Ontario Center For Rehabilitation And Healthcare

F-F550.

Residents #8 and #350 did not receive timely emptying of their urinal (container used to urinate in) causing urine to spill on the resident or having to empty the contents out a window in order to urinate. Resident #28 did not receive timely incontinence care and had not received a shower in four weeks. Resident #48 was observed on multiple occasions soaked through their incontinence brief, pad, and sheets. This resulted in psychosocial harm to Resident #8, #28, and #48 that is not Immediate Jeopardy.

Sufficient Nursing Staffing - Refer to citation

F-F585.

Residents #88 and #350 did not have thorough investigations of their grievances and in some cases no follow up was provided. There was no evidence that the facility ruled out abuse or neglect.

Resident Call System - Refer to citation text under

F-F600.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 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 provided Level of Harm - Minimal harm or incontinence care for approximately six hours. Resident #73 was left sitting in their wheelchair for potential for actual harm approximately 14 hours without care. Resident #76 waited approximately 21 hours for incontinence care. Resident #350 did not receive wound care as ordered by the physician for multiple days. In addition, multiple Residents Affected - Many grievances were filed by the residents related to the issues which were not followed up by the Administration team. These issues resulted in the likelihood of serious injury, serious harm or death for all of the residents in

the facility (current census 95), which resulted in Immediate Jeopardy.

Resident Rights - Refer to citation

F-F677.

Residents #28 and #48 did not receive incontinence care for extended periods of time (up to 13 hours) and Resident #65 was not assisted to the bathroom for hours causing the resident to be left incontinent for an extended period of time.

Grievances - Refer to citation

F-F686 Treatment/Services to Prevent/Heal Pressure Ulcers.

Review of the Facility Assessment, revised 01/03/2025, revealed the facility was licensed for 98 beds with an average daily census of 94 residents. Resident care and services included, but were not limited to, assistance with daily living, bowel and bladder care, and monitoring of skin integrity. The facility's minimum staffing pattern listed five Certified Nursing Assistants total for day shift, four for evening shift and two for night shift. The minimum staffing pattern listed two Licensed Nurses (Registered Nurse and/or Licensed Practical Nurse) for day shift, one and a half for evening shift and one for night shift. The facility's staffing plan did not list a direct care staff (Certified Nursing Assistant) to resident ratio.

During entrance conference on 01/21/2025 at 9:23 AM, with the Facility Administrator and Corporate Administrator, it was reported that the facility census was 95 residents.

Observations and interviews on 01/21/2025 on the second-floor resident unit (census of 46) included:

-At 9:18 AM, Registered Nurse Manager #1 said there were only two Certified Nursing Assistants on the unit because the facility had nine call ins for the shift.

-At 10:25 AM, Resident #65 was in bed with several days of beard growth and stringy, greasy hair. Resident #65 stated showers were hit or miss and they had gone two to three weeks without a shower. Resident #65 stated no one had been in to help them yet that morning and they had last received care at 5:00 AM. Resident #65's brief was saturated and a strong odor of urine present. Resident #65 stated they knew when

they needed to go to the bathroom but could not get help to the bathroom so they wore an incontinence brief and would have to wait to get cleaned up.

-At 11:16 AM, Resident #350 said neither a nurse nor a Certified Nursing Assistant had come in to help them yet today, and therapy said they could not go to therapy because they were not ready. Resident #350 said there was not enough staff to help, and they have had to wait hours for care (assistance with incontinence care, dressing changes to their wounds and help with emptying their urinal).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 -At 12:04 PM, Certified Nursing Assistant #3 said when their day started there were only two Certified Nursing Assistants (on the unit), and they had not gotten to all residents yet (to provide care). Level of Harm - Actual harm -At 1:50 PM, Resident #88 said the facility was short-staffed all the time and there was a day shift last month Residents Affected - Some where there was one Certified Nursing Assistant for the entire unit and on one day a few months ago they were unable to get out of bed all day due to not enough staff.

