Ontario Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and address early signs of pressure injury (localized damage to the skin and underlying soft tissue typically occurs over bony prominences like the tailbone, heels, and hips caused by prolonged or intense pressure) development for one (1) of three (3) sampled residents (Resident 1). This failure placed Resident 1 at risk for worsening skin breakdown, pain, infection, delayed treatment, and other complications related to pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for 55 out of 55 residents when a live roach was observed in kitchen food preparation area. This failure had the potential to contaminate food, food preparing surfaces, and equipment which will place residents at risk for food borne illness and infections. During a concurrent observation and interview on February 17, 2026, at 12:28 PM, with Dietary Supervisor (DS- a person who oversees food services in the facility), in the kitchen, a live roach was observed crawling on the wall above the kitchen sink. The DS caught the roach with a piece of aluminum foil. The DS stated she was not sure how the roach came inside the kitchen. DS further stated, it is not acceptable to have roaches inside the kitchen as it is a concern for contamination and infection. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR - a screening assessment to ensure individuals who are identified to have a significant mental illness [SMI] or intellectual/developmental [I/DD] disability are appropriately placed in nursing homes for long term care) was completed accurately for one of two sampled residents (Resident 8) when PASRR screening assessment for Resident 8 did not include her diagnoses of anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), depression (a mental health condition characterized by persistent feelings of sadness, loss of interest in activities) and psychotic disorder not due to a substance or known physiological condition (severe mental illness). [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for one of two medication carts (Medication Cart Station 2) reviewed for medication storage. This failure had the potential for drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by an unauthorized person in a highly vulnerable population of 55 residents. During a concurrent interview and record review on February 18, 2026, at 4:15 PM, with the Administrator (Admin), the Narcotic Floor Release (NFR- narcotic records, a form used by the facility to verify counting of controlled drugs at the change of shift by oncoming and off going licensed nurses) NFR- dated February 1, 2026, through February 18, 2026, was reviewed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff followed safe infection control practices for 2 of 24 sampled residents (Residents 5 and 6) when:1. A Certified Nursing Assistant (CNA) did not use appropriate personal protective equipment (PPE- equipment used to minimize injuries and illness) while providing hygiene care to Resident 5, who was on Enhanced Barrier Precautions (EBP- health care staff wear gowns and gloves during high contact care (providing hygiene, dressing, bathing, wound care, changing linens and device care) to prevent the spread of resistant germs).2. A Certified Hospice Health Aid (CHHA) did not use appropriate PPE while changing linens for Resident 6 who was on EBP precautions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 11 of 25 resident's rooms (1, 2, 3, 4, 6, 7, 8, 9, 11, 14, and 21) had the required 80 square feet (Sq Ft - unit of measurement) of space for each resident. This failure had the potential to negatively impact resident comfort, dignity, and safety by limiting adequate space for movement, equipment placement and staff assistance of 26 residents who reside in those 11 rooms.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure all food items removed from its original container were dated and labeled. This deficient practice had the potential to affect all residents who received food from the kitchen.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to refer the resident to the appropriate state-designated authority for Level II preadmission screening and resident review (PASARR) evaluation after the resident was identified to have a newly evident mental illness diagnosis for 1 (Resident #26) of 2 sample residents reviewed for PASARR.

Inspectors wroteBased on interview and record review, the facility failed to ensure the preadmission screening and resident review (PASARR) was accurate at the time of admission for 1 (Resident #15) of 2 sampled residents reviewed for PASARR.

Inspectors wroteBased on observation, interview, record review, facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) for 1 (Resident #150) of 5 sampled residents reviewed for infection control.

