Ontario Center for Rehabilitation and Healthcare

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure comfortable and safe temperature levels were maintained for residents residing on two (2) of two (2) resident use floors (Second (2nd) floor and Third (3rd) floor). Specifically, multiple residents were exposed to cold ambient air temperatures, reported feeling cold, and one (1) resident was observed actively shivering.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure assessments (Minimum Data Set (a resident assessment tool)) accurately reflected resident status for 6 of 22 residents reviewed (Residents #6, #70, #82, #101, #104, and #108). Specifically, cognitive assessments (Brief Interview for Mental Status (a cognitive screening tool)) were documented as not assessed without evidence the interview could not be completed, and required sections of the assessment were left incomplete.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure the infection prevention and control program was implemented to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of two (2) residents reviewed (Resident #5 and Resident #96). Specifically, Resident #5 was provided a meal tray stored in a cart with soiled trays, creating a risk for cross-contamination and potential transmission of pathogens, and Resident #96 who was on enhanced barrier precautions (an infection control strategy using gloves and gowns during high-contact resident care to reduce the spread of infection) received high-contact care without appropriate personal protective equipment. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility did not properly maintain the nurse call system for one (1) of three (3) resident use floors (Second (2nd) floor). Specifically, a central station call system panel was not present and the audible component for the call system was not working properly.

Inspectors wroteBased on observations, interviews and record review, the facility did not provide services to meet professional standards of quality for one (1) of three (3) residents reviewed (Resident #18) for nutrition, for one (1) of five (5) residents reviewed (Resident #7) for drugs and medications, and for one (1) of one (1) residents reviewed (Resident #14) for respiratory care. Specifically, there was no documented evidence that weights (Resident #18) and vital signs (blood pressure and heart rate) (Resident #7) were obtained per the physician's orders and/or had documented results (numerical values). In addition, Resident #14 was receiving continuous oxygen without physicians orders.

Inspectors wroteBased on observations, interviews and record reviews conducted during the extended Recertification Survey and complaint investigations (#NY00349354, #NY00357725, #NY00362904) from 01/21/2025 to 01/31/2025, the facility failed to ensure residents' right to be free from abuse, mistreatment or neglect for six (6)(Residents #8, #48, #65, #73, #76 and #350) of eight (8) residents reviewed for abuse and neglect. Specifically, Resident #8 and Resident #48 did not receive timely incontinence care. Resident #65 did not receive wound care as ordered by the physician for multiple days and was not assisted with toileting or incontinence care for approximately six hours. Resident #73 was left sitting in their wheelchair in their room for approximately 14 hours without incontinence care despite multiple attempts to alert staff via call light and telephone calls to the nurse's station. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Extended Recertification Survey from 01/21/2025 to 01/31/2025, for two (Second Floor and Third Floor) of two resident units, the facility did not ensure sufficient staffing to provide nursing services to attain or maintain the highest practical physical, mental, and psychosocial well-being for residents in the facility. Specifically, there were multiple observations of residents incontinent of bladder or bowel for extended periods of time, several residents who reported going weeks without showers and observed unkept with unclean hair. This resulted in psychosocial harm to Residents' #8, #28, #65, #73 and #76 that is not Immediate Jeopardy and is evidenced by the following: For additional information see the Centers for Medicare/Medicaid Services Form 2567: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Extended Recertification Survey and complaint investigation (#NY00349354) from 01/21/2025 to 01/31/2025, for four (4) (Resident #8, #28, #48, and #350) of seven (7) residents reviewed, the facility failed to ensure residents were treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of quality of life. Specifically, Residents #8 and #350 did not receive timely emptying of their urinal (a device used to urinate in) resulting in spillage on the resident or having to empty the urinal out a window in order to use it. Resident #28 did not receive timely incontinence care and had not received a shower for four (4) weeks. Resident #48 was observed on multiple occasions with urine soaked through their incontinence brief, incontinence pad, and bed linens. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the Extended Recertification Survey and complaints investigations 01/21/2025 to 01/31/2025, facility did not ensure it was administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Extended Recertification Survey from 01/22/2025 to 01/31/2025, for three (first, second, and third floors) of three resident use floors the facility did not properly maintain the nurse call system. Specifically, central nurse call system panels were not present or functioning properly, the audible component for the call system was not working properly, and there was no documented testing of nurse call devices on the first floor.