Observations and interviews on 01/21/2025 on the third-floor resident unit (census of 49) included:

-At 9:09 AM, Licensed Practical Nurse Manager #1 said there were three Certified Nursing Assistants for the day shift (due to call-ins).

-At 11:01 AM, Resident #28 said they were last changed (provided incontinence care) at 4:00 AM and day staff had not been in yet to help the resident get up or provide incontinence care. Resident #28 said they were incontinent of both bowel and bladder. Resident #28 said there had been only one Certified Nursing Assistant on the night shift. Resident #28 said they were told there was not enough staff to give them a shower, and it had been four weeks since they had received one or had their hair washed.

-At 11:51 AM, Resident #8 was visibly incontinent of stool and stated they had been waiting since they woke up (approximately four hours ago) to be changed but had no response to their call light.

-At 3:12 PM, Resident #73 was sitting in their wheelchair and was unable to provide an interview. The resident's roommate (Resident #299) who was alert and oriented stated staff got Resident #73 up at 10:00 AM on Sunday (two days prior) and they remained in their wheelchair until 1:00 AM (15 hours later). When interviewed, Certified Nursing Assistant #1 stated they did put Resident #73 to bed Monday morning at approximately 12:00 AM and 12:30 AM and it was due to short staffing.

During an interview on 01/22/2025 at 1:24 PM, Resident #76 stated they were concerned with not being changed on Sunday (01/19/2025) from 8:30 AM until Monday (01/20/2025) at 8:30 AM. Resident #76 stated

they were so soaked their sheets were soiled and wet, and they had put their call light on numerous times, but it was turned off by staff, who stated they knew the resident needed assistance but they were short staffed.

During an interview on 01/24/2025 at 10:36 AM, Certified Nursing Assistant #3 stated when they arrived to work on 01/20/2025 at 6:00 AM, five to six residents including Resident #76 were very soiled, and Resident #76 and their roommate (Resident #74) stated they had not been changed at all during the night.

During a special Resident Council meeting on 01/22/2025 at 1:31 PM with five residents present, one resident said their grievances about poor staffing and long wait times for assistance had been ongoing for months. Review of the monthly Resident Council meeting minutes from July 2024 to December 2024 revealed residents voiced concerns related to long wait times (including call bells) during four of six meetings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Review of scheduled nurse staffing sheets for the two units for the past six months revealed multiple night shifts where there were two nurses (Registered Nurse and/or Licensed Practical Nurse and two Certified Level of Harm - Actual harm Nursing Assistants for the entire facility (average census of 94).

Residents Affected - Some Review of a staffing spreadsheet for the past three weeks revealed the following nurse staffing levels with an average daily census of 94:

-On 01/05/2025, there was one Licensed Practical Nurse in the entire facility from 10:00 PM to 6:00 AM. The facility provided separate documentation that included the Director of Nursing worked on 01/05/2025, but did not include the hours worked.

-On 01/10/2025, there was three Certified Nursing Assistants for the entire facility from 10:00 PM to 6:00 AM.

-On 01/19/2020 evening shift there was two Licensed Practical Nurses and three Certified Nursing Assistants for the whole facility.

-On 01/19/2025 and 01/20/2025 night shift there was one Licensed Practical Nurse and three Certified Nursing Assistants for the whole facility.

-On 01/24/2025, there were four Certified Nursing Assistants documented as having worked on the second floor from 6:00 AM to 2:00 PM but the facility could not provide documented evidence (via timecards or punches) that two of the four Certified Nursing Assistants had worked from 6:00 AM to 2:00 PM.

During an interview on 01/21/2025 at 12:02 PM, the Director of Human Resources stated when nursing staff call in (unable to work), they try to call more staff in, and notify the administrative team (Administrator, the Director of Nursing and the Assistant Director of Nursing) of call ins. The Director of Human Resources said

it was a record call in day (01/21/2025) with two nurses and seven certified nursing assistants that called in (for the day shift).

