CANANDAIGUA, NY - Federal inspectors discovered severe staffing shortages at Ontario Center for Rehabilitation and Healthcare that left residents without basic care for extended periods, with some waiting over 24 hours to be changed from soiled clothing.
The January 2025 inspection revealed systemic failures in the 98-bed facility's ability to provide adequate nursing care to its 95 residents, resulting in documented cases of neglect and compromised medication administration.
Critical Staffing Shortages Documented
Federal inspectors found the facility operating with dangerously low staffing levels across multiple shifts. On January 21, 2025, administrators reported nine staff call-ins for a single shift, leaving just two certified nursing assistants to care for 46 residents on the second floor unit.
Documentation revealed alarming staffing patterns: - January 5: Only one Licensed Practical Nurse for the entire facility from 10 PM to 6 AM - January 10: Three Certified Nursing Assistants for all 94 residents during night shift - January 19-20: One Licensed Practical Nurse and three CNAs for the entire facility during night shift - Record call-in day with two nurses and seven CNAs absent simultaneously
The facility's minimum staffing plan called for five CNAs during day shift, four for evening, and two for night shift facility-wide. However, inspectors found these minimums were routinely not met, with no established CNA-to-resident ratio guidelines.
Residents Left in Degrading Conditions
Inspection findings documented multiple instances of residents experiencing prolonged neglect due to insufficient staffing:
Resident #76 reported the most severe case - left unchanged from 8:30 AM Sunday until 8:30 AM Monday (24 hours), becoming so soiled that bed sheets were saturated. The resident repeatedly activated their call light, but staff turned it off, stating they knew assistance was needed but were short-staffed.
Additional documented cases included: - Resident #65: Had gone 2-3 weeks without a shower, found with saturated brief and strong urine odor at 10:25 AM, last received care at 5:00 AM - Resident #28: Last changed at 4:00 AM, told no shower available due to staffing - had gone four weeks without bathing - Resident #8: Visibly incontinent, waited four hours to be changed with no response to call light - Resident #73: Left in wheelchair for 15 consecutive hours (10:00 AM to 1:00 AM) due to short staffing
Medical Consequences and Health Risks
Prolonged exposure to urine and feces creates serious health hazards for nursing home residents. Skin breakdown occurs rapidly when moisture and bacteria remain in contact with fragile skin, particularly in elderly residents who may have compromised circulation and healing capacity.
Key medical risks from delayed incontinence care include: - Pressure ulcer development within hours of exposure - Urinary tract infections from bacterial growth - Skin breakdown and painful dermatitis - Increased fall risk from attempting self-care - Psychological trauma and loss of dignity
Federal nursing home regulations require incontinence care every two hours or as needed to prevent these complications. The documented 24-hour delay in changing represents a severe departure from accepted care standards.
Medication Administration Compromised
The Medical Director confirmed receiving notification from administration about medications not being given or administered late due to staffing shortages. This creates additional safety risks, as missed or delayed medications can lead to:
- Uncontrolled pain and suffering - Medication withdrawal symptoms - Disease progression from untreated conditions - Potential emergency situations requiring hospitalization
Licensed Practical Nurse #2 reported that wound dressings frequently went undone because only one nurse was available for nearly 50 residents.
Controlled Substance Security Failures
Beyond staffing issues, inspectors found medication storage violations that could enable drug theft or diversion. The second-floor medication cart contained 25 blister packs of controlled substances - including psychotropic medications, antianxiety drugs, antidepressants, and opioids - stored improperly in mobile carts rather than permanently fixed compartments.
Federal regulations require controlled substances to be stored behind double locks in secured cabinets. The facility's own policy mandated controlled drugs be kept in "double door, double locked, double keyed, steel, wall mounted drug cabinets" except during active medication passes.
Ongoing Resident Complaints Ignored
Monthly Resident Council meeting minutes from July through December 2024 showed residents voiced staffing concerns and long wait times during four of six meetings. During a special council meeting on January 22, 2025, residents stated grievances about poor staffing and wait times had been ongoing for months.
Staff confirmed residents' concerns: - CNA #4: "residents told them they were not getting changed at night at all" - LPN #2: "there was not enough staff and not enough help to ensure the residents got the care they needed" - RN Manager #1: acknowledged "ongoing issues with staffing" causing "less time spent on each resident's care"
Administrative Response Inadequate
Despite documented evidence of unsafe conditions, facility leadership appeared overwhelmed and unable to implement effective solutions. The Director of Nursing acknowledged not having enough staff and requesting additional personnel from administration, but stated 90% of CNAs and 65% of Licensed Nurses were employed through agencies, suggesting heavy reliance on temporary staffing.
The Administrator's stated minimum staffing levels (two Licensed Nurses and five CNAs for day shift) were consistently not met, yet no emergency protocols appeared to be implemented to address the crisis.
Federal Violations and Consequences
The inspection resulted in multiple federal violations including: - F686: Failure to provide treatment and services to prevent pressure ulcers - F725: Insufficient nurse staffing (Level: Actual Harm, Residents Affected: Some) - F761: Improper drug storage and labeling - F835: Failure to administer facility effectively
These violations indicate systemic failures that put residents at immediate risk. The "Actual Harm" designation for staffing violations means inspectors found evidence that residents were injured or experienced negative outcomes due to the facility's failures.
Industry Standards and Expectations
Federal nursing home standards require facilities to provide sufficient nursing staff to ensure residents receive necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Accepted industry practices include: - Two-hour incontinence care rounds minimum - Adequate staffing to respond to call lights within reasonable timeframes - Secure storage of controlled substances per DEA regulations - Regular bathing and hygiene maintenance - Timely medication administration per physician orders
The documented conditions at Ontario Center represent significant departures from these basic care standards that all nursing home residents deserve.
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.
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