Inspectors wroteBased on record review and interviews conducted during the Extended Recertification Survey and complaint investigations (NY00370078, NY00362904 and NY00349354) from 01/21/2025 to 01/31/2025, the facility did not ensure that thorough and prompt efforts were made to resolve grievances for two (Residents #88 and #350) of 27 residents reviewed. Specially, Resident #88's grievances were not thoroughly investigated and there was no follow-up when the resident voiced dissatisfaction with the facility's resolution to one of their grievances. For Resident #350, there was no evidence a thorough investigation was completed to determine if abuse, neglect, or mistreatment had been ruled out, and the facility did not follow-up with the residents regarding grievance resolution. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Extended Recertification Survey and complaint investigations (#NY00357725, #NY00349354) from 01/21/2025 to 01/31/2025, for three (Residents #28, #48, #65) of nine residents reviewed, the facility did not ensure that residents who were dependent on staff for assistance received the necessary services to maintain grooming and personal hygiene. Specifically Resident #28 did not receive incontinence care timely and did not receive showers and hair washing for an extended period of time. Resident #48 did not receive incontinence care timely. Resident #65 was not assisted to the bathroom by staff for an extended period resulting in being incontinent. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Extended Recertification Survey and complaint investigation (NY00363528) from 01/21/2025 to 01/31/2025, the facility did not ensure that residents received care in accordance with professional standards of practice for two (Residents #12 and #350) of 27 residents reviewed. Specifically, Resident #350 did not receive wound care treatments per physician orders on multiple occasions and Resident #12's ordered x-ray was not performed until 15 days after it was ordered. This is evidenced by the following: 1. Resident #350 had diagnoses that included diabetes, peripheral vascular disease (a condition where arteries and/or veins become narrowed or blocked, reducing blood flow to the limbs), and chronic venous ulcers (wounds caused by reduced blood flow in the limbs). [...]

Inspectors wroteBased on observation, interviews and record review conducted during the Extended Recertification Survey from 01/21/2025-01/31/2025, the facility did not ensure an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections was maintained for 3 (Residents' #65, #350 and #351) of 24 residents reviewed. Specifically, appropriate Personal Protective Equipment (PPE) was not worn by nursing staff in residents' room that were identified by the facility as requiring Enhanced Barrier Precautions while preforming high contact care to residents. Additionally, observations of multiple facility staff who had declined the influenza vaccine were not wearing face masks while in resident care areas during the current influenza season as determined by the Department of Health. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Extended Recertification Survey from 01/21/2025 to 01/31/2025 for one (Resident #65) of four residents reviewed, the facility did not ensure residents received the necessary care, treatment and services consistent with professional standards of practice to promote the healing of a pressure ulcer, prevent infection, and prevent new ulcers from developing (unless the individual's clinical condition demonstrates they were unavoidable). Specifically, Resident #65 who preferred to spend most of their time in bed, was not assisted with toileting, and was left incontinent of urine for multiple hours. Resident #65 developed a pressure ulcer to their right buttock and had not received treatments to the area for several days. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Extended Recertification Survey from 01/21/2025 to 01/31/2025, for two (Residents #20 and #351) of two residents reviewed, the facility did not provide appropriate treatment and care, based upon current standards of practice and the residents' comprehensive assessment and care plan to prevent urinary tract infections to the extent possible. Specifically, Resident #20 had a history of urinary tract infections and was observed with their indwelling urinary catheter drainage bag (including the drainage port and catheter tubing) lying uncovered (no barrier) on a soiled chair and above the level of the bladder. Resident #351's indwelling urinary catheter drainage bag was observed on the ground without a barrier and above the level of the bladder on multiple occasions. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Extended Recertification Survey from 01/21/2025 to 01/31/2025, the facility did not ensure all drugs and biologicals were properly stored in accordance with State and Federal Laws for one (second-floor north medication cart) of two medication carts and one (third-floor medication room) of two medication rooms reviewed. Specifically, the second-floor north medication cart contained controlled medications (medications such as narcotics and opioids that have the potential for abuse and addiction) that were not in a permanently affixed compartment per the regulations and the third-floor medication room contained multiple undated/unlabeled medications. This is evidenced by the following: [...]

