Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ontario Grove Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
Staff failed to follow COVID-19 isolation protocols when a CNA entered an isolation room without required eye protection and another CNA exited an isolation room without closing the door, despite facility policy and CDC guidance. Both CNAs acknowledged awareness of the protocols but did not adhere to them during care of residents under droplet precautions.
The facility did not provide documentation for one of the required semi-annual fire alarm control panel battery load voltage tests, as discovered during a review of records and staff interviews. The Maintenance Director and Assistant Administrator were unaware of this requirement, resulting in noncompliance with NFPA standards for fire alarm system maintenance.
The facility did not perform or document a required monthly 30-minute load test of its emergency generator, as required by NFPA standards. This lapse was due to a transition between Maintenance Directors and resulted in non-compliance with emergency power system testing requirements, affecting all residents and both smoke compartments.
Surveyors found that annual inspection records for kitchen cooking equipment were missing, as confirmed by the Assistant Administrator during document review and interview. This deficiency affected one smoke compartment and 24 residents, with no documentation available to show compliance with required maintenance standards.
Surveyors identified multiple failures in food storage, labeling, and sanitation, including spoiled cilantro left in a refrigerator, a dirty produce storage box with lettuce, improperly sealed and freezer-burned pork ribs, and a container of noodles missing a use by date. Staff and supervisors confirmed that facility policies were not followed, potentially affecting all residents receiving meals from the kitchen.
A resident with a history of atrial fibrillation, tachycardia, and dysphagia, who spoke Cantonese, was provided with a communication board labeled in Spanish instead of their spoken language. This failure was confirmed by an LVN and the DON, who acknowledged that the facility's policy on accommodating communication needs was not followed, leaving the resident without an effective way to communicate with staff.
A resident with multiple medical conditions was found with used suction tubing and a Yankauer tip left uncovered and unlabeled on the bedside table. The equipment was not stored in a sanitary manner, and staff interviews revealed a lack of awareness regarding proper procedures for changing and labeling suction equipment, contrary to facility policy.
Three residents, each with significant medical or mobility issues, were found unable to access their call lights due to improper placement, such as being wrapped around a bed rail, placed on a headwall fixture, or left under the bed. Staff confirmed the call lights were not within reach, and facility leadership acknowledged that the policy requiring accessible call systems was not followed.
Nine resident rooms were found to provide less than the required 80 square feet of livable space per resident, with each room housing three residents in 231 square feet (77 sq. ft. per resident). Facility staff confirmed the deficiency and noted that no safety hazards or resident complaints were present.
A resident with neurogenic bowel did not have a bowel movement for several days, despite being prescribed medications for bowel regularity and stool softening. The Bisacodyl suppository was not administered, and the Lactulose solution was given only once. The DON noted that the LVN failed to document the absence of bowel movements and may not have reviewed the records, leading to a lack of communication with the physician.
A resident with a history of falling and a femur fracture reported that call lights were not answered promptly during certain shifts, leaving them without necessary assistance for activities of daily living. Despite the facility's policy requiring timely responses, the resident experienced delays, particularly at night, impacting their care and safety.
Failure to Follow COVID-19 Isolation Protocols
Penalty
Summary
The facility failed to implement its infection control program to prevent the spread of COVID-19 when two Certified Nurse Assistants (CNAs) did not adhere to established protocols for droplet isolation precautions. In one instance, a CNA entered a COVID-19 isolation room to serve a lunch tray without wearing the required eye protection, despite clear signage and the availability of face shields at the door. The CNA acknowledged awareness of the requirement but stated she forgot to put on the eye protection. The Director of Nursing (DON) and Infection Prevention Nurse (IPN) confirmed that this action was not in accordance with the facility's Respiratory Virus Prevention & Control Plan, which mandates the use of appropriate personal protective equipment (PPE) including eye protection for staff entering isolation rooms. In a separate incident, another CNA exited a COVID-19 isolation room without closing the door behind her, contrary to facility practice and CDC guidance, which require doors to remain closed to limit the spread of respiratory droplets. The CNA admitted she was aware of the requirement but forgot to close the door. The DON confirmed that while there was no written policy specifically about door closure, it was the facility's practice to keep doors closed for residents under droplet isolation. Review of the facility's policies and CDC guidance further supported the expectation that doors should be kept closed for residents with suspected or confirmed COVID-19. These lapses in protocol were observed during the care of residents under droplet isolation precautions.
