Ontario Center For Rehabilitation And Healthcare

During an interview on 01/22/2025 at 9:11 AM Resident #10 stated they did not receive quarterly statements from the facility, were not given any money to buy things like pizza and did not know if or how much money they had in their account.

Review of a Resident Statement Landscape form dated 01/30/2025 revealed Resident #10 had a personal funds account with a balance of $9,800.12.

Review of Resident Fund Statements from 03/29/2024 to present revealed all quarterly statements had been signed by the facility as rep payee (the facility manages the resident's Social Security benefits if they are unable to).

When requested, the facility was unable to provide evidence that Resident #10 or their representative were provided with any statements of Resident #10's personal fund account.

During an interview on 01/30/2025 at 4:15 PM the Business Office Manager stated Resident #10 had fluctuating levels of cognition, the facility was the rep payee, and statements are not sent to residents who are not cognitively intact.

The Business Office Manager stated copies of the quarterly Resident Fund Statements for personal funds accounts should be sent the resident representatives if they had one,but was unsure if Resident #10 had a representative.

During an interview on 01/30/2025 at 5:11 PM with the Administrator and the Corporate Administrator, the Corporate Administrator stated cognitively intact residents, resident representatives of cognitively impaired residents, and both representatives and residents with fluctuating cognition should receive quarterly statements for personal funds accounts.

Review of Resident #10's medical record revealed the resident's brother was their Health Care Proxy (resident representative). 10 NYCRR 415.26(h)(5)(iii)

335564 01/31/2025

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

recommendations had been implemented.

335564 01/31/2025

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

Daily Living Care and Support; Grievances; Skin and Pressure Injury Prevention; and a newly

jeopardy to resident health or safety -Five (5) per diem staff members and four (4) staff members who are on vacation and/or sick leave have been notified and will be educated prior to their next scheduled shift.

-Four (4) of four (4) leadership staff, including Administrator, Director of Nursing, Assistant Director of Nursing and Director of Social Work, were educated on the grievance process. -A weekly on-call rotation for clinical leadership was implemented. -A full house skin sweep audit was completed, newly identified wounds had treatments ordered and were scheduled for wound rounds to be completed 01/29/2025. -Full house treatment completion audit conducted with no wound care treatments identified as missing or incomplete. -Full house call bell audit completed with three (3) call bells replaced. -Full house incontinence rounding completed with incontinence care provided as needed. -Audits to be continued each shift for wound treatment completion, call light accessibility and function, and incontinence care. 10 NYCRR 415.4 (b)(1)(i)

335564 01/31/2025

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

During an interview on 01/22/205 at 10:21 AM the Ombudsman from the Office of the State Long Term Care Ombudsman Program stated that they had not received the facility's notices of transfers and discharges from the facility for the past year.

During an interview on 01/30/2025 at 11:41 AM the Director of Social Work stated residents' discharge/transfer notices were not currently being sent to the Ombudsman though it was the responsibility of the Social Worker to send them.

The Director of Social Work stated the last notification sent was in October 2024.

During an interview on 01/31/2025 at 2:25 PM the Administrator stated they were not aware the facility was not sending copies of the notice of resident discharges/transfers to the Long-Term Care Ombudsman program, The facility was unable to provide any documentation that the Office of the State Long Term Care Ombudsman office had been notified of residents' transfers and discharges per the regulations. 10 NYCRR 415.3(i)(1)(iii)(a-c)

During an interview on 01/27/2025 at 11:05 AM the Director of Nursing stated residents who can use the bathroom should be toileted and not left to be incontinent. 10 NYCRR 415.12(a)(3)

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

Review of the physician order at 4:56 PM revealed a lumbosacral spine x-ray was ordered.

During an interview on 01/21/2025 at 11:51 AM, Resident #12 said they have had constant back pain for a long time and a doctor had said two to three weeks prior that they would get an x-ray, but nothing had been done yet.

In a medical progress note dated 01/23/2025 Physiatry (a medical specialty that helps residents regain function and quality of life after injury or illness) Nurse Practitioner #1 documented that Resident #12 was picked up by therapy for rehabilitation due to generalized weakness, poor endurance, functional decline and low back pain.

