Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Healthcare Center during CMS and state inspections, most recent first.
Failure to identify and document early skin changes led a resident with DM type 1, impaired mobility, weakness, and a Braden score of 11 to progress from MASD on the sacral/coccyx area to a Stage 3 pressure injury. Weekly skin/wound assessments noted MASD, but a required assessment was missed and the WCN and Admin acknowledged there was no documentation showing progression from Stage 1 or Stage 2 before the wound was found as Stage 3.
Pest Control Program Not Maintained in Kitchen: A live roach was observed crawling on the wall above the kitchen sink during an observation with the DS. The DS caught the roach and stated it was not acceptable to have roaches in the kitchen because of contamination and infection concerns. The Dietician, IP, and DON all stated that roaches in the kitchen are unacceptable and create a high risk of food contamination and infection for residents.
PASRR screening was completed inaccurately for a resident whose admission record included depression, anxiety disorder, and a psychotic disorder. The PASRR Level I screening marked serious mental illness as “NO” and resulted in a Level I negative determination with Level II not required. The MDSC stated the screening did not reflect the resident’s diagnoses, and the DON acknowledged the PASRR was not accurate and the facility policy was not being followed.
Missing Controlled Substance Reconciliation Signatures: The facility failed to maintain accurate controlled medication records for Medication Cart Station 2. Review of the NFR showed multiple missing oncoming and off-going shift signatures for narcotic counts, and the Admin confirmed the omissions. An LVN stated staff are responsible for signing the NFR at the start and end of shift to verify the narcotic count and keep the cart intact, while another LVN said the process helps hold staff accountable and avoid drug diversion. The DON stated the facility's Controlled Substances policy was not followed.
A CNA and a CHHA failed to wear required gown and gloves while providing high-contact care to two residents on EBP. One resident had diabetes, PVD, neuropathy, and a diabetic ulcer, and the other had diabetes, hemiplegia, a gastrostomy, hospice care, and VRE colonization. Both residents’ care plans directed staff to use gown and gloves during high-contact care, and the IP and DON confirmed the PPE expectation was not followed.
Insufficient Resident Room Space: The facility failed to ensure 11 resident rooms met the required 80 sq ft per resident. During an environmental tour, the MS verified that rooms housing two to four residents measured only 70.06 to 78.37 sq ft per resident. The Admin stated the rooms were smaller than required and that a waiver had been submitted, while a CNA stated the rooms were wheelchair accessible and had sufficient space for care.
The facility did not adhere to its policy of dating and labeling food items removed from their original containers, as observed by surveyors. Unlabeled and undated bags of corn tortillas and cookies were found in the dry storage. Interviews with the Dietary Supervisor and Administrator confirmed that these items should have been dated to ensure freshness, but were missed.
A facility failed to refer a resident for a Level II PASARR evaluation after the resident was diagnosed with anxiety disorder, PTSD, and major depressive disorder. Despite having intact cognition and active diagnoses, there was no evidence of referral in the medical record. The DON, who was not employed at the time of admission, acknowledged the oversight during an interview.
A facility failed to ensure the accuracy of the PASARR for a resident admitted with an anxiety disorder. The PASARR Level I Screening incorrectly indicated the absence of a serious mental disorder, despite the resident's medical history and MDS assessment showing an active diagnosis of anxiety disorder. The DON acknowledged the PASARR should have been accurate.
A facility failed to implement enhanced barrier precautions for a resident with a G-tube, as required by their infection control policy. An LVN administered medications without wearing a gown, despite the policy mandating gown and glove use during high-contact activities. Staff interviews confirmed the policy requirements, and the Administrator acknowledged the expectation for staff to follow procedures.
The facility did not meet the required room size of 80 sq ft per resident in 11 rooms, with sizes ranging from 69.35 to 78.75 sq ft. Despite this, a CNA reported no impact on care, and the Administrator and DON noted no care issues related to room size.
Failure to Identify and Document Progression of Sacral/Coccyx Skin Breakdown
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with diabetes mellitus type 1, difficulty walking, muscle weakness, and a Braden Scale score of 11, indicating high risk for pressure injury. Weekly skin and wound assessments dated April 10, 2026, and April 17, 2026, identified moisture-associated skin damage on the sacral and coccyx area. The resident’s clinical record did not contain a weekly skin/wound assessment for April 24, 2026. A later weekly skin/wound assessment documented that the sacral/coccyx moisture-associated skin damage had progressed to a Stage 3 pressure injury measuring 2.5 cm long by 3 cm wide by 0.3 cm deep, with 80% granulation tissue, 20% slough, and moderate serosanguinous drainage. During interview and record review, the WCN stated there was no documentation showing the wound progressed from Stage 1 or Stage 2 before being identified as Stage 3, acknowledged the missed wound assessment between April 17, 2026, and April 30, 2026, and stated the required assessment and progress note were not completed. The Admin also acknowledged the resident’s early skin changes were not identified, resulting in the MASD progressing to a Stage 3 pressure injury.
