The Villages of Orleans Health and Rehabilitation
14012 Route 31, Albion, NY 14411
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Follow this homeThe Villages of Orleans Health and Rehabilitation is a nursing home in Albion, New York. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionJanuary 31, 2025 (1 year ago)
- Health citations since October 25, 202126 (New York average 21)
- Fines in the past three years1, $71,112 in total
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of October 8, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Name
CMS lists a new name for this home. It was THE VILLAGES OF ORLEANS HEALTH AND REHAB CENTER.
Health inspection on August 21, 2026
2 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
59 of 592 New York homes (10%) got a citation at the actual harm level in 2026.
Show the 2 citations
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 28, 2026.
CMS has cited this home for F0689 5 times since 2021.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on September 25, 2026.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of April 29, 2026
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Health inspection on November 17, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on January 31, 2025
11 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 11 citations
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 14, 2025.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on March 14, 2025.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 14, 2025.
CMS has cited this home for F0578 2 times since 2021.
Citation F0604. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
CMS lists it as corrected on March 14, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on March 14, 2025.
CMS has cited this home for F0609 3 times since 2023.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on March 14, 2025.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 14, 2025.
Citation F0812. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on March 14, 2025.
CMS has cited this home for F0812 2 times since 2023.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 14, 2025.
Citation F0730. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on March 14, 2025.
Citation F0732. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on March 14, 2025.
Fire safety inspection on January 31, 2025
12 citationsCMS lists this as a standard inspection.
Show the 12 citations
Citation K0100. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet other general requirements.
CMS lists it as corrected on March 14, 2025.
CMS has cited this home for K0100 2 times since 2021.
Citation K0271. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on March 14, 2025.
CMS has cited this home for K0271 2 times since 2023.
Citation K0291. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on March 14, 2025.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on March 14, 2025.
CMS has cited this home for K0321 3 times since 2021.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on March 14, 2025.
CMS has cited this home for K0324 2 times since 2021.
Citation K0325. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed hallway dispensers for alcohol-based hand rub.
CMS lists it as corrected on March 14, 2025.
CMS has cited this home for K0325 2 times since 2023.
Citation K0345. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on April 11, 2025.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 14, 2025.
CMS has cited this home for K0353 3 times since 2021.
Citation K0355. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on March 14, 2025.
CMS has cited this home for K0355 3 times since 2021.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on March 14, 2025.
Citation K0712. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on March 14, 2025.
CMS has cited this home for K0712 2 times since 2023.
Citation K0781. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on March 14, 2025.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.6 to 3.1 hours per resident per day.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of April 25, 2024
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of January 31, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Health inspection on January 12, 2024
2 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
37 of 592 New York homes (6%) got a citation at the immediate jeopardy level in 2024.
CMS fine of $71,112 on January 12, 2024.
Show the 2 citations
Citation F0760. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on February 9, 2024.
Citation F0622. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 9, 2024.
Health inspection on October 18, 2023
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on November 16, 2023.
Health inspection on July 21, 2023
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation F0801. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on September 8, 2023.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on September 8, 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 8, 2023.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on September 8, 2023.
Citation F0661. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
CMS lists it as corrected on September 8, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 8, 2023.
Citation F0803. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 8, 2023.
Fire safety inspection on July 21, 2023
15 citationsCMS lists this as a standard inspection.
Show the 15 citations
Citation K0111. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
CMS lists it as corrected on September 8, 2023.
CMS has cited this home for K0111 2 times since 2021.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on September 8, 2023.
Citation K0271. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on September 8, 2023.
Citation K0281. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install proper backup exit lighting.
CMS lists it as corrected on September 8, 2023.
Citation K0293. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on September 8, 2023.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on September 8, 2023.
Citation K0325. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed hallway dispensers for alcohol-based hand rub.
CMS lists it as corrected on September 8, 2023.
Citation K0347. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly provide smoke detection systems in areas open to corridors.
CMS lists it as corrected on September 8, 2023.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on September 8, 2023.
Citation K0355. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on September 8, 2023.
Citation K0712. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on September 8, 2023.
Citation K0918. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on October 15, 2023.
CMS has cited this home for K0918 2 times since 2021.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on September 8, 2023.
Citation K0351. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on September 8, 2023.
Citation E0037. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Establish staff and initial training requirements.
CMS lists it as corrected on September 8, 2023.
Health inspection on October 25, 2021
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 24, 2021.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 24, 2021.
Fire safety inspection on October 25, 2021
12 citationsCMS lists this as a standard inspection.
Show the 12 citations
Citation K0100. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet other general requirements.
CMS lists it as corrected on December 24, 2021.
Citation K0111. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
CMS lists it as corrected on December 24, 2021.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on December 24, 2021.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 24, 2021.
Citation K0355. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on December 24, 2021.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on December 24, 2021.
Citation K0521. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on December 24, 2021.
Citation K0911. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on December 24, 2021.
Citation K0918. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on December 24, 2021.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on December 24, 2021.
Citation K0225. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on December 24, 2021.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on December 24, 2021.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (585) 589-5637
- Last standard health inspection
- January 31, 2025 (1 year ago)
- Certified beds
- 120
- Residents per day, on average
- 115.6
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Comprehensive at Orleans
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
More health citations than the New York average (26 vs 21).
Questions
When was The Villages of Orleans Health and Rehabilitation last inspected?
CMS lists January 31, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does The Villages of Orleans Health and Rehabilitation have?
CMS lists 26 health citations since October 25, 2021. CMS also calls these deficiencies.
Has The Villages of Orleans Health and Rehabilitation been fined?
CMS lists 1 fine in the past three years, $71,112 in total.
What is the CMS star rating of The Villages of Orleans Health and Rehabilitation?
Its CMS overall star rating is 1 of 5.
Is The Villages of Orleans Health and Rehabilitation a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.