During an interview on 01/24/2025 at 9:59 AM, Certified Nursing Assistant #4 said normal staffing should be five or six Certified Nursing Assistants (each unit), but they usually had four or even two or three (today). Certified Nursing Assistant #4 said when they only had two to three Certified Nursing Assistants, it would take longer to get to all the residents, showers were not done, and they could only round (provide cares) on residents one or two times during the shift (when they should be rounding every two hours). Certified Nursing Assistant #4 stated residents told them they were not getting changed at night at all. Certified Nursing Assistant #4 said they have told their nurse and/or nurse manager that residents were not getting changed or showered and rounds not being done.

During an interview on 01/24/2025 at 11:26 AM, Licensed Practical Nurse #2 said there was not enough staff and not enough help to ensure the residents got the care they needed. Licensed Practical Nurse #2 stated there was usually only two Certified Nursing Assistants on the floor to take care of almost 50 residents, and

they cannot get everything done. Licensed Practical Nurse #2 said often wound dressings did not get done because there was only one nurse. Licensed Practical Nurse #2 stated they have spoked to Registered Nurse Manager #1, the Director of Nursing, and the Administrator about the issues but they did not feel they were being addressed and were told they (leadership) were working on it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During an interview on 01/24/2025 at 12:10 pm, Registered Nurse Manager #1 said there were ongoing issues with staffing, which included a lot of staff call-ins, staff just not showing up and newly hired staff not Level of Harm - Actual harm staying. Registered Nurse Manager #1 stated at times they only had one Licensed Practical Nurse on the unit or only two Certified Nursing Assistants for the unit on day shift causing less time spent on each Residents Affected - Some resident's care.

During an interview on 01/28/2025 at 3:26 PM, the Director of Human Resources stated when there are call-ins, they send group messages to all staff (not on the schedule that day), the Administrator, the Director of Nursing, the Assistant Director of Nursing, unit managers, and nursing supervisors. The Director of Human Resources stated the minimum nurse staffing levels were four Licensed Nurses and eight Certified Nursing Assistants for the building for day and evening shift and two Licensed Nurses and four Certified Nursing Assistants for night shift. The Director of Human Resources said they do use agency nursing staff that were hired as in-house employees by the corporation but were unsure if there were any other agencies in use.

During an interview with the Administrator and the Corporate Administrator on 01/30/2025 at 5:44 PM, the Administrator said minimum nurse staffing levels were based on clinical acuity, which was determined by the Regional Director of Nursing, who would see what the residents' needs were in the building and adjust accordingly. The Administrator stated the minimum nurse staffing levels for the entire building (average census 95) consisted of two Licensed Nurses and five Certified Nursing Assistants for the day shift, one and

a one-half Licensed Nurses and four Certified Nursing Assistants for the evening shift, and one Licensed Nurse and two Certified Nursing Assistants for the night shift. The Administrator said they like to have one Registered Nurse for at least eight hours daily and one always on call.

During an interview on 01/31/2025 at 10:04 AM the Director of Nursing said they did not have enough staff and have asked the Administrator for more staff. In a follow-up interview at 1:19 PM, the Director of Nursing said five to six Certified Nursing Assistants and two to three Licensed Nurses during the day shift would be needed to provide resident care. The Director of Nursing stated they thought 90% of Certified Nursing Assistants and 65% of Licensed Nurses were employed by an agency affiliated with the organization. The Director of Nursing said they were not privy to if the facility used third party agencies for staffing.

During a telephone interview on 01/31/2025 at 11:24 AM, the Medical Director stated they were notified by Administration two to three weeks prior that there was a shift where medications had not been given or were not given on time due to staffing.

10 NYCRR 415.13 (a)(1)(i-iii)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 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 Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 49447 Residents Affected - Few Based 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:

The facility policy Controlled Substance Management dated August 2022, included the proper storage of controlled drugs was in a double door, double locked, double keyed, steel, wall mounted drug cabinet during non-med pass times and in locked controlled drug compartment of medication cart during med pass times.

During an observation on 01/22/2025 at 10:32 AM the third-floor medication room had a narcotic cabinet that was empty except for a pill box that contained approximately 80 undated/unlabeled pills.