Failure to Document Semi-Annual Fire Alarm Battery Testing
Penalty
Summary
The facility failed to maintain the fire alarm system in accordance with regulatory requirements, as evidenced by the lack of documentation for one of the required semi-annual fire alarm control panel battery load voltage tests. During a document review and interview, the Maintenance Director and Assistant Administrator were unable to provide records for this testing and stated they were not aware of the requirement. This deficiency affected both smoke compartments and all residents in the facility. The absence of documentation for the semi-annual battery testing was identified during a review of facility records and confirmed through staff interviews. No issues were reported with the fire alarm system itself at the time of the survey, but the required testing and documentation were not completed as mandated by NFPA 101 and NFPA 72 standards.
Failure to Conduct and Document Monthly Generator Load Test
Penalty
Summary
The facility failed to maintain the emergency power supply system as required by NFPA 101 and NFPA 110 standards. Specifically, the facility did not conduct the required monthly 30-minute load test of the emergency generator for one month, as evidenced by the absence of documentation for the test in August 2024. This deficiency was identified during a document review and interview with the Assistant Administrator and Maintenance Director, who confirmed that the facility was between Maintenance Directors at the time, resulting in the missed test. The generator in question is a 4 kilowatt gasoline-powered unit with a 25-gallon backup fuel supply. The lack of a monthly load test meant that the facility could not demonstrate that the generator and associated equipment were capable of supplying emergency power within the required 10 seconds, as stipulated by regulatory standards. The deficiency affected both smoke compartments and all 51 residents in the facility, as the emergency power system is essential for maintaining critical services during a loss of normal utility power. Surveyors found that the facility was unable to provide written records of the required monthly generator load test for the specified period. The absence of this documentation indicated non-compliance with the operational inspection and testing requirements outlined in NFPA 110, which mandates that emergency power supply systems be inspected weekly and exercised under load at least monthly. No issues were identified with the residents at the time of the survey, and the deficiency was limited to the failure to perform and document the required generator test.
Plan Of Correction
K 918 Ontario Grove Healthcare and Wellness Centre Plan of Correction for Life and Safety June 17, 2025 Submitted by: Belinda Busuego, RN DON Submitted on: 6/24/2025 Ontario Grove Healthcare & Wellness submits this response and Plan of Correction as part of the requirements under state and federal law. The Plan of Correction is submitted in accordance with specific regulatory requirements. It shall not be construed as admission of any alleged deficiency cited or any liability. The provider submits this plan of correction with the intention that it is inadmissible by any third party to any civil, criminal action or proceedings against the provider or its employees, agents, officers, directors, or stakeholders. The facility reserves the right to challenge the cited findings if at any time the provider determines that the disputed findings are relied upon in a manner adverse to the interests of the provider either by the governmental agencies or third parties. The facility desires that this plan of correction be considered the facility's allegation of compliance. "Preparation, submission and or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of Correction is prepared, submitted and/or executed solely because it is required by the provisions of federal and state law." K324 Cooking Facilities 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 6/17/2025, Maintenance Supervisor conducted the annual kitchen equipment inspection to ensure no malfunction of the fuel-fired kitchen cooking equipment in the kitchen. No issues identified. 2. How the facility will identify other residents having the potential to be affected by the same deficient and what corrective action will be taken. On 6/17/2025, Maintenance Supervisor conducted the annual kitchen equipment inspection to ensure no malfunction of the fuel-fired kitchen cooking equipment in the kitchen. No issues identified. 3. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. On 6/17/2025, Assistant Administrator conducted a one-to-one in-service with Maintenance Supervisor to ensure that the annual kitchen equipment inspection is conducted as required. Maintenance Supervisor will conduct annual kitchen appliance inspection to ensure that kitchen cooking equipment is functioning and protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. The Maintenance Supervisor will report identified issues to the Administrator or Assistant Administrator for corrective actions. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance process. Maintenance Supervisor will present kitchen inspection findings on QA&A meeting for further evaluation and recommendations for 3 months. 5. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance process. Maintenance Supervisor will present monthly load test results to the QA&A meeting for further evaluation and recommendations for 3 months.
