Ontario Grove Healthcare & Wellness Centre, LP

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection control program to help prevent the spread of COVID-19 (a highly infectious disease caused by a respiratory virus) when: 1. Certified Nurse Assistant 1 (CNA 1) failed to wear the required eye protection before entering a COVID-19 isolation room on December 19, 2025. 2. Certified Nurse Assistant 2 (CNA 2) did not ensure that the isolation room door was closed when exiting a COVID-19 isolation room on December 19, 2025. These failures had the potential to cause harm to the 54 residents residing within the facility by causing cross contamination of the environment and increasing the risk of exposure and spread of the COVID-19 virus.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, label, and maintain food and food storage areas in a sanitary manner, as required by professional food service standards when: 1. One bunch of cilantro, which was turning black, was found inside of a plastic bag at the bottom shelf of the refrigerator. 2. One produce storage box that contained whole heads of lettuce was found with debris (dirt). 3. A box, containing fully cooked boneless pork ribs, dated May 9, 2025, was found open with its internal plastic liner unsealed and with freezer burn (food got too dry and frosty due to being exposed to air in the freezer for too long). 4. One 12 quart (qt- unit of measurement) clear plastic container labeled Noodles Pasta, did not have a Use by: date was found inside the dry storage room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accommodation of communication needs to one resident reviewed for language (Resident 24) when Resident 24's communication board was in a different language than the one spoken by Resident 24. This failure had the potential to delay Resident 24's request and did not provide Resident 24 with a method to communicate with facility staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective infection prevention and control program (proper methods used to stop the spread of germs and protect residents, staff and visitors from getting sick) for one of three residents reviewed for infection control (Resident 17) when Resident 17's suction tubing (flexible tube, used to remove bodily fluids and debris from one's airway or surgical site) was left open to air and without a dated label. This failure had the potential to result in cross-contamination (germs or bacteria from one dirty surface or item get spread to something clean, which can make people sick) causing preventable infection to Resident 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was accessible for three of three residents reviewed for environment (Residents 36, 54, and 159) when Residents 36, 54, and 159's call lights were found inaccessible to the three residents. This failure had the potential to result in leaving Residents 36, 54, 159 unable to use the call light system to call for any assistance the residents may require.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.) of livable space per resident for nine of 19 resident rooms (Rooms 26, 27, 28, 29, 30, 31, 32, 33, and 34) when Rooms 26, 27, 28, 29, 30, 31, 32, 33, and 34 measured less than 80 square feet per resident. This failure had the potential for the residents housed in Rooms 26, 27, 28, 29, 30, 31, 32, 33, and 34 to not have the ability to move about freely if the square footage limited their personal space.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate treatment and assessment of bowel elimination for one of four sample residents (Resident 1) when record indicated resident 1 has not had bowel movement (BM) from February 7, 2025, through February 11, 2025. This failure potentially resulted in Resident 1 readmission to the hospital with abnormal vital sign.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights are answered in a timely manner for one of three sampled residents (Residents 1). This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Residents 1) when Resident 1 ' s requests for assistance with activities of daily living were not responded to promptly.

Inspectors wroteBased on observation, interview, record review, the facility failed to follow proper sanitization and food handling practices when: 1. Raw thawing beef and bacon was stored on the same shelf as raw thawing chicken breast. 2. The dishwashing machine was not sanitizing the dishes. 3. The ice machine was found to have brown residue under the ice dispenser and on the ceiling of the ice storage bin. 4. A floor repair was unfinished, and the surface was not easily cleanable. These failures had the potential to expose 51 highly susceptible residents who received food from the kitchen to cause foodborne illness (illness caused by the ingestion of contaminated food or beverage) due to cross contamination (the transfer of harmful substances or disease-causing microorganisms to food).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the advance directives (written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated), were completed in accordance with the facility policy for one of six residents (Resident 27) reviewed for advance directives. This failure had the potential to result in a delay of treatment for Resident 27 related to advance directives, or for life sustaining measures to be rendered against what the resident wanted.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours, seven days a week. This failure had the potential to prevent 54 residents from reaching their highest practicable level of well-being when oversite by an RN was not utilized by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pharmacy recommendations identified from the Medication Regimen Review (MRR- thorough evaluation of a resident's medication regimen in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities) were followed up in accordance with federal regulations and facility policy, for two of five residents (Residents 3 and 26) reviewed for unnecessary medications when: 1. The pharmacy recommendation, from May 12, 2022, for Resident 3's use of Seroquel (medication to treat mood disorders), was not communicated to the physician. 2. The pharmacy recommendation, from May 12, 2022, for Resident 26's use of Abilify (medication for mood disorders), was not communicated to the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure secure storage of medications when one of three medication carts (Treatment Cart) was found to be unlocked while unattended by a licensed nurse. This failure had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 54 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and utilize a planned vegetarian menu for one of 51 residents(Resident 45). This failure has the potential to adversely affect Resident 45's nutritional status.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of a completed Physician Orders for Life-Sustaining Treatment (POLST-voluntary form used statewide as a physician order that converts a resident's wishes regarding life-sustaining treatment and resuscitation into physician orders.) was filed in the medical record of one of six residents (Resident 209) reviewed for advance directive (written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated), in accordance with the facility procedure. This failure has the potential to place Resident 209 at risk of unmet care needs in the event of an emergency requiring lifesaving interventions due to the POLST not being accessible.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection control program to help prevent the spread of infections and other infectious diseases when four staff members did not complete the screening log (a log used to screen staff and visitors for COVID-19 [A highly infectious disease caused by the SARS-CoV-2 virus] symptoms and exposure upon entering the facility) on multiple occasions. This failure had the potential to place 54 residents residing within the facility to be at risk of exposure to COVID-19 virus.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for nine of 19 resident rooms (rooms 26, 27, 28, 29, 30, 31, 32, 33, and 34). This failure had the potential to affect the resident's health and safety and prevent the residents from maintaining their highest level of well-being by limiting the movements of these residents in their rooms.