During an interview on 01/22/2025 at 10:42 AM Licensed Practical Nurse Manager #1 stated they did not have any residents on the floor who used a pill box and did not know whose it was but that any resident pill boxes should be labeled with resident identifiers.

During an interview on 01/22/2025 at 11:20 AM Registered Nurse Manager #1 stated controlled substances are stored in the medication carts (two carts on the unit) and removed when a resident is discharged .

During an observation on 01/23/2025 at 10:39 AM the second-floor north medication cart contained 25 blister packs of controlled medications for multiple residents including psychotropic (medications used to treat mental health conditions), antianxiety, antidepressant, and opioid medications that were stored in the medication cart. The medications were not stored in a permanently fixed compartment per the regulations. When interviewed at this time Licensed Practical Nurse #2 stated all controlled medications are stored in the medication cart and they do not use the double locked cabinet in the medication room. Licensed Practical Nurse #2 stated the medication carts are not affixed to the wall and the carts have wheels that you can unlock and roll the cart around. There was no chain or lock that could be used to affix the medication cart to

the wall.

Multiple observations on 01/23/2025 on the second floor resident unit hallways during the day shift revealed

the medication carts were left in the hallways not affixed to anything and with no nurse in sight.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During an interview on 01/30/2025 at 1:20 PM the Director of Nursing stated controlled medications should always be stored behind two locks in the secured double door cabinet in the medication room, unless they Level of Harm - Minimal harm or are being used during the shift and then only the medications being used should be kept in the medication potential for actual harm cart. If the controlled medications are being kept in the medication carts all the time, there is an increased risk for diversion (theft). Residents Affected - Few 10 NYCRR 415.18(e)(1-4)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46526 potential for actual harm Based on observations, record review, and interviews conducted during the Extended Recertification Survey Residents Affected - Many 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; and the governing body is responsible and accountable for the Quality Assurance and Performance Improvement program. Specifically, the administration did not ensure residents were free from neglect, there was sufficient nurse staffing to provide nursing services based on residents' assessments, residents were treated with respect and dignity, the nurse call bell system functioned as intended, and that grievances were thoroughly investigated and a follow-up provided to the resident and/or their representative.

The is evidenced by the following:

The facility's 2025 Quality Assurance and Performance Improvement Plan included that the facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. The Administrator was responsible for assuring that

the facility's Quality Assurance and Performance Improvement Program complied with federal, state, and local regulatory agency requirements. The Administrator was the chairperson of the Quality Assurance and Performance Improvement Committee, and the role of the Administrator consisted of (but not limited to):

-Planning, developing, organizing, implementing, coordinating and directing the Quality Assurance and Performance Improvement Program, in accordance with current rules, regulations, and guidelines that govern the facility.

-Helping to identify quality areas that are appropriate for performance improvement projects.

-Implementing recommendations from the Quality Assurance and Performance Improvement Committee as

they relate to the Quality Assurance and Performance Improvement Program.

The Facility assessment dated [DATE REDACTED], included (but not limited to) services provided by the facility were skilled nursing, subacute services, physical therapy, occupational therapy, and speech therapy. The average daily census was 94 residents. Care and services offered by the facility based on resident's needs included activities of daily living, bowel/bladder care, skin integrity, mental health, medications, infection prevention and control, and other special care needs.

Free from Abuse and Neglect - Refer to citation

F-F725.

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 were observed unkept with unclean hair. Interviews with multiple staff including the Director of Nursing stated they did not have enough staff to provide timely incontinence care, showers, or treatments and that they have asked the Administrator for more staff.

Activities of Daily Living Care Provided for Dependent Residents - Refer to citation

F-F919

For three of three residential 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 During an interview on 01/22/2025 at 3:30 PM with the Administrator and the Corporate Administrator, the Corporate Administrator stated the call bell system was installed in 2018 and that the overhead lights should Level of Harm - Minimal harm or light up and audibly tone. The Corporate Administrator said staff should be trained during orientation on the potential for actual harm call bell system, and they saw no issue with the panels not being in place as the system still functioned.

