, jagged, dirty fingernails, indicating inadequate grooming and personal hygiene care.
F 0684: The facility did not ensure residents received treatment and care according to professional standards; Resident #39 on Hospice lacked a Hospice care plan, and Resident #92 on diabetic tube feed had no blood sugar monitoring orders.
F 0685: Resident #138 did not receive proper vision care as the facility failed to act on optometry recommendations for cataract surgery and did not assist the resident in obtaining glasses.
F 0695: Resident #30 was not administered oxygen at the prescribed 2 liters per minute; certified nurse aides improperly adjusted oxygen liter flow and changed portable oxygen tanks without nurse oversight.
F 0756: Consultant pharmacist failed to identify and recommend gradual dose reduction for Resident #137's continued use of Ativan despite lack of behaviors warranting its use.
F 0758: Resident #137 lacked documented gradual dose reductions and behavioral interventions for psychotropic medication Ativan; no evidence supported continued use.
F 0761: Medication carts on Unit 1 and Unit 2 contained expired medications and inhalers without open dates, violating medication storage and labeling standards.
F 0804: Food served in the Main Dining Room and Units 1 and 3 was at unsafe temperatures, with hot foods served cold or lukewarm, affecting palatability and safety.
Report Facts
Expired medication count: 3
Medication carts reviewed: 3
Residents reviewed for psychotropic medications: 5
Residents reviewed for respiratory care: 2
Residents reviewed for quality of care: 6
Residents reviewed for ADL care: 4
Temperature of ham: 109
Temperature of sweet potatoes: 132
Temperature of cabbage: 129
Temperature of ham: 100
Temperature of sweet potatoes: 138
Temperature of cabbage: 116
Temperature of ham: 116
Temperature of sweet potatoes: 130
Temperature of cabbage: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in resident-to-resident abuse incident and failure to report |
| LPN #2 | Nurse Manager | Interviewed regarding multiple deficiencies including abuse investigation, medication management, and hospice care |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including abuse investigation, medication management, and hospice care |
| Medical Director | Medical Director | Interviewed regarding medication management and clinical decisions |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed regarding medication regimen reviews and failure to recommend gradual dose reduction |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding medication cart storage and expired medications |
| LPN #1 | Nurse Manager | Interviewed regarding medication cart storage and expired medications |
| RN #3 | Assistant Director of Nursing | Interviewed regarding medication cart storage and labeling |
| Dietary Manager | Dietary Manager | Interviewed regarding food temperature deficiencies |
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