Inspectors wroteBased on interview and record review, the facility failed to provide one of 14 sampled residents with a dignified experience when he was told to have a bowel movement in the shower, after he tried to get up from the shower chair and walk to the bathroom. This failure led to Resident 402 feeling embarrassed and for the experience to not be homelike.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 403) had a Physicians order for padded side rails for a resident with a history of seizures. This had the potential to result in Resident 403 being restrained without his consent.

Inspectors wroteBased on interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS - facility assessment tool) assessments, for two of 14 residents reviewed for (Residents 27 and 49), when: 1. For Resident 27, the MDS assessment, dated April 15, 2019, was not coded for fall since admission when the resident had an actual fall on April 13, 2019. 2. For Resident 49, the MDS assessment was inaccurately coded for discharged status. These failed practices had the potential to result in unmet care needs for Resident 27 and 49, which can potentially jeopardize their health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure an individualized comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated, and implemented for two of 14 residents (Residents 5 and 24), when: 1. Resident 5 had an unwitnessed fall on January 11,2019, and the care plan was not updated until March 8, 2019. 2. Resident 24's medical record did not have documentation of a revised comprehensive care plan after Resident 24 experienced an unwitnessed fall on April 23, 2019. These failures had the potential to cause inadequate management and interventions by placing Resident's health and safety to at risk in order to prevent a recurrence.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician order for one of 14 sample residents (Resident 9) was carried out timely. This failure had the potential of not meeting the care and needs of the resident.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the post dialysis assessment was completed for one of 14 sampled residents (Resident 149). This failure had the potential of not meeting the needs of the resident after dialysis treatment.

Inspectors wroteBased on observation, interview and record review, the facility's nursing staff failed to demonstrate competency in administration of medication when a Licensed Vocational Nurse 3 (LVN 3) administered Symbicort inhaler medication (medication to improve lung function) to Resident 399 without instructing the resident to rinse her mouth with water. This failure had the potential to cause harm by placing Resident 399 at an increased risk of developing an infection in the mouth and throat due to not rinsing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. One of two of the sanitation buckets for wiping down food contact surfaces had the improper concentration of sanitizer. 2. One tray and one plastic bin in the dry storage did not have a cleanable surface when it was lined with parchment paper (baking paper treated or coated to make them non-stick) and a paper towel and food was stored on top. These failures had the potential to lead to harmful bacteria and cross contamination that could lead to foodborne illness for a medically compromised population of 50 residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation for four of 14 residents reviewed for comprehensive care plan, post fall assessment, and consent forms (Residents 12, 24, and 40) when: 1. Resident 24's medical record did not have documentation of a post fall assessment after Resident 24 experienced an unwitnessed fall on April 23, 2019. 2. Resident 12 did not have a complete and accurate documentation for the influenza (flu a contagious respiratory virus) and pneumonia (is an infection in one or both of the lungs) consent forms. 3. Resident 40 did not have a complete and accurate documentation for the influenza and pneumonia consent forms. These failures had the potential to cause inadequate management of Residents 12, 24, and 40's medical condition, placing their health and safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the infection control and prevention program when two staff (a certified nurse aide - CNA and a housekeeper - HSK) did not perform hand washing. This failure had the potential of transmission of infection to vulnerable residents whose conditions were already compromised.

Inspectors wroteBased on interview and record review, the facility failed to have documentation of screening and eligibility for one of 14 sampled residents (Resident 403) to receive the influenza (flu) vaccine (protect against infection by the flu virus). This failure had the potential for Resident 403 to not be protected from the influenza virus by not being provided the opportunity to receive the vaccine if he chose to receive it.

Inspectors wroteBased on observation and interview, the facility failed to meet the required square footage (sq./ft.) for nine rooms (Rooms 26,27,28,29,30,31,32,33, and 34.) This failure had the potential to limit freedom of movement and affect the health and safety of nine residents who resides in these rooms.