Residents Affected - Many During an interview on 01/27/2025 at 1:47 PM the Administrator stated they had received grievances related to wound care, toileting assist, and incontinence care not being provided and the Director of Nursing should be following up on these concerns. The Corporate Administrator stated approximately one to two weeks ago

they had identified issues with residents' grievances at the facility and a Quality Assurance and Performance Improvement meeting was held with the interdisciplinary team. Discussions were conducted related to the grievance policy and what grievances entailed. The Corporate Administrator said they set up a weekly call to make sure grievances were identified and everything completed but had not yet had the ability to check if the suggestions/recommendations had been done.

During an interview on 01/31/2025 at 2:25 PM, the Administrator stated the facility's Quality Assurance and Performance Improvement committee were aware of concerns related to care not being provided (incontinence care, showers, and grooming), dressing changes not being done, and sufficient staffing.

10 NYCRR 415.26

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47642 potential for actual harm Based on observation, interviews and record review conducted during the Extended Recertification Survey Residents Affected - Some 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.

The facility policy Enhanced Barrier Precautions dated 05/30/2024, documented Enhanced Barrier Precautions would be initiated and implemented for residents as applicable in accordance with federal and/or state regulations and/or in accordance with Centers for Disease Control guidance to reduce the risks of transmission of Multiple Drug-Resistant Organisms. Enhanced Barrier Precautions is applicable for resident with any of the following:

a. Infection or colonization with a Multiple Drug-Resistant Organisms.

b. Wounds (e.g. any type of wound requiring a dressing)

c. Indwelling medical devises (e.g., central line, urinary catheter, feeding tube, tracheostomy/ ventilator, etc.)

Issue 1

1. Resident #350 had diagnoses that included diabetes (high blood sugars), peripheral vascular disease (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). The Minimum Data Set Resident assessment dated [DATE REDACTED] included Resident #350 was cognitively intact and had seven venous and/or arterial ulcers (wounds).

The Comprehensive Care Plan dated 01/08/2025 included Resident #350 had venous wounds to both legs and was on Enhanced Barrier Precautions.

During an observation of wound care on 01/21/2025 at 10:54 AM Resident #350 had an Enhanced Barrier Precautions sign posted outside their door which included for staff to wear a gown and gloves with hands on care. Nurse Practitioner #1 wearing gloves, but no gown, removed Resident #350's wound dressings on both legs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an observation of wound care on 01/27/2025 at 10:53 AM Registered Nurse #1 wearing gloves, but no gown, provided wound care to Resident #350's multiple leg wounds. Wound care orders included Level of Harm - Minimal harm or cleansing each wound, drying, applying Aquacell AG (medicated dressing material) to the wound bed and potential for actual harm cover with a dressing. During an immediate interview Registered Nurse #1 stated they did not believe Resident #350 was on precautions, and that the Enhanced Barrier Precaution sign was for the roommate. Residents Affected - Some Registered Nurse #1 stated they did not recall receiving education on Enhanced Barrier Precautions at this facility.

During a follow up interview on 01/30/2025 at 10:59 AM Registered Nurse #1 stated Enhanced Barrier Precautions signs were posted outside of the doors to residents' room and when providing hands on care (wound care, catheter care, incontinence care) for those residents' staff should wear appropriate personal protective equipment, including gowns and gloves, to prevent cross contamination.

2.Resident #65 had diagnoses that included a right leg fracture (broken bone), Parkinson's disease (a progressive movement disorder), and malnutrition. The Minimum Data Set Resident assessment dated [DATE REDACTED] included Resident #65 was cognitively intact, incontinent of bladder and bowel, and required assistance from staff for transfers and toileting hygiene.

The Comprehensive Care Plan initiated 12/24/2024 included Resident #65 had an actual skin impairment to

the right shin and right thigh and was on Enhanced Barrier Precautions.

