Ontario Healthcare Center
Ontario Healthcare Center in Ontario, CA — inspection on February 20, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 8s admission Record (contains medical and demographic information), the admission Record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included depression, anxiety disorder, and other psychotic disorder not due to a substance or known physiological condition.During a review of Resident 8's Preadmission Screening and Resident Review (PASRR) Level I screening (a level 1 screening includes assessment of the resident's medical diagnoses to determine if the resident has or is suspected of having a PASRR condition [i.e. SMI, or I/DD]), dated December 16, 2025, it indicated in section III for Serious Mental Illness . 9.
Diagnosed Serious Mental Illness.
Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of psychosis, delusions, and/or mood disturbance? The answer was marked NO.
Further review of the PASRR indicated, Result of Level I Screening: Level I- Negative, resolution status LII (Level II -triggered when the initial Level 1 screening identifies a potential need for specialized care, meaning the individual being assessed is suspected of having SMI or I/DD) - not required.
During an interview on February 19, 2026, at 2:24 PM, with Minimum Data Set Coordinator (MDSC), the MDSC stated Resident 8's PASRR dated December 16, 2025, did not reflect Resident 8's diagnoses.
The MDSC further stated the facility should have accurately screened the resident and corrected the PASRR to include the diagnoses on readmission to the facility.During a concurrent interview and record review on February 20, 2026, at 3:03 PM, with the Administrator, the facility's policy and procedure (P&P) titled, admission Criteria, revised March 2019, was reviewed.
The P&P indicated, . 9.
All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) process.b. if the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred o the state PASARR representative for the Level II (evaluation and determination) screening process.
The DON acknowledged that based on Resident 8's admission records, the PASRR was not accurate, and that the P&P was not being followed.
055707 02/20/2026
Ontario Healthcare Center 1661 S Euclid Ave Ontario, CA 91762
services of a licensed pharmacist.
medications (medications that are controlled by the government because it may be abused or cause
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.
The NFR indicated there were eight signatures missing as follows:-February 4, 2026, oncoming day shift (7 AM to 3:00 PM)-February 5, 2026, oncoming day shift (7 AM to 3:00 PM and off going evening shift (3:00 PM to 11:00 PM)-February 11, 2026, oncoming night shift (11:00 PM to 7:00 AM)-February 13, 2026, off going night shift (11:00 PM to 7:00 AM)-February 16, 2026, oncoming evening shift (3:00 PM to 11:00 PM)-February 17, 2026, off going night shift (11:00 PM to 7:00 AM)-February 17, 2026, off going evening shift (3:00 PM to 11:00 PM)The Admin confirmed there were missing signatures for reconciling the narcotic inventory in the NFR.
During an interview on February 18, 2026, at 4:20 PM, with Licensed Vocational Nurse (LVN) and Admin, LVN 1 stated, the nursing staff are responsible for signing the NFR at the start of their shift and at the end of their shift. LVN 1 stated it is important for nursing staff to fill out the NFR to verify that the narcotic count is correct and that the cart is intact.
During an interview on February 18, 2026, at 4:30 PM, with LVN 2, LVN 2 stated the expectation is to fill out the NFR at the start and end of shift because it is important to hold the staff accountable and to avoid drug diversion.During a concurrent interview and record review on February 20, 2026, at 2:40 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Controlled Substances, dated November 2022, was reviewed.
The P&P indicated, dispensing and Reconciling Controlled Substances. 1.
Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up. 3.
Nursing staff count controlled medication inventory at the end of each shift, using records to reconcile the inventory count. 4.
The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.
The DON stated the policy was not followed and should have been because the nursing staff should ensure the narcotic count is correct for drug diverging.
055707 02/20/2026
Ontario Healthcare Center 1661 S Euclid Ave Ontario, CA 91762
was on EBP.
The IP confirmed and verified both Resident 5 and Resident 6 were on EBP and stated,
layer of precautions to protect the residents from us and to prevent the spread of MDRO.During a
(DON), the facility's Policy and Procedures (P&P) titled Enhanced Barrier Precautions, dated April 2024 was reviewed.
