CANANDAIGUA, NY — Federal health inspectors documented alarming hygiene and personal care failures at Ontario Center for Rehabilitation and Healthcare, where residents were observed going weeks without showers and sitting in soiled garments for extended periods. The facility's own nursing leadership confirmed the breakdowns were the direct result of chronic understaffing that administration failed to address.
The inspection, concluded on January 31, 2025, resulted in a citation under F725, a federal regulation requiring nursing facilities to provide sufficient staffing to meet the daily living needs of every resident. The findings paint a picture of a facility where basic human dignity standards were not being met.
Residents Left in Soiled Clothing for Hours
During multiple observations throughout the inspection, surveyors found residents who were incontinent of bladder or bowel and left without assistance for extended periods of time. Incontinence care is one of the most fundamental responsibilities in a nursing facility. When residents cannot manage their own toileting needs, they depend entirely on staff to maintain their comfort, skin integrity, and dignity.
Prolonged exposure to urine and fecal matter creates serious medical risks. Skin that remains in contact with moisture breaks down rapidly, a process known as moisture-associated skin damage. This can progress to pressure injuries — commonly called bedsores — which in severe cases can expose underlying tissue, muscle, or even bone. These wounds are painful, slow to heal, and can become infected, potentially leading to sepsis, a life-threatening condition.
Federal standards require that incontinence care be provided promptly — typically within minutes of an episode, not hours. The extended delays documented at Ontario Center represent a significant departure from accepted clinical practice.
Weeks Without Basic Bathing
Beyond incontinence care, inspectors found that several residents reported going weeks without receiving a shower. Surveyors observed these individuals appeared unkempt, with visibly unclean hair and poor overall hygiene.
Regular bathing is not merely a comfort measure. It is a clinical necessity in congregate care settings where infection risk is elevated. Inadequate hygiene increases the likelihood of urinary tract infections, skin infections, and fungal conditions — all of which are particularly dangerous for elderly residents with compromised immune systems. Federal regulations require that nursing homes assist residents with bathing at least weekly, or more frequently based on individual care plans.
The failure to provide regular bathing also carries significant psychological consequences. Loss of personal hygiene is closely associated with depression, social withdrawal, and diminished self-worth among nursing home residents. Being left unclean for prolonged periods can feel dehumanizing, eroding the sense of dignity that federal law explicitly requires facilities to maintain.
Nursing Leadership Confirmed the Problem
Perhaps the most revealing aspect of the inspection was the candor of the facility's own clinical staff. During interviews, multiple staff members, including the Director of Nursing, told inspectors directly that they did not have enough personnel to provide timely incontinence care, showers, or treatments.
Staff reported that they had repeatedly asked the Administrator for additional staffing to address the shortfalls. Those requests, according to staff accounts, were not acted upon. This acknowledgment from the facility's senior nursing officer is significant — it indicates the staffing crisis was not a surprise to leadership but rather a known, ongoing problem that persisted without corrective action.
Under federal law, nursing home administrators bear ultimate responsibility for ensuring adequate staffing levels. The Centers for Medicare & Medicaid Services requires that facilities employ enough qualified personnel to meet the assessed needs of every resident, 24 hours a day. When a facility's own Director of Nursing states publicly that staffing is insufficient, it raises serious questions about administrative priorities and resource allocation decisions.
What Federal Standards Require
The F725 citation specifically addresses the obligation of nursing facilities to maintain sufficient nursing staff with the appropriate competencies to meet resident needs. Facilities must evaluate staffing continuously and adjust levels based on resident acuity, not simply budget targets.
Ontario Center for Rehabilitation and Healthcare is located at 3600 County Road 10, Canandaigua, New York. The complete inspection report, including all findings and the facility's plan of correction, is available for public review through the CMS Care Compare database. Families with concerns about care quality at this or any nursing facility can contact the New York State Department of Health or the local Long-Term Care Ombudsman program.
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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