Pest Control Program Not Maintained in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program for 55 out of 55 residents when a live roach was observed in the kitchen food preparation area. During a concurrent observation and interview on February 17, 2026, at 12:28 PM, a live roach was seen crawling on the wall above the kitchen sink. The Dietary Supervisor caught the roach with a piece of aluminum foil and stated she was not sure how the roach came inside the kitchen. She also stated that it was not acceptable to have roaches inside the kitchen because it was a concern for contamination and infection. During interviews and record review, the Dietician stated that it is important to have a pest control program inside the kitchen because of the high risk of food contamination that could affect residents' health. The Infection Preventionist reviewed the facility's Infection Control and Pest Control policies and stated that the policy was not followed because there was a live roach in the kitchen. The Director of Nursing also stated that roaches inside the kitchen are unacceptable, that the facility should be free of pests, and that roaches in the kitchen pose a high risk of food contamination and can cause infection for residents.
Inaccurate PASRR Screening for a Resident with Mental Health Diagnoses
Penalty
Summary
PASRR screening for one resident was not completed accurately. The resident’s admission record showed diagnoses of depression, anxiety disorder, and other psychotic disorder not due to a substance or known physiological condition. However, the resident’s PASRR Level I screening dated December 16, 2025, marked the question about diagnosed serious mental illness as “NO,” and the screening result was recorded as Level I negative with Level II not required. During interview, the MDS Coordinator stated the PASRR did not reflect the resident’s diagnoses and that the facility should have accurately screened the resident and corrected the PASRR on readmission. The Administrator reviewed the facility’s admission criteria policy, which stated that all new admissions and readmissions are screened for mental disorders, intellectual disabilities, or related disorders per the PASRR process, and acknowledged that the PASRR was not accurate and that the policy was not being followed.
Missing Controlled Substance Reconciliation Signatures
Penalty
Summary
The facility failed to maintain accurate records of controlled medications for one of two medication carts reviewed, specifically Medication Cart Station 2. During a concurrent interview and record review, the Narcotic Floor Release for February 1, 2026, through February 18, 2026, showed eight missing signatures for shift-to-shift narcotic reconciliation, including missing oncoming and off-going signatures on multiple dates across day, evening, and night shifts. The Administrator confirmed that the signatures were missing for reconciling the narcotic inventory in the NFR. During interviews, an LVN stated that nursing staff are responsible for signing the NFR at the start and end of their shifts, and that completing the form is important to verify the narcotic count and ensure the cart is intact. Another LVN stated the expectation is to complete the NFR at the start and end of shift to hold staff accountable and avoid drug diversion. Review of the facility's Controlled Substances policy showed that controlled substance inventory is to be monitored and reconciled, and that the nurse coming on duty and the nurse going off duty make the count together and document and report discrepancies. The DON stated the policy was not followed.
Failure to Use Required PPE for Residents on EBP
Penalty
Summary
The facility failed to ensure staff followed infection control practices for two residents who were on Enhanced Barrier Precautions (EBP). Resident 5 had diagnoses including diabetes, peripheral vascular disease, and peripheral neuropathy, and had orders for EBP due to a diabetic ulcer. During an observation, a CNA was brushing Resident 5’s hair without a gown or gloves. In interview, the CNA stated Resident 5 was on EBP and that a gown and gloves should have been worn. Resident 5’s care plan also directed staff to use gown and gloves during high-contact care activities, including hygiene care. Resident 6 had diagnoses including diabetes, hemiplegia, gastrostomy, and hospice care, and had orders for EBP related to a gastrostomy tube and colonization of MDRO VRE. During an observation, a CHHA was removing and changing linens for Resident 6 without a gown. In interview, the CHHA stated she was not sure whether Resident 6 was on precautions, then confirmed Resident 6 was on EBP and should have worn a gown when removing linens. Resident 6’s care plan directed staff to use gown and gloves during high-contact care activities, including changing linens. The Infection Preventionist and DON later confirmed both residents were on EBP and that staff should have worn gown and gloves during high-contact care.
Insufficient Resident Room Space
Penalty
Summary
The facility failed to ensure 11 of 25 resident rooms met the required 80 square feet of space per resident. During an interview, the administrator stated that rooms 1, 2, 3, 4, 6, 7, 8, 9, 11, 14, and 21 were smaller than the required size and that the facility had previously submitted a room waiver for all 11 rooms. The administrator also stated there were not any issues with care in relation to the size of the rooms. During a concurrent observation and interview with the Maintenance Supervisor, an environmental tour of rooms 1, 2, 3, 4, 6, 7, 8, 9, 11, 14, and 21 showed that each of the rooms did not provide the required space per resident. The rooms housed two, three, or four residents and measured between 70.06 and 78.37 square feet per resident. The Maintenance Supervisor verified that all 11 rooms did not have the required 80 square feet of space for each resident. A CNA later stated that the rooms were wheelchair accessible and had sufficient space to provide care, and the administrator again stated there had been no issues with care in relation to the smaller rooms.