Inspectors wroteBased on interviews and record review conducted during the Extended Recertification Survey from 01/21/2025 to 01/31/2025, the facility did not ensure each resident was educated and offered the influenza and/or the pneumococcal immunizations (vaccine) for three (Resident #12, #53, #351) of five residents reviewed. Specifically, the facility was unable to provide evidence the residents or their representatives had been provided educational material and offered, received or declined the pneumococcal and/or influenza immunizations. The facility policies Infection Control-Influenza Vaccine dated 08/22/2024 and the Pneumococcal Vaccine dated 11/27/2024 included all residents and/or their resident representative will be offered and provided the influenza and pneumococcal vaccines. Residents have the opportunity to refuse the vaccine(s). [...]

Inspectors wroteBased on interviews and record reviews conducted during the Extended Recertification Survey from 01/21/2025 to 01/31/2025 for one (Resident #10) of two residents reviewed, the facility did not ensure that individual financial records were provided to the residents through quarterly statements. Specifically, neither Resident #10 nor their identified resident representative were provided with any quarterly personal fund statements over an extended period of time. This is evidenced by the following: The facility policy Resident Funds Account last reviewed August 2020 included the facility will provide on request, and at least quarterly to the resident or the resident's designated or legal representative, a statement showing the account balance including funds deposited and withdrawn and interest accrued. 1. [...]

Inspectors wroteBased on, interviews, and record review conducted during the Extended Recertification Survey from 01/21/2025 to 01/31/2025 for three (Residents #20, #76, and #248) of three residents reviewed the facility did not ensure that a copy of resident's transfer and/or discharge notices were sent to a representative of the Office of the State Long Term Care Ombudsman. This is evidenced by the following: Resident #20 had diagnoses that included urinary retention (unable to empty the bladder), benign prostatic hyperplasia (enlargement of the prostate), and chronic kidney disease. A review of the electronic health record revealed Resident #20 was transferred to the hospital on [DATE], 11/14/2024, 12/02/2024, 12/19/2024, and 12/24/2024. Resident #76 had diagnoses that included bilateral below the knee amputations, history of deep vein thrombosis (blood clot), and anxiety. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (NY00342658), for one (Resident #12) of two residents reviewed for drugs and medication, the facility did not provide services to meet professional standards of quality. Specifically, nursing staff did not ensure medications were consumed by the resident and were left unattended with the resident in a common area. This was evidenced by the following. Review of the facility policy Medication Administration Review, dated August 2019, documented that Licensed Nurses must ensure that all medications are administered and documented. Resident #12 had diagnoses that included multiple sclerosis (a disease that affects the central nervous system), epilepsy (a brain condition that causes seizures), and hypertension (high blood pressure). [...]

Inspectors wroteBased on interviews and record review conducted during an Abbreviated Survey (NY00320939), for three (Residents #1, #2 and #3) of three residents reviewed the facility did not ensure a written notice of the facility's bed hold policy was provided to the residents or their representatives at the time of transfer to the hospital, or for emergency transfers, within 24 hours. Specifically, the facility could not provide evidence that any of the residents or their representatives were given written information regarding their bed hold policy in allowing the residents to return to the facility following a hospital discharge at the time of their transfer. This was evidenced by the following: 1. Resident #2 had diagnoses that included bacteremia, major depressive disorder, and anemia. The Minimum Data Set Resident Assessment, dated 5/21/24, revealed the resident was cognitively intact. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during an Abbreviated Survey (Complaint #NY00314833), for two (Resident #11 and Resident #12) of three residents reviewed for Activities of Daily Living, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #11 did not receive assistance with shaving and washing their hair. Resident #12 did not receive assistance with shaving and nail care. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during an Abbreviated Survey (Complaint # NY00314833) it was determined that for one (Resident #12), of three residents reviewed for accidents the facility did not ensure that each resident received the appropriate assistance devices to prevent accidents. Specifically, Resident #12 required the use of a Hoyer lift ( a mechanical lift device) for safe transfers. During an observation two staff members transferred the resident without using a mechanical lift. This is evidenced by the following: [...]

Inspectors wroteBased on observations, record review, and interview conducted during the Recertification Survey completed 1/11/23, it was determined that for three (first, second and third floors) of three resident use floors, the facility did not provide a safe, functional, and sanitary environment for residents, staff, and the public. Specifically, unapproved chemical treatment of the domestic hot water system was occurring without approval of the New York State Department of Health.

