Ontario Center for Rehabilitation and Healthcare

In the surveyor’s words

From the most serious findings on record at Ontario Center for Rehabilitation and Healthcare, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jan 31, 2025

  Based on observations, interviews and record reviews conducted during the extended Recertification Survey and complaint investigations (#NY00349354, #NY00357725, #NY00362904) from 01/21/2025 to 01/31/2025, the facility failed to ensure residents' right to be free from abuse, mistreatment or neglect for six (6)(Residents #8, #48, #65, #73, #76 and #350) of eight (8) residents reviewed for abuse and neglect. Specifically, 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 incontinence care for approximately six hours. […]

• Actual harm, patternF725Jan 31, 2025

  Based on observations, interviews, and record review conducted during the Extended Recertification Survey from 01/21/2025 to 01/31/2025, for two (Second Floor and Third Floor) of two resident units, the facility did not ensure sufficient staffing to provide nursing services to attain or maintain the highest practical physical, mental, and psychosocial well-being for residents in the facility. Specifically, 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 observed unkept with unclean hair. […]

• Actual harm, isolatedF550Jan 31, 2025

  Based on observations, interviews, and record review conducted during the Extended Recertification Survey and complaint investigation (#NY00349354) from 01/21/2025 to 01/31/2025, for four (4) (Resident #8, #28, #48, and #350) of seven (7) residents reviewed, the facility failed to ensure residents were treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of quality of life. Specifically, Residents #8 and #350 did not receive timely emptying of their urinal (a device used to urinate in) resulting in spillage on the resident or having to empty the urinal out a window in order to use it. Resident #28 did not receive timely incontinence care and had not received a shower for four (4) weeks. […]

• No harm, potential for more than minimal, widespreadF835Jan 31, 2025

  Based on observations, record review, and interviews conducted during the Extended Recertification Survey 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. […]

• No harm, potential for more than minimal, widespreadF919Jan 31, 2025

  Based on observations, interviews, and record review conducted during the Extended Recertification Survey 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. […]