Missing Annual Kitchen Equipment Inspection Records
Penalty
Summary
The facility failed to maintain required documentation for the inspection of kitchen cooking equipment. During a document review and interview with the Assistant Administrator, it was found that records of annual kitchen appliance inspections were missing. The Assistant Administrator confirmed that the documentation for these inspections was not available at the time of the survey. This deficiency affected one of two smoke compartments and involved 24 of 51 residents. The lack of inspection records was specifically related to the maintenance of fuel-fired kitchen cooking equipment, as required by NFPA 101 and NFPA 96 standards. No additional information about the medical history or condition of the residents involved was provided in the report.
Deficient Food Storage, Labeling, and Sanitation Practices Identified
Penalty
Summary
The facility failed to store, label, and maintain food and food storage areas in a sanitary manner according to professional food service standards. During observations, a bunch of cilantro that was turning black and wet was found in a refrigerator, and both the Dietary Services Supervisor (DSS) and Assistant Administrator confirmed it was spoiled and should have been discarded. Additionally, a produce storage box containing whole heads of lettuce was found with visible dirt and debris at the bottom, and staff acknowledged the box had not been cleaned as required by facility policy. An opened box of fully cooked boneless pork ribs was found in the freezer with its internal plastic liner unsealed and showing signs of freezer burn, which staff confirmed was not safe for residents due to the risk of bacterial growth and ice formation. In the dry storage room, a large container of noodles pasta was found with a prep date but missing a use by date, and the DSS stated the label was incomplete and did not meet policy requirements. These failures were confirmed through interviews and record reviews, where staff and supervisors acknowledged that facility policies and procedures for food storage, labeling, and sanitation were not followed. The deficiencies had the potential to affect all 53 residents who receive meals from the facility's kitchen, as the improper storage and handling of food items could lead to contamination and foodborne illness. No specific residents or their medical histories were mentioned in relation to the deficiencies.
Failure to Provide Communication Board in Resident's Language
Penalty
Summary
A deficiency occurred when a resident, admitted with diagnoses including atrial fibrillation, tachycardia, and dysphagia, was not provided with a communication board in their spoken language. The resident's records indicated that they spoke Cantonese, but during an observation, the communication board available in the resident's room was labeled in Spanish. This discrepancy was confirmed by a Licensed Vocational Nurse, who acknowledged that the board was not in the correct language and should have been in Cantonese. Further review of the facility's policy on accommodating residents' communication needs revealed that adaptive devices, such as communication boards, should be provided to assist residents in expressing their needs. The Director of Nursing confirmed that the policy was not followed in this instance, resulting in the resident not having an effective method to communicate with staff.
Improper Storage and Labeling of Suction Equipment
Penalty
Summary
A deficiency was identified when a resident with dementia, congestive heart failure, and gastrostomy status was observed with a portable suction machine at the bedside. The suction tubing, including the Yankauer tip, showed signs of prior use with dried residue and was left uncovered, resting directly on the bedside table. The tubing was not bagged, capped, or stored in a sanitary manner, and there was no date or label indicating when it was last used or replaced. The suction canister was also unlabeled. These observations were made during a routine check inside the resident's room. Interviews with staff revealed that the LVN was unaware of the facility's policy regarding the frequency of changing or replacing Yankauer suction tubing. The DON confirmed that the Yankauer tip was single-use and should have been discarded after use, and that both the suction canister and tubing should be labeled with the date of replacement. A review of the facility's policy indicated that critical and semi-critical items must be sterilized or disinfected and stored appropriately, which was not followed in this instance.
Call Light System Inaccessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to three residents, as observed during multiple room visits and confirmed through staff interviews and record reviews. In one instance, a resident with dementia, dysphagia, and type 2 diabetes was found unable to reach the call light, which was wrapped around the bed rail and nearly touching the floor. The resident attempted but was unable to access it, and a Licensed Vocational Nurse confirmed its inaccessibility. Another resident with mobility issues, cognitive communication deficit, and a history of falls was found with the call light placed on top of the headwall light fixture, out of reach. The resident was unaware of the call light's location, and a Certified Nursing Assistant confirmed it was not within reach. A third resident with a history of right femoral neck fracture had the call light under the bed, also out of reach, and did not know its location. This was confirmed by a Licensed Vocational Nurse. A review of the facility's policy and procedure on the call system indicated that residents should be able to call for staff assistance from their rooms and toileting/bathing facilities. During interviews, the Director of Nursing and Assistant Administrator acknowledged that the policy was not followed in these cases and confirmed that the call lights were not accessible to the residents as required.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet of livable space per resident in nine resident rooms, specifically Rooms 26 through 34. During an environmental tour and measurement, each of these rooms, which housed three residents each, was found to have only 231 square feet, equating to 77 square feet per resident. This was confirmed through observation, interviews, and record review with facility staff, including the Assistant Administrator and Maintenance Supervisor. The Assistant Administrator acknowledged that these rooms did not meet the regulatory requirement for space per resident and stated that the facility had room waivers for these rooms. No safety hazards or complaints regarding space or room issues were reported by the residents occupying these rooms at the time of the survey. The deficiency was based solely on the physical measurements of the rooms and the facility's acknowledgment that the rooms did not meet the required square footage per resident.
Failure to Implement Bowel Elimination Treatment
Penalty
Summary
The facility failed to implement appropriate treatment and assessment of bowel elimination for a resident diagnosed with neurogenic bowel, who had not had a bowel movement from February 7, 2025, through February 11, 2025. The resident was admitted with a diagnosis that included neurogenic bowel, a condition affecting bowel function. Despite the absence of bowel movements, the prescribed medications for bowel regularity and stool softening were administered, but the Bisacodyl suppository, intended for rectal insertion as needed for constipation, was not administered. Additionally, the Lactulose oral solution was administered only once, and there were no nursing notes or reports made to the physician regarding the resident's lack of bowel movements over several days. During an interview and record review, the Director of Nursing (DON) indicated that the Licensed Vocational Nurse (LVN) failed to document the resident's lack of bowel movements, possibly due to not receiving a report from the Certified Nursing Assistant (CNA). The DON also noted that the LVN may not have reviewed the resident's bowel movement records. The facility's policy on bowel and bladder training indicated that the licensed nurse is responsible for carrying out the physician's orders, which was not adequately followed in this case.
Failure to Respond to Call Lights Promptly
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the timely response to call lights, which is crucial for providing care and services to residents. This deficiency was observed in the case of a resident who was admitted with a history of falling and a displaced intertrochanteric fracture of the left femur. The resident, who was cognitively intact with a BIMS score of 15, reported difficulties in receiving assistance during specific shifts, particularly between 3:00 PM and 11:00 PM, and from 11:00 PM to 7:00 AM. The resident expressed that there were instances when calls for help went unanswered until the morning, affecting their ability to receive necessary assistance with activities of daily living, such as diaper changes. The facility's policy, titled Communication - Call System, mandates that nursing staff answer call bells promptly and courteously. However, during an interview, the Director of Staff Developer acknowledged that call lights should be answered in a timely manner, indicating a lapse in adherence to the policy. The resident's MDS Section G assessment indicated a need for setup or clean-up assistance with various daily activities, highlighting the importance of timely staff response to call lights. The failure to respond promptly to the resident's requests for assistance potentially jeopardized their health and safety, as they were left without necessary care during critical times.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ontario
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Las Colinas Post Acute | 0.3 mi | ★★★★★ | 24 | 0 |
| Upland Rehabilitation And Care Center | 0.9 mi | ★★★★★ | 1 | 0 |
| Heritage Park Nursing Center | 1 mi | ★★★★★ | 1 | 0 |
| Villa Mesa Care Center | 1.2 mi | ★★★★★ | 19 | 0 |
| Community Extended Care Hospital Of Montclair | 2.9 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.