The P&P indicated, .a. gloves and gown are applied prior to performing the high contact resident care activity.
The DON stated that the policy was not followed and should have been for Resident 5 and Resident 6.
The DON stated it is important to follow the policy to prevent because the staff should not cross contamination and reduce the spread of infections from one resident to another.
055707 02/20/2026
Ontario Healthcare Center 1661 S Euclid Ave Ontario, CA 91762
During a concurrent observation and interview on February 17, 2026, at 4:00 PM with the Maintenance Supervisor (MS), during an environmental tour of rooms 1, 2, 3, 4, 6, 7,8, 9, 11, 14, and 21, The following measurements were noted as follows:- room [ROOM NUMBER] had two residents (Resident 22 and 34) and measured 77.91 square feet (Sq Ft. -unit of measurement) for each resident.- room [ROOM NUMBER] had two residents (Resident 58 and 25) and measured 78.14 Sq Ft. for each resident. - room [ROOM NUMBER] had two residents (Resident 8 and 10) and measured 76.59 Sq Ft. for each resident.- room [ROOM NUMBER] had two residents (Resident 7 and 53) and measured 76.73 Sq Ft. for each resident.- room [ROOM NUMBER] had two residents (Resident 14 and 45) and measured 77.78 Sq Ft. for each resident.- room [ROOM NUMBER] had two residents (Resident 37 and 40) and measured 78.37 Sq Ft. for each resident.- room [ROOM NUMBER] had two residents (Resident 21 and 52) and measured 77.91 Sq Ft. for each resident.- room [ROOM NUMBER] had four residents (Resident 17, 39, 54, and 55) and measured 70.95 Sq Ft. for each resident.- room [ROOM NUMBER] had three residents (Resident 3, 11 and 51) and measured 76.66 Sq Ft. for each resident.- room [ROOM NUMBER] had three residents (Resident 15, 28, and 64) and measured 77.54 Sq Ft. for each resident.- room [ROOM NUMBER] had two residents (Resident 12 and 33) and measured 70.06 Sq Ft. for each resident.The MS verified that all 11 rooms (room [ROOM NUMBER], 2, 3, 4, 6, 7, 8, 9, 11, 14 and 21) did not have the required 80 Sq Ft of space for each resident.
During an interview on February 18, 2026, 2:57 PM with Certified Nurse Assistant (CNA) CNA 1, stated the size of all rooms in the facility are wheelchair accessible and have sufficient space to provide care.
During an interview on February 20, 2026, at 2:50 PM with the Admin, the Admin stated there have been no issues with care in relation to the rooms that are less than 80 Sq Ft.
area.This failure had the potential to contaminate food, food preparing surfaces, and equipment which
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.
During an interview on February 18, 2026, at 3:30 PM, with the Dietician, the Dietician stated, it is important to have a pest control program inside the kitchen as there is a high risk of food contamination that could affect the health of residents.During a concurrent interview and record review on February 19, 2026, at 2:55 PM, with the Infection Preventionist (IP- an individual who is responsible for preventing infection in the facility), the facility's policy and procedure (P&P) titled, Infection Control, dated April 2025, and Pest Control, dated May 2008, were reviewed.
The Infection Control P&P indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.
The IP stated, as there was a live roach in kitchen there is a high chance of contaminating and infecting the food.
The Pest Control P&P indicated, The facility shall maintain an effective pest control program, the IP stated, policy was not followed as there was roach in the kitchen.During a concurrent interview and record review on February 20,2026, at 2:35 PM, with Director of Nursing (DON), the facility's P&P titled, Sanitation, dated November 2022, was reviewed.
The P&P indicated, Policy statement.
The food service area is maintained in a clean and sanitary manner.
Policy interpretation and implementation .
- All kitchen, kitchen areas and dining area are kept clean, free from garbage and debris and
protected from rodents and insects.
The DON stated roaches inside the kitchen are unacceptable and she said the facility should be free of pest.
The DON further stated roaches inside the kitchen pose a high risk of food contamination of food and can cause infection for residents.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
055707 02/20/2026
Ontario Healthcare Center 1661 S Euclid Ave Ontario, CA 91762