During an observation of wound care on 01/25/2025 at 1:58 PM Resident #65 had an Enhanced Barrier Precaution sign posted outside their door. Licensed Practical Nurse #2 wearing gloves, but no gown, removed the resident's wound dressings and applied two new wound dressings.

During an interview on 01/31/2025 at 9:52 AM Licensed Practical Nurse #2 stated precautions are posted outside the resident's door and include the type of precautions. Enhanced Barrier Precautions should be used with residents who had wounds. Licensed Practical Nurse #2 stated they did not wear a gown while providing wound care and should have.

3.Resident #351 had diagnoses that included neurogenic bladder (impaired bladder function due to damaged nerves), a leg fracture, and depression. The Minimum Data Set Resident assessment dated [DATE REDACTED] included Resident #351 had severe cognitive impairment and had an indwelling urinary catheter.

During an observation on 01/25/2025 at 1:58 PM Resident #351 had a sign for Enhanced Barrier Precautions posted outside their door. Licensed Practical Nurse #2, wearing gloves, but no gown, unhooked

the resident's urinary catheter drainage bag, emptied the drainage bag of urine into a urinal and emptied the urinal into the toilet.

During an interview on 01/31/2025 at 9:52 AM Licensed Practical Nurse #2 stated Enhanced Barrier Precautions were used with residents who had indwelling medical devices such as urinary catheters. Licensed Practical Nurse #2 stated they should have worn a gown while providing care to the resident's urinary catheter drainage bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 01/30/2025 at 11:17 AM with the Assistant Director of Nursing (newly hired Infection Preventionist) and the Registered Nurse/Regional Director of Clinical Services and covering Infection Level of Harm - Minimal harm or Preventionist stated residents on Enhanced Barrier Precautions are those with open wounds, catheters and potential for actual harm residents who have positive multidrug resistant organism cultures. Any staff providing direct hands-on care should be wearing appropriate personal protective equipment of gowns, gloves, goggles (if appropriate) and Residents Affected - Some masks (if appropriate) and all staff received education at orientation and annual in-servicing.

Issue 2

The facility policy Influenza Vaccine dated 08/22/2024, documented that staff will provide consent or declination for the influenza (flu) vaccine each year. Individuals refusing the vaccination may be required to wear a standard face mask in resident care areas throughout flu season, as defined and required by the state Department of Health.

During an interview on 01/31/2025 at 10:37 AM the Corporate Licensed Practical Nurse stated staff that received the flu vaccine this year have a purple sticker on their ID badges. If staff do not have the purple sticker on their badge this would reflect not receiving the flu vaccine and should be wearing a surgical mask

in resident care areas.

During an observation and interview on 01/31/2025 at 10:45 AM Licensed Practical Nurse #6 was on the 2nd floor residential unit preparing and administering medications and was not wearing a mask. Licensed Practical Nurse #6 stated they did not receive the flu vaccine this year, did not have a purple sticker on their ID badge, and should be wearing a mask.

During an interview and observation on 01/31/2025 at 10:50 AM on the 2nd floor the Director of Maintenance was standing at nurses' station not wearing a mask. The Director of Maintenance stated they did not receive

the flu vaccine this year and should be wearing one.

During an interview on 01/31/2025 at 2:25 PM the Administrator stated they were aware that facility staff who had not received the current flu season vaccination were not appropriately masking as defined and required by the state Department of Health.

10 NYCRR 415.19(a)(b)(1-3)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47642 potential for actual harm Based on interviews and record review conducted during the Extended Recertification Survey from Residents Affected - Few 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). A resident's refusal of the vaccine(s) shall be documented on the informed consent for influenza vaccine and pneumococcal vaccine and placed in the resident's medical record and will include the resident or resident's representative was provided education regarding the benefits and potential side effects of the vaccine.

1.Resident #12 had diagnoses that included dementia, delusional disorders, and blindness. The Minimum Data Set Resident Assessment, dated 12/12/2024, included Resident #12 had impaired cognition and listed their daughter as their Health Care Proxy.

