When the assistant tested the call button herself, nothing happened. She told inspectors the button should make noise and promised to tell someone about the problem.
This scene at Ontario Center for Rehabilitation and Healthcare in January illustrates a facility where basic safety systems had broken down across multiple floors. Federal inspectors found call systems that didn't work, staff who ignored infection control protocols, and missing vaccination records for vulnerable residents.
The nurse call system problems extended throughout the building. On the third floor, inspectors found the central monitoring panel unplugged and non-operational at the nurses' station. Call lights outside resident rooms would illuminate when pressed, but produced no audible alerts to notify staff.
The Director of Facilities told inspectors the call system tablet "gets unplugged and does not work at times." He wasn't sure why the panel was off or how long it had been that way. The system was old, he said, and they couldn't get replacement parts anymore.
On the second floor, there was no monitoring panel at all. It had been removed five months earlier because it was "no longer fixable," according to the Director of Facilities. He also admitted he wasn't sure what the different colored lights meant or why the system lacked audible tones.
Staff had adapted to the broken system by constantly scanning hallways for illuminated lights above room doors. Certified Nursing Assistant #8 explained they would "look down the hall and see a light on over the resident's door." The assistant added that call buttons would only make noise "if the resident pressed it repeatedly."
But even this workaround failed. In one resident's room, inspectors pressed the call button and observed no audible or visual signal at all. When they notified the Licensed Practical Nurse Manager, she promised to call maintenance for repairs.
The facility's own testing logs revealed gaps in safety checks. Quarterly inspections documented call stations in resident rooms on the second and third floors only. The logs didn't specify whether bedside or bathroom call buttons were tested, and completely omitted first-floor common bathrooms and shower areas on upper floors.
According to the manufacturer's manual, the nurse call system required both power and network connections to operate properly. The system was designed to display different colored lights for various emergency types: red for bedside calls, white for toilet calls, flashing red for emergencies, and flashing blue for code blue situations.
The Corporate Administrator defended the broken system during interviews, telling inspectors staff could "look down the hallways to see if there are call lights on when they do not have a panel." She saw "no issue with the panels not being in place as the system still functioned."
Beyond the call system failures, inspectors discovered staff routinely ignored infection control protocols designed to prevent disease transmission. The facility had implemented Enhanced Barrier Precautions for residents with wounds, medical devices, or drug-resistant infections, requiring staff to wear gowns and gloves during direct care.
Resident #350, who had diabetes and seven venous ulcers on both legs, was clearly marked for Enhanced Barrier Precautions with a sign outside the door. Yet on January 21, a nurse practitioner provided wound care wearing only gloves, no gown. Six days later, a registered nurse made the same error while cleaning and dressing the resident's multiple leg wounds.
When questioned immediately afterward, Registered Nurse #1 claimed she didn't believe the resident was on precautions and thought the sign was for the roommate. She said she didn't recall receiving education about Enhanced Barrier Precautions at the facility.
Resident #65, recovering from a right leg fracture and dealing with Parkinson's disease, also had wounds requiring Enhanced Barrier Precautions. Licensed Practical Nurse #2 removed and applied wound dressings while wearing gloves but no gown. During a later interview, the nurse acknowledged she "should have" worn a gown.
The same nurse provided catheter care to Resident #351 without proper protection. While wearing gloves, she unhooked the resident's urinary catheter drainage bag, emptied it, and disposed of the contents. She later admitted Enhanced Barrier Precautions applied to residents with indwelling medical devices and that she "should have worn a gown."
The Assistant Director of Nursing and Regional Director of Clinical Services confirmed that any staff providing hands-on care to residents on Enhanced Barrier Precautions should wear appropriate protective equipment including gowns, gloves, goggles, and masks as appropriate.
Vaccination compliance presented another serious gap. The facility failed to document whether residents had been educated about, offered, received, or declined influenza and pneumococcal vaccines.
Resident #12, who had dementia and was legally blind, had a daughter serving as health care proxy. Inspectors found no evidence the daughter had received educational materials about vaccine benefits and risks, or documentation of vaccine decisions.
Resident #53 was cognitively intact but hadn't received an updated pneumococcal vaccine since November 2015. Resident #351, who had severe cognitive impairment, last received the pneumococcal vaccine in November 2014, with no documentation of influenza vaccination or family education about either vaccine.
The Assistant Director of Nursing admitted the facility was unaware that Resident #53 needed an updated pneumococcal vaccine and couldn't provide written documentation that any residents or representatives had been educated about, received, or declined vaccinations.
Staff vaccination compliance also fell short. The facility required unvaccinated staff to wear masks in resident care areas during flu season, marked by purple stickers on ID badges for those who received shots.
Licensed Practical Nurse #6 was observed preparing and administering medications on the second floor without wearing a mask. She confirmed she hadn't received the flu vaccine, had no purple sticker, and "should be wearing a mask."
The Director of Maintenance stood at the nurses' station without a mask, acknowledging he hadn't received the flu vaccine and "should be wearing one."
The Administrator admitted during interviews that the facility had received grievances about wound care, toileting assistance, and incontinence care not being provided. A Quality Assurance meeting had been held with the interdisciplinary team about one to two weeks before the inspection to address these concerns, but the Corporate Administrator hadn't yet verified whether recommended improvements had been implemented.
The Administrator also acknowledged awareness that staff who hadn't received flu vaccines weren't appropriately masking as required by state health department regulations, and that the Quality Assurance Committee knew about gaps in resident vaccination documentation.
These systematic failures left residents vulnerable in a facility where the most basic safety systems—call buttons to summon help and protective equipment to prevent infection—weren't working as designed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ontario Center For Rehabilitation and Healthcare from 2025-01-31 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Ontario Center For Rehabilitation and Healthcare
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