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Ontario Center for Rehabilitation and Healthcare Inspection Report, Violations & Safety Grade (Canandaigua, New York)

3062 County Complex Drive, Canandaigua, New York 14424

Phone: 5853964345

CMS Overall:1/5

Overview & Bed Count

Certified Beds

Avg Residents/Day

94.4

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Ontario

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

Yes

CMS Star Ratings

Overall1/5

Health1/5

Staffing1/5

Quality3/5

Nurse Staffing Check

Metric	This Facility	New York Avg	Difference
RN Hours per Resident per Day	0.49	0.73	-0.24
Total Nurse Hours per Resident per Day	3.00	3.69	-0.69
CMS Staffing Rating	1/5	2.9/5	-
Nursing Staff Turnover	81.2%	40.3%	-

Health Citation History

41 health citations on record

Date	Category	Description	Severity
2026-03-17	Resident Rights Deficiencies	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	E – Moderate Harm Potential
2026-03-17	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	E – Moderate Harm Potential
2026-03-17	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2026-03-17	Environmental Deficiencies	Make sure that a working call system is available in each resident's bathroom and bathing area.	E – Moderate Harm Potential
2026-03-17	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	D – Moderate Harm Potential
2025-01-31	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	K – Immediate Jeopardy
2025-01-31	Nursing and Physician Services Deficiencies	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	H – Actual Harm
2025-01-31	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	G – Actual Harm
2025-01-31	Administration Deficiencies	Administer the facility in a manner that enables it to use its resources effectively and efficiently.	F – Moderate Harm Potential
2025-01-31	Environmental Deficiencies	Make sure that a working call system is available in each resident's bathroom and bathing area.	F – Moderate Harm Potential
2025-01-31	Resident Rights Deficiencies	Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	E – Moderate Harm Potential
2025-01-31	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	E – Moderate Harm Potential
2025-01-31	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	E – Moderate Harm Potential
2025-01-31	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2025-01-31	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	D – Moderate Harm Potential
2025-01-31	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	D – Moderate Harm Potential
2025-01-31	Pharmacy Service Deficiencies	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 locked, compartments for controlled drugs.	D – Moderate Harm Potential
2025-01-31	Infection Control Deficiencies	Develop and implement policies and procedures for flu and pneumonia vaccinations.	D – Moderate Harm Potential
2025-01-31	Resident Rights Deficiencies	Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.	B – Minimal Harm Potential
2025-01-31	Resident Rights Deficiencies	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	B – Minimal Harm Potential
2024-11-02	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	D – Moderate Harm Potential
2024-07-02	Resident Rights Deficiencies	Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.	D – Moderate Harm Potential
2024-04-05	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2024-04-05	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2023-01-11	Environmental Deficiencies	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	F – Moderate Harm Potential
2023-01-11	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	E – Moderate Harm Potential
2023-01-11	Nutrition and Dietary Deficiencies	Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.	E – Moderate Harm Potential
2023-01-11	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2023-01-11	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	D – Moderate Harm Potential
2023-01-11	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2023-01-11	Quality of Life and Care Deficiencies	Provide enough food/fluids to maintain a resident's health.	D – Moderate Harm Potential
2023-01-11	Pharmacy Service Deficiencies	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 locked, compartments for controlled drugs.	D – Moderate Harm Potential
2023-01-11	Administration Deficiencies	Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.	D – Moderate Harm Potential
2023-01-11	Resident Rights Deficiencies	Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.	B – Minimal Harm Potential
2021-06-09	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	E – Moderate Harm Potential
2021-06-09	Resident Rights Deficiencies	Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	D – Moderate Harm Potential
2021-06-09	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	D – Moderate Harm Potential
2021-06-09	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2021-06-09	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2021-06-09	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	D – Moderate Harm Potential
2021-06-09	Quality of Life and Care Deficiencies	Provide safe, appropriate dialysis care/services for a resident who requires such services.	D – Moderate Harm Potential

Fire Safety Citation History

15 fire safety citations on record

Date	Category	Description	Severity
2025-01-31	Miscellaneous Deficiencies	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	E – Moderate Harm Potential
2025-01-31	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	D – Moderate Harm Potential
2023-01-11	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	F – Moderate Harm Potential
2023-01-11	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	E – Moderate Harm Potential
2023-01-11	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure that testing and maintenance of electrical equipment is performed.	D – Moderate Harm Potential
2023-01-11	Emergency Preparedness Deficiencies	Develop a communication plan.	C – Minimal Harm Potential
2023-01-11	Emergency Preparedness Deficiencies	Establish staff and initial training requirements.	C – Minimal Harm Potential
2021-06-09	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2021-06-09	Smoke Deficiencies	Properly select, install, inspect, or maintain portable fire extinguishes.	E – Moderate Harm Potential
2021-06-09	Smoke Deficiencies	Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.	E – Moderate Harm Potential
2021-06-09	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2021-06-09	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2021-06-09	Gas, Vacuum, and Electrical Systems Deficiencies	Meet requirements for the installation and maintenance of electrical systems.	E – Moderate Harm Potential
2021-06-09	Construction Deficiencies	Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.	D – Moderate Harm Potential
2021-06-09	Gas, Vacuum, and Electrical Systems Deficiencies	Have proper medical gas storage and administration areas.	D – Moderate Harm Potential

Total Penalties & Fines

$117,878

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2025-01-31	Fine	$117,878	-

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Need Help Finding Safe Care?

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3-Year Complete Report ($19)

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