Review of Resident #12 electronic health record revealed no documented evidence any educational material regarding the benefits and potential side effects of the influenza or pneumococcal vaccines had been provided to the resident's Health Care Proxy or if the vaccines had been offered, received or declined with a signed declination form.

2.Resident #53 had diagnosis that included dementia, hypertension, and a stroke. The Minimum Data Set Resident Assessment, dated 12/11/2024, included Resident #53 was cognitively intact.

Review of Resident #53 electronic health record revealed they last received the pneumococcal vaccine on 11/11/2015 and they were due for an update.

3.Resident #351 had diagnoses that included neurogenic bladder (impaired bladder function due to damaged nerves), a leg fracture (broken bone), and depression. The Minimum Data Set Resident assessment dated [DATE REDACTED] included Resident #351 had severe cognitive impairment.

Review of Resident #351 electronic health record revealed their last pneumococcal vaccine was received on 11/5/2014. There was no documentation that Resident #351 had received the influenza vaccine or their Health Care Proxy educated regarding the risks, benefits and side effects of both the influenza and updated pneumococcal vaccines or had declined.

In an interview on 01/30/2025 at 1:27 PM the Assistant Director of Nursing (newly hired Infection Preventionist) stated the facility was unaware that Resident #53 was in need of an updated pneumococcal vaccine and they were unable to provide any written documentation that any of the residents or representatives had been educated, received or declined the vaccinations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 In an interview on 01/31/2025 at 2:25 PM the Administrator stated the facility offers the residents immunizations and they and the Quality Assurance Committee were aware of gaps in resident vaccination Level of Harm - Minimal harm or documentation. potential for actual harm 10 NYCRR 415.19(a)(3) Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26883 potential for actual harm Based on observations, interviews, and record review conducted during the Extended Recertification Survey Residents Affected - Many 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. The findings are:

The facility electrical equipment policy dated 12/18/2024, documented: 1. Patient Care Related Electrical Equipment (PCREE) shall be tested before being put into service for the first time and after any repair or modification that might have compromised electrical safety. 3. Testing and maintenance of the PCREE will be based on the manufacturer's service manual recommendations but tested annually at a minimum. 4. Documentation including a record of PCREE tests, repairs and modifications, whether performed by facility staff or an outside vendor, will be maintained at the facility.

When observed on 01/21/2025 at 9:43 AM, the nurse call panel/station was unplugged and not operational in

the corner of the third-floor nurse station desk. Overhead lights were observed outside of all resident rooms and one for each hallway. Call lights were lit up outside resident rooms, but no audible tones were heard and there was no panel available to see exact locations where pull stations were activated. During an interview at

this time the Director of Facilities stated the call system tablet gets unplugged and does not work at times, and they were not sure why the panel was off or how long it had been that way. The Director of Facilities also stated the system was old and they could not get parts anymore, and there was no panel on the second floor as it was no longer fixable and removed 5-months ago. The Director of Facilities also stated they were not sure what the different colored lights on the overhead call lights meant and were not sure why the system did not have an audible tone.

When observed on 01/21/2025 at 10:00 AM, the nurse call button was tested at the bedside of resident room [ROOM NUMBER] and there was one initial tone heard and then stopped. The overhead light in the corridor outside room [ROOM NUMBER] came on and when the activation was cancelled, the overhead light stayed on.

When observed on 01/21/2025 at 10:10 AM, the nurse call button was tested at bedside in resident room [ROOM NUMBER] and the corridor overhead light lit up and no audible tone was noted. Additionally, there was no nurse call system panel at the nurse station on the second floor. During an interview at this time the Director of Facilities stated the second-floor tablet had not been in use for about 5 months but there was the installation hardware in the communication room that was for use with the vendor to see what call bells have gone off.

