The December 19 incident at Ontario Grove Healthcare & Wellness Centre violated the facility's own infection control practices designed to prevent respiratory droplets from spreading into common areas where other residents and staff move throughout the day.
CNA 2, as identified in the inspection report, had just finished delivering a lunch tray to a resident in droplet isolation when inspectors observed her leaving the room at 12:25 PM. She walked directly to the nurse's station without closing the door.
The Director of Nursing had confirmed just five minutes earlier that residents in that room were under droplet isolation for COVID-19. A sign posted on the right side of the door indicated the isolation status.
When confronted about the violation at 12:30 PM, CNA 2 acknowledged she knew the requirement to keep isolation room doors closed. She told inspectors she simply forgot to close the door when she left.
The Director of Nursing discovered the open door during a follow-up check at 12:35 PM. She spoke with the isolated resident and closed the door herself.
During an interview that afternoon, the Director of Nursing explained that staff are expected to keep doors closed for residents under droplet isolation "to limit the spread of respiratory droplets into common areas."
But the facility's written policies told a different story.
When inspectors asked for the specific policy governing door closure requirements for droplet isolation, administrators couldn't find one. The Director of Nursing admitted on December 20 that "the facility was not able to locate a written policy and procedures specific to door closure for residents under droplet isolation."
Instead, she said, keeping doors closed was simply "the facility's practice" to remain consistent with CDC infection control guidance for managing residents with suspected or confirmed COVID-19.
The facility did have a broader policy titled "Testing of Residents and HCP with Signs/Symptoms of Respiratory Illness," last revised in May 2024. That policy referenced CDC guidance, which clearly states that patients with suspected or confirmed COVID-19 should be placed in single-person rooms with doors kept closed "if safe to do so."
The policy also specified that if multiple patients must share a room, only those with the same respiratory pathogen should be housed together.
The Director of Nursing acknowledged that staff did not follow the policy during the December 19 incident.
The violation occurred despite clear signage marking the isolation room and the facility's stated practice of maintaining closed doors for COVID patients. The nursing assistant's admission that she knew the requirements but forgot to follow them highlighted a gap between policy awareness and implementation.
Federal inspectors classified the violation as having caused minimal harm with potential for actual harm, affecting few residents. The finding came during a complaint investigation at the 120-bed facility.
The incident raises questions about infection control training and oversight at Ontario Grove Healthcare. While the Director of Nursing quickly corrected the immediate problem by closing the door, the facility's inability to produce a written policy specific to isolation room door requirements suggests broader gaps in infection control documentation.
The timing of the violation, during the lunch hour when staff movement peaks and the nursing assistant was making routine deliveries, underscores the importance of consistent protocol adherence during high-activity periods.
COVID-19 droplet isolation protocols exist specifically to prevent respiratory particles from infected patients from reaching common areas where they could expose other vulnerable residents. An open door during active patient care directly undermines that protection.
The facility's reliance on informal practices rather than documented procedures for critical infection control measures like door closure requirements leaves room for the kind of oversight that occurred when CNA 2 forgot to close the door.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ontario Grove Healthcare & Wellness Centre, Lp from 2025-12-23 including all violations, facility responses, and corrective action plans.
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