Inspectors wroteBased on observation, document review, and interview, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 11 (Rooms 1 - 4, Rooms 6 - 9, room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]) of 24 resident rooms in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices in the kitchen when: 1. One table mounted can opener was observed with rust (a reddish-brown brittle coating form on iron when is exposed to air and moisture) in the slide bar (used to adjust different can sizes) near the knife, and in the washer inside the slide bar. 2. The ice machine had a hard deposit of white-greenish-black buildup inside the ice machine. These failures had the potential to contaminate residents' food and cause foodborne illnesses to a population 49 of 51 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper disposal of garbage and refuse when one of two lids on garbage receptacles, was not closed and there was trash on the ground. This failure had the potential to attracts pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed safe infection control practice as evidenced by staff did not perform hand hygiene (cleaning hand) after touching contaminated (dirty) areas and before handling a resident's meal tray for one of 20 sampled residents (Resident 9). This failure had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to a vulnerable resident whose health conditions are already compromised.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the medical record for four residents (Residents 13, 19, 23, and 49) clearly indicated if the residents had advanced directives (advance directive is a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions). All four residents had incomplete documentation on their Physicians Orders for Life Sustaining Treatment (POLST - written medical orders that addresses a limited number of critical medical decisions) when: 1) For Resident 13, section D (section which includes information regarding advanced directives) of the POLST, was not completed. 2) For Resident 19, section D of the POLST was not completed. 3) For Resident 23, section D of the POLST was not completed. 4) For Resident 49, section D of the POLST was not completed. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide one of three sampled residents (Resident 154) with beneficiary liability protection notifications (notification letter/s which explain resident rights regarding financial liability and the right to appeal) when the resident was discharged from Medicare Part A services (services covered by insurance payer) on August 12, 2021. This failure had the potential for Resident 154 to be uninformed regarding his specific rights and protections related to financial liability for potential incurred medical expenses as well as the right to appeal.

Inspectors wroteBased on interview, and record review, the facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS - a computerized resident assessment tool) for two of 20 sampled residents (Resident 13 and 19) when: 1. Resident 13's RAI-MDS submitted by the facility on November 8, 2021, did not indicate the resident had weight gain, but instead had listed weight loss. 2. Resident 19's RAI-MDS submitted by the facility on December 1, 2021, inaccurately indicated the resident did not use tobacco products. These failures in MDS coding had the potential to result in unmet care needs for Residents 13 and 19, which can potentially jeopardize their health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 20 sampled residents (Resident 29) had a fall mat (a cushioned mat which may aid in lessening the severity of injury during a fall) next to his bed as was specified in the resident's care plan (an individualized plan for the medical care of a resident). This failure had the potential for the resident to sustain an injury during a fall in which the severity of the injury may have been lessened had the fall mat been in place.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff followed the physician's order as evidenced by the blood sugar testing and insulin (medication to control blood sugar) administration record were not completed for one of 20 sample residents (Resident 252). These failures resulted in poor coordination of care and had the potential to cause diabetes complications that can negatively affect Resident 252's health such as high or low blood sugar, and diabetic neuropathy (a common and serious complication of diabetes that damage nerves).

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a resident's weight on admission for one of 20 sampled residents (Resident 13). This failure had the potential to negatively affect Resident 13's health such as inaccurate assessment of nutritional status and fluid balance, and wrong medication quantities on weight-based medication dosing.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records for two residents (Residents 29 and 49) were complete when Restorative Nursing Assistant (RNA) services (services from health-care professionals who are responsible for providing restorative and rehabilitation care for residents) were not documented in the Residents' medical records for January 2022, and February 2022. This failure resulted in Resident 29 and 49 to have incomplete medical record documentation which led to inaccurate records of services provided to the residents, and the residents' progress or decline not being identified timely.

Inspectors wroteBased on interview and record review, the facility failed to ensure two staff members (Certified Nursing Assistants- CNA 4, and CNA 5) unvaccinated for COVID-19 (an illness caused by a virus), were tested for COVID-19 twice a week as specified by the facility's policy and procedure during the week of January 23, 2022. This failure had the potential to compromise the health and safety of all residents residing within the facility by increasing the risk of exposure to COVID-19 by not performing screening testing of unvaccinated staff entering the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the required square footage (sq/ft) of 80 square feet per resident for nine of 24 rooms. This failure had resulted in the limited freedom of movement for one resident (Resident 5), who needed a Hoyer lift (a mechanical device used to transfer people from one surface to another) and an extra wide wheelchair, which required the roommate's bed to be moved at an angle to facilitate maneuvering her into and out of the room and had the potential to impact the comfort of Resident 5's roommate who occupied the room.