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey completed on 1/11/23, it was determined that for two (2nd floor and 3rd floor) of two units reviewed for medication storage, the facility did not have a consistent system to account for the receipt, usage, disposition, and reconciliation of all controlled medications (narcotics). Specifically, the controlled medications count sheets and the signatures of staff members for each shift-to-shift count were not consistently completed to validate the correct controlled substance count was done and was accurate. This is evidenced by the following: The facility policy Narcotic Count, dated August 2018, documented that the oncoming and outgoing nurses assigned to the medication cart are responsible for ensuring the accuracy of the controlled drug count. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey and complaint investigations (#NY00297231 and #NY00307562), completed on 1/11/23, it was determined that the facility did not follow the meal menus to ensure the nutritional needs of the residents. Specifically, residents did not receive menu items as listed on their meal tickets.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey completed on 1/11/23, it was determined for one (Resident #54) of five residents reviewed for unnecessary medications, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed for each resident that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs. Specifically, a CCP was not developed for use of psychotropic medications that included targeted symptoms, measurable goals, and person-centered nonpharmacological interventions. The finding is: Resident #54 had diagnoses that included anxiety disorder, depression and recent hip fracture. [...]

Inspectors wroteBased on interviews, and record reviews conducted during the Recertification Survey, completed on 1/11/23, it was determined that for one (Resident #1) of five residents reviewed for Unnecessary Medications, the facility did not ensure the services provided or arranged by the facility as outlined in the resident's Comprehensive Care Plan (CCP) met professional standards of quality. Specifically, Resident #1 had two orders for the same medication, dosage, and frequency both active at the same time. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE], with diagnoses of left tibia fracture, fibromyalgia (widespread muscle pain), and anxiety. The Minimum Data Set Assessment, dated 11/1/22, included that Resident #1 was cognitively intact, and had received an antianxiety medication in the previous seven days. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey completed on 1/11/23, it was determined that for one (Resident #15) of nine residents reviewed for activities of daily living (ADLs), the facility did not ensure that ADL care was provided for dependent residents. Specifically, Resident #15's facial hair was not shaved. This is evidenced by the following: Resident #15 was admitted to the facility on [DATE], with diagnoses of end-stage renal disease (requiring hemodialysis), gout, and diabetes. The Minimum Data Set Assessment, dated 11/27/22, included that the resident was cognitively intact and required set-up help and supervision of one-staff member with bathing. [...]

Inspectors wroteBased on observations, interviews and record reviews conducting during the Recertification Survey, completed on 1/11/23, it was determined that for one (Resident #15) of six residents reviewed for nutrition, the facility did not ensure that the resident's daily fluid intake was monitored to ensure their needs as ordered by the physician were met. Specifically, the physician ordered fluid restriction was not being consistently documented or monitored. This is evidenced by the following: The facility policy, Fluid Restrictions, dated last revised in December 2019, included that the physician order should include the number of milliliters (mLs) of fluids permitted for each day, and nursing fluids are divided into medications passes and the individual's daily routine. The policy stated that nursing is responsible for recording the intake and output of fluids for each shift. [...]

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey completed on 1/11/23, it was determined that for one (2 North hallway) of two medication carts reviewed, the facility did not ensure that all drugs and biologicals were properly labeled and stored in accordance with State and Federal laws. Specifically, multiple medications were found pre-poured, unlabeled and undated for future medication administration. Additionally, a large bottle of Tylenol was on top of a medication cart and unsupervised for an extended length of time. This is evidenced by the following: The facility policy Medication Administration, dated December 2019, documented that medications may not be prepared in advance and must be administered within one hour their prescribed time, unless otherwise specified. [...]

Inspectors wroteBased on observations and interview conducted during the Recertification Survey completed on 1/11/23, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances.

Inspectors wroteBased on interviews and record reviews during the Recertification Survey completed on 1/11/23, it was determined the facility did not provide one (Resident #29) of one resident reviewed for personal funds, with their individual financial record through quarterly statements. Specifically, Resident #29 was not provided with their personal fund statement on a quarterly basis per their preference or on request.

