Health inspection·December 2, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the advance directives (written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated), were completed in accordance with the facility policy for one of six residents (Resident 27) reviewed for advance directives. This failure had the potential to result in a delay of treatment for Resident 27 related to advance directives, or for life sustaining measures to be rendered against what the resident wanted. Findings: During an observation, on November 29, 2022, at 9:06 AM, Resident 27 was in her room, lying down in bed. During a review of Resident 27's medical record, the admission Record (contains demographic and medical information), indicated Resident 27 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (kidneys no longer work), dependence on renal dialysis (process that removes wastes in place of your kidneys), diabetes mellitus (when pancreas does not produce enough insulin), and heart failure (heart is unable to pump blood around the body properly). During a concurrent interview and record review, with the Social Services Director (SSD), on December 2, 2022, at 8:25 AM, the SSD reviewed Resident 27's California Advance Health Care Directive (CAHCD), dated May 14, 2022 (approximately six months ago), which indicated it was completed by Resident 27 with two witness signatures. Further review indicated it was missing the Ombudsman's (resolve disputes from a neutral, independent viewpoint) signature. During further interview and record review with the SSD, the SSD verified the CAHCD was not signed by the Ombudsman and should have been. The SSD was not able to find documented evidence that the Ombudsman was informed. The SSD stated, I did not inform the Ombudsman because I did not know about it and I missed it. During a concurrent interview and record review, with the Director of Nursing (DON) and the SSD, on December 2, 2022, at 8:35 AM, the facility's policy and procedure (P&P) titled, Advance Directives Operation Manual- Social Services, dated December 1, 2013, indicated, .II. If the resident chooses to execute an Advance Directive, the Director of Social Services or his or her designees will contact the Ombudsman so that the Ombudsman can witness the resident signing the Advance Directive . The Page 1 of 13 055693 055693 12/02/2022 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0578 DON and the SSD stated the facility did not follow the policy. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055693 Page 2 of 13 055693 12/02/2022 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours, seven days a week. Residents Affected - Few This failure had the potential to prevent 54 residents from reaching their highest practicable level of well-being when oversite by an RN was not utilized by the facility. Findings: A review of the facility's staffing schedules for the months of October 2022 through November 2022 was conducted on December 1, 2022 at 9:15 AM. It indicated there were no RNs on duty for eight consecutive hours during the following dates: 1. October 6, 2022 2. October 23, 2022 3. October 31, 2022 4. November 25, 2022 A review of the facility's timekeeping punches for the Registered Nurses was conducted on December 1, 2022, at 3:00 PM. It indicated a RN did not work for eight consecutive hours (on duty) on the following dates: 1. October 22, 2022 2. October 27, 2022 3. November 18, 2022 4. November 20, 2022 5. November 21, 2022 During an interview and concurrent record review, on December 2, 2022, at 2:00 PM, the Director of Nursing (DON) and Administrator reviewed the staffing sheets and timekeeping punches. The Administrator stated the facility has a full-time DON, but does not always staff a RN for eight consecutive hours a day, seven days a week. The facility was requested to provide documented evidence to prove the DON worked in the facility on the dates reviewed from staffing schedules and timekeeping punches. The facility was unable to provide documentation. During a follow up interview with the DON, on December 2, 2022 at 2:37 PM, the DON stated he couldn't find proof that he worked on the days reviewed, and acknowledged that there would be no way to prove that he did work those days. 055693 Page 3 of 13 055693 12/02/2022 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the pharmacy recommendations identified from the Medication Regimen Review (MRR- thorough evaluation of a resident's medication regimen in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities) were followed up in accordance with federal regulations and facility policy, for two of five residents (Residents 3 and 26) reviewed for unnecessary medications when: 1. The pharmacy recommendation, from May 12, 2022, for Resident 3's use of Seroquel (medication to treat mood disorders), was not communicated to the physician. 2. The pharmacy recommendation, from May 12, 2022, for Resident 26's use of Abilify (medication for mood disorders), was not communicated to the physician. These failures had the potential to place Residents 3 and 26's at risk of experiencing adverse effects such as congestive heart failure (when the heart cannot pump blood adequately), infections, and even death. Findings: 1. During an observation, on November 29, 2022, at 10:20 AM, Resident 3 was in her room, lying down in bed, watching television. During a review of Resident 3's medical record, the admission Record (contains demographic and medical information), indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included dementia (inability to remember, think or make decisions that interferes with doing everyday activities), psychosis (when people lose contact with reality) and depression (mood disorder that cause persistent feeling of sadness and loss of interest). A review of Resident 3's physician's orders, dated November 27, 2022, indicated Resident 3 had an order to receive Seroquel 50 mg [mg- milligrams unit of measurement], 1 tablet by mouth two times a day for Psychosis . During a telephone interview, with the Consultant Pharmacist (CP), on December 1, 2022, at 3:00 PM, the CP stated he reviewed Resident 3's medications in May 2022 and recommended to assess the risks versus the benefits of receiving Seroquel due to a Black Box Warning [serious life-threatening side effects or risks]. During a concurrent interview and record review, with the Social Services Director (SSD), on December 2, 2022, at 10:13 AM, the SSD reviewed a facility document regarding Resident 3's use of Seroquel titled Note To Attending Physician/Prescriber, dated May 12, 2022, which indicated, A review of the literature by the FDA [Food and Drug Administration] suggest an increased risk of death in elderly patients with dementia who receive atypical and traditional antipsychotics (medication used to treat symptoms of psychosis) . Please assess the risks versus benefits of therapy in this patient in order to keep the facility in compliance. The resident [Resident 3] has orders for Seroquel and has a medical history of dementia. The SSD stated the document has not been signed by a physician. 