Physiatry Nurse Practitioner #1 documented that Resident #12 was pending a lumbosacral spine x-ray which appeared to have not been done yet, and the primary care provider and Director of Nursing were made aware.

Review of Resident #12's Radiology Results Report dated 01/24/2025, revealed the x-ray was obtained on 01/24/2025 at 2:20 PM, and the findings included a compression fracture of the lower spine that was not identified on a previous study 11/16/2021.

The report included no further follow-up necessary at this time.

During an interview on 01/31/2025 at 9:55 AM, Registered Nurse #1 said a new order for a diagnostic test (x-ray) would go into the computer system (electronic health record) and they should be told in report if an x-ray needed to be done.

Registered Nurse #1 said it the Assistant Director of Nursing, the Director of Nursing or the Physician are responsible to ensure the x-ray was done.

Registered Nurse #1 stated they did not recall Resident #12 having an x-ray ordered on 01/09/2025.

During an interview on 01/31/2025 at approximately 10:30 AM, Registered Nurse Manager #1 said there was a certain format to follow when entering x-ray orders and both nurses and medical providers are able to enter the x-ray orders.

Registered Nurse Unit Manager #1 stated x-rays are not always completed on the day shift, and if not, it should be passed on to the next shift or call to find out why it had not been done.

Registered Nurse Unit Manager #1 stated they were not aware Resident #12 had an x-ray ordered.

Registered Nurse Manager #1 stated the delay could have been because the ordering provider did not know how to put the order in the computer, and they do not always inform nursing staff know when an order is entered. 10 NYCRR 415.12

335564 01/31/2025

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

During an observation of incontinence

buttocks area dated 01/23/2025 and was saturated with urine.

The surrounding area was reddened and had an open wound measuring approximately one quarter inch by one quarter inch.

During an interview on 01/25/2025 at 1:58 PM, Licensed Practical Nurse #2 stated they did not know if the open wound on Resident #65 was new.

Review of Resident #65's electronic health record from 01/01/2025 to 01/27/2025 revealed no documentation of a skin impairment or pressure ulcer to the right buttock and no wound treatment orders were in place.

During an observation and interview on 01/28/2025 at 8:22 AM, the Assistant Director of Nursing assessed Resident #65.

The incontinence brief was removed and there was no dressing covering the open wound on Resident #65's buttock.

The surrounding area remained reddened wotj the wound edges macerated (the softening and breaking down of skin due to prolonged exposure to moisture).

The wound was not measured.

When interviewed at that time, the Assistant Director of Nursing stated the open wound looked like a stage two pressure ulcer and there was no documentation of the wound in Resident #65's medical record.

The staff should have reported the new skin impairment, and the nurse should have documented a note in the electronic health record when it was discovered.

The Assistant Director of Nursing stated Resident #65 was at high risk for pressure ulcers and being left in bed and not assisted with incontinence care or toileting needs could potentially cause a pressure ulcer to develop.

During an interview on 01/31/2025 at 1:20 PM, the Director of Nursing stated any new skin impairment should be reported immediately to the registered nurse, assistant director of nursing, director of nursing, and medical provider so an assessment could be completed and wound treatment orders placed. Resident #65 was at high risk for pressure ulcer development and the pressure ulcer could have been prevented by timely addressing their incontinence and toileting needs. 10 NYCRR 415.12 (c)(1)

335564 01/31/2025

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

335564 01/31/2025

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

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)

335564 01/31/2025

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

Based on observations, interviews, and record review conducted during the Extended Recertification

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.

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 are being used during the shift and then only the medications being used should be kept in the medication cart. If the controlled medications are being kept in the medication carts all the time, there is an increased risk for diversion (theft). 10 NYCRR 415.18(e)(1-4)

335564 01/31/2025

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

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

335564 01/31/2025

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

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)

335564 01/31/2025

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

335564 01/31/2025

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

resident pressed their call button because they are constantly looking and could see the red light and

monitor (nurse call system central monitor) on the second floor, but the third floor did have

10NYCRR: 415.29, 415.29(b); 415.29(j)(1), 10NYCRR: 713-1.3(b), 713-3.25(g)

335564 01/31/2025

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

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.

335564

Form Approved OMB

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

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

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).

335564

Form Approved OMB

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

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

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

335564

Form Approved OMB

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