Inspectors wroteBased on observations, interviews and record reviews conducted during a Recertification Survey, completed on 6/9/21, it was determined that for nine (Residents #7, #14, #27, #63, #67, #70, #76, #82 and Resident A) of ten residents reviewed, the facility did not provide food and drink that was palatable, attractive and at a safe and appetizing temperature. Specifically, the issues involved food that was unpalatable, not served at preferable temperatures and was unattractive related to frequently being served meals in Styrofoam (disposable dishware). This is evidenced by, but not limited to, the following: 1. Resident A has diagnoses including hypertension, diabetes mellitus and arthritis. The Minimum Data Set (MDS) Assessment, dated 3/20/21, revealed the resident was cognitively intact. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, completed on 6/9/21, for one (Resident #56) of two residents reviewed, the facility did not allow the resident to make choices about aspects of their life that were significant to them. Specifically, the resident did not receive showers as per their stated preferences. This is evidenced by the following: Resident #56 was readmitted to the facility on [DATE] with diagnoses including amputation of the left leg, morbid obesity, and a recent urinary tract infection. The Minimum Data Set Assessment, dated 5/4/21, revealed that the resident had moderately impaired cognition, required extensive assistance to total dependence of two staff members for personal hygiene and bathing and had stated that being able to choose their bathing routine was very important to them. [...]

Inspectors wroteBased on observation ,interview and record review conducted the Recertification Survey and complaint investigations ( #NY00273585 and #NY00272080), completed on 6/9/21, it was determined that for two (Residents #56 and #58) of six residents reviewed, the facility did not thoroughly investigate alleged violations of potential abuse neglect or mistreatment. Specifically, bruises of unknown origin for Resident #56 and a grievance by Resident #58 regarding lack of care were not thoroughly investigated to rule out abuse, neglect, or mistreatment. This is evidenced by the following: The facility policy Abuse, dated February 2019, included allegations of suspected abuse, neglect, mistreatment, injury of unknown origin or misappropriation of property shall be promptly and thoroughly investigated by facility management. [...]

Inspectors wroteBased on observation, interview and record review during the Recertification Survey and complaint investigation (#NY200273585), completed on 6/9/21, the facility did not ensure that two of five residents reviewed received the necessary services to maintain good nutrition, grooming and personal hygiene. Specifically, Resident #58 was not provided a meal tray and was not given showers as requested and Resident #67 lacked nail care. This is evidenced by the following: 1. Resident # 58 was admitted on [DATE] with diagnoses including COVID-19, critical illness myopathy (muscle disease), and diabetes. Review of the Minimum Data Set (MDS) Assessment, dated 5/10/21, included the resident was cognitively intact, required extensive assistance of two staff for bathing, assist of one staff for eating and received the majority of their calories via a feeding tube. [...]

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey, completed on 6/9/21, it was determined that for two of three residents reviewed the facility did not ensure that each resident received adequate supervision and assistance to prevent accidents. Specifically, Resident #27 did not receive supervision at meals related to aspiration precautions and Resident #70 did not receive assistance with ambulation and transfers to minimize risk for falls. This was evidenced by: Review of the facility policy Aspiration Precautions, dated February 2019, revealed staff were to sit the resident upright or as close as possible for any intake and must be supervised for all intake of liquid and solids. 1. Resident #27 had diagnoses that included chronic obstructive pulmonary disease, diabetes, and Alzheimer's disease. [...]

Inspectors wroteBased on observations, interviews, and record reviews during the Recertification Survey, completed on 6/9/21, it was determined that for one (Resident #49) of one resident reviewed for bowel and bladder incontinence, the facility did not ensure that the resident received the treatment and care in accordance with professional standards of practice, the resident's comprehensive person-centered care plan and the resident's choice in order to maintain continence and restore bowel function to the extent possible. Specifically, the facility did not develop and implement a person-centered care plan with measurable goals and interventions to effectively restore and manage the resident's bowel function. This is evidenced by the following: Resident #49 has diagnoses including a femur fracture, heart failure, and hypertension. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, completed on 6/9/21, it was determined for one (Resident #76) of two residents reviewed, the facility did not ensure that dialysis services provided were consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, facility staff did not notify the medical team to initiate new dialysis orders regarding a new medication and a fluid restriction. Additionally, there was no Comprehensive Care Plan (CCP), including person centered goals, interventions, and preferences, for the resident's dialysis needs. This is evidenced by the following: [...]