055693 Page 4 of 13 055693 12/02/2022 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review, with the Psychiatrist, on December 2, 2022, at 10:54 AM, the Psychiatrist reviewed a facility document regarding Resident 3's use of Seroquel titled Note To Attending Physician/Prescriber, dated May 12, 2022, and stated the facility did not send this document to him. 2. During an observation, on November 29, 2022, at 10:40 AM, in the activity room, Resident 26 was in her wheelchair, participating in activities. During a review of Resident 26's medical record, the admission Record indicated Resident 26 was admitted to the facility on [DATE], with diagnoses which included epilepsy (convulsions), dementia, depression, Alzheimer's disease (a type of dementia that affects memory, language and thought) and psychosis. A review of Resident 26's physician's orders, dated August 1, 2022, indicated an order for Resident 26 to receive Abilify 20 mg 1 tablet by mouth in the morning for Psychosis . During a telephone interview, with the CP, on December 1, 2022, at 3:10 PM, the CP stated he reviewed Resident 26's medications in May 2022 and recommended to assess the risks versus the benefits of receiving Abilify due to a Black Box Warning. During a concurrent interview and record review, with the SSD, on December 2, 2022, at 10:15 AM, the SSD reviewed a facility's document regarding Resident 26's use of Abilify titled, Note To Attending Physician/Prescriber, dated May 12, 2022, which indicated, A review of the literature by the FDA [Food and Drug Administration] suggest an increased risk of death in elderly patients with dementia who receive atypical and traditional antipsychotics . Please assess the risks versus benefits of therapy in this patient in order to keep the facility in compliance. The resident [Resident 26] has orders for Abilify and has a medical history of dementia. The SSD stated the document had not been signed by a physician. During a concurrent interview and record review, with the Psychiatrist, on December 2, 2022, at 11:00 AM, the Psychiatrist a facility's document regarding Resident 26's use of Abilify titled, Note To Attending Physician/Prescriber, dated May 12, 2022, and stated the facility did not send this document to him. During a concurrent interview and record review on December 2, 2022, at 2:15 PM, with the Director of Nurses (DON), the DON reviewed the facility's policy and procedure (P&P) titled, Consultant Pharmacist Notes to Physicians, dated January 5, 2018, and stated the facility did not follow the policy. During a review of the facility's policy and procedure (P&P) titled, Consultant Pharmacist Notes to Physicians, dated January 5, 2018, which indicated, .The facility, under the Direction of the Director of Nursing, will establish an organized and reproducible system for conveyance of the consultant pharmacist's recommendations to the attending Physician .Procedures .After having received the consultant pharmacist's recommendations for the Attending Physicians, the director of nursing or designee will: .1. Send (mail or fax) the consultant pharmacist's Notes to the Physician's office .3. Once signed and dated by the Physician, these notes may be place in the chart as a Physician's Order. Even if a request is declined by the Physician, it will help the facility document that an irregularity or a potential problem has been addressed: all responses may kept on the Resident's chart. 055693 Page 5 of 13 055693 12/02/2022 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure secure storage of medications when one of three medication carts (Treatment Cart) was found to be unlocked while unattended by a licensed nurse. This failure had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 54 residents. Findings: During a concurrent observation and interview, on December 1, 2022, at 5:18 AM, with a Licensed Vocational Nurse (LVN 1), one medication cart (a cart used by licensed nurses to transport medication to resident rooms), was located outside of room [ROOM NUMBER]. It was unlocked while unattended by a licensed nurse. LVN 1 stated it was a treatment cart (a cart used by licensed nurses to transport and store medical treatments and supplies). During further observation and interview, with LVN 1, on December 1, 2022, at 5:22 AM, LVN 1 opened the drawers of the medication cart and acknowledged the cart was left unlocked. LVN 1 counted five drawers in the medication cart containing topical medications (ointments) for nine residents. LVN 1 stated the cart must always be kept locked when unattended. During an interview, with the Director of Nursing (DON), on December 1, 2022, at 2:20 PM, the DON stated medication carts were expected to be locked when left unattended to prevent unauthorized access to the medications. During a concurrent interview and record review, with the DON, on December 1, 2022, at 2:23 PM, the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated January 23, 2021, was reviewed. The P&P indicated, .Procedures .B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access . The DON stated the facility did not follow their policy and procedure. 055693 Page 6 of 13 055693 12/02/2022 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and utilize a planned vegetarian menu for one of 51 residents(Resident 45). This failure has the potential to adversely affect Resident 45's nutritional status. Findings: During a review of Resident 45 clinical record, the admission Record (contains demographic and medical information), the admission Record indicated Resident 45 was admitted to the facility on [DATE], with diagnoses of hypertension (high blood pressure), dementia (inability to remember, think, or make decisions that interferes with everyday activity), and weakness. During a review of Resident 45's physician order, dated July 28, 2022, indicated Resident 45 had a diet order of No Added Salt Regular texture, Vegetarian diet. During an observation, on November 29, 2022, at 11:45 AM, in the kitchen, a [NAME] (Cook 1) was plating food for the residents. During follow up observation and concurrent interview, on November 30, 2022, at 11:59 AM, in the kitchen, [NAME] 1 was plating food for the residents. [NAME] 1 served Resident 45 a quesadilla for lunch. [NAME] 1 stated she prepared Resident 45 a cheese quesadilla. During an interview, with [NAME] 2, on November 30, 2022, at 3:07 PM, in the kitchen, [NAME] 2 stated they do not use a planned vegetarian menu. She stated she will just remove the meat from the meal for residents on vegetarian diet. She further stated her dinner plan was to make the Resident 45 an enchilada with cheese. During an interview with the Registered Dietitian (RD 1), on December 1, 2022, at 2:33 PM, in the