During an observation and interview on 01/21/2025 at 11:40 AM, Resident #90 stated they could not reach their tray table. Resident #90 pressed their call light button, which did not light up outside the resident's room and it did not make a sound. Certified Nursing Assistant #7 was in the hallway and came into the room of Resident #90 (after Surveyor intervention). Certified Nursing Assistant #7 pressed Resident #90's call light and observed that it did not light up or make a sound. Certified Nursing Assistant #7 stated the call light should make a noise, and they would tell someone.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 During an observation and interview on 01/21/2025 at 11:52 AM, the nurse call light in resident room [ROOM NUMBER] was pressed and did not activate an audible or visual signal. When notified by the surveyor at this Level of Harm - Minimal harm or time, Licensed Practical Nurse Manager #1 stated they would call maintenance to come fix it. potential for actual harm

During an interview on 01/22/2025 at 10:46 AM, Certified Nursing Assistant #8 stated they would know if a Residents Affected - Many resident pressed their call button because they would look down the hall and see a light on over the resident's door. Certified Nursing Assistant #8 also stated the call button would only make a noise if the resident pressed it repeatedly.

When observed on 01/22/2025 at 9:07 AM, the nurse call was activated for rooms [ROOM NUMBERS] and

the overhead corridor lights outside the rooms came on but no audible tone was noted.

When observed on 01/22/2025 at 9:17 AM, the nurse call was activated in the bathroom of resident room [ROOM NUMBER] and the corridor overhead light came on outside the room, one audible tone was noted

the nothing further. Additionally, there was no panel operational or plugged in at the nurse station desk.

When interviewed on 01/22/2025 at 3:30 PM, the Administrator and Corporate Administrator stated they found out the call bell system was installed in 2018 and there was only one call system for the building. The Corporate Administrator stated the overhead lights should light up and audibly tone, and the overhead light would go red if activated at the bathroom and green when cleared. The Administrator stated staff should be trained during orientation on the call bell system, and they saw no issue with the panels not being in place as

the system still functioned. The Corporate Administrator stated that staff can look down the hallways to see if there are call lights on when they do not have a panel to look at and staff should note any issues with call bells not working.

Record review on 01/23/2025 at 11:00 AM, revealed quarterly nurse call system logs for 2024 documented

the call stations in resident rooms on the second and third floors were tested , only. The logs did not specify whether call stations were tested at the bed sides or at the resident room toilets. Additionally, the logs did not document testing/inspection of any areas on the first floor common bathrooms and shower areas on the second and third floors. Nurse call system annunciator panels were also not listed as tested or identified to need repairs in these logs.

Record review of the nurse call system manufacturers specification manual on 01/23/2025 at 11:30 AM, revealed the intended use section listed: 'Use this product only for the purpose it was designed for.' The general purposes section listed: 'This document describes the implementation, programming and testing of

the call station and auxiliary nurse station. The stations are a combination of hardware and software, a touchscreen PC with software that gives an overview of pending nurse calls.'

Record review on 01/23/2025 at 11:45 AM revealed the hardware installation manual for the nurse call system listed the following: under the type of calls section, the chart listed the color lights for each light to correspond to the activation type/location. Call at bed would be a red light, call at toilet would be a white light, assistance toilet would be a green light, emergency would be a flashing red light, code blue would be a flashing blue light, and technical alarm would be a yellow light. The mounting instructions section for the tablet listed annunciators and visual display calls from the stations in the system, and the auxiliary PC (tablet) is a wall mounted staff console. The manual also listed that the tablet needs to have a power and network connection to operate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 44 335564 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335564 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ontario Center for Rehabilitation and Healthcare 3062 County Complex Drive Canandaigua, NY 14424

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 During an interview on 01/23/2025 at 12:49 PM, Registered Nurse #1 stated they would know if a resident pressed their call button because they are constantly looking and could see the red light and pointed to the Level of Harm - Minimal harm or light above a resident's room. Registered Nurse #1 stated they think there is a different alarm if a call button potential for actual harm in the bathroom is pressed. Registered Nurse #1 stated they did not have a monitor (nurse call system central monitor) on the second floor, but the third floor did have something. Residents Affected - Many 10NYCRR: 415.29, 415.29(b); 415.29(j)(1),

10NYCRR: 713-1.3(b), 713-3.25(g)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 44 335564