Failure to Date and Label Food Items
Penalty
Summary
The facility failed to ensure that all food items removed from their original containers were properly dated and labeled, as required by their policy titled 'Labeling and Dating of Food,' revised on 01/03/2018. This policy mandates that all food be dated and labeled to prevent contamination, deterioration, and dehydration. During an initial tour of the kitchen, the surveyor observed four unlabeled and undated bags of corn tortillas in the dry storage. Additionally, a gallon-sized undated bag containing nine snickerdoodle cookies was noted on a shelf in the dry storage during a subsequent kitchen observation. Interviews with the Dietary Supervisor (DS) and the Administrator revealed that all food should be labeled with a use-by date to ensure freshness. The DS acknowledged that the food items should have been dated and labeled, admitting that they must have been missed. The Administrator confirmed that all items should be dated when removed from their original packaging to ensure freshness.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation after the resident was diagnosed with a newly evident mental illness. The resident, admitted on 07/16/2021, had a medical history that included disorders of muscle, neuromuscular dysfunction of the bladder, and functional quadriplegia. The resident received diagnoses of anxiety disorder on 03/21/2023, post-traumatic stress disorder (PTSD) on 04/19/2023, and major depressive disorder on 08/31/2023. Despite these diagnoses, there was no evidence in the medical record indicating that the resident was referred for a Level II PASARR evaluation. The resident's quarterly Minimum Data Set (MDS) assessment, dated 09/19/2024, showed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, and listed active diagnoses of anxiety disorder, depression, and PTSD. The resident's care plan included focus areas for depression, PTSD, and anxiety disorder, with corresponding medication use. During an interview, the Director of Nursing (DON) stated he was not employed at the facility when the resident was admitted, suggesting a possible gap in continuity of care or oversight regarding the PASARR referral process.
Inaccurate PASARR Screening for Resident with Anxiety Disorder
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) for a resident at the time of admission. The resident was admitted with a medical history that included an anxiety disorder. However, the PASARR Level I Screening conducted the day after admission incorrectly indicated that the resident did not have a serious diagnosed mental disorder, such as an anxiety disorder. This discrepancy was identified during a review of the resident's records, which included an annual Minimum Data Set (MDS) assessment showing an active diagnosis of anxiety disorder. During an interview, the Director of Nursing, who was not employed at the facility at the time of the resident's admission, acknowledged that the PASARR should have been accurate.
Failure to Implement Enhanced Barrier Precautions for Resident with G-tube
Penalty
Summary
The facility failed to ensure staff implemented enhanced barrier precautions (EBP) for a resident with a gastrostomy tube (G-tube), as required by their infection prevention and control program. The facility's policy, dated April 2024, mandates the use of gowns and gloves during high-contact resident care activities, including medication administration for residents with indwelling medical devices like G-tubes. However, during an observation, a Licensed Vocational Nurse (LVN) was noted administering medications to the resident via enteral route while only wearing gloves, contrary to the policy that required both gown and gloves. Interviews with various staff members, including a Registered Nurse, the Director of Staff Development, the Infection Preventionist, and the Director of Nursing, confirmed that the facility's policy required the use of gowns during such procedures. The LVN's failure to adhere to the policy was acknowledged by the Administrator, who stated that the expectation was for staff to follow the facility's procedures to ensure resident safety. The resident involved had a medical history of conditions requiring a G-tube, and the care plan specifically directed staff to use enhanced barrier precautions.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum size of 80 square feet per resident in multiple occupancy rooms. Specifically, 11 out of 24 resident rooms were found to be below this standard, with room sizes ranging from 69.35 to 78.75 square feet per resident. This deficiency was identified through a Client Accommodations Analysis signed by the Administrator. Despite the room size issue, a Certified Nursing Aide reported that the room sizes did not hinder the provision of proper care. Additionally, during an interview, the Administrator and the Director of Nursing stated that there had been no issues with care related to the room sizes.
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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) |
|---|---|---|---|---|
| Inland Christian Home | 1.2 mi | ★★★★★ | 0 | 0 |
| Trellis Chino | 2.6 mi | ★★★★★ | 27 | 0 |
| Las Colinas Post Acute | 2.7 mi | ★★★★★ | 24 | 0 |
| Montclair Manor Care Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Ontario Grove Healthcare & Wellness Centre, Lp | 3 mi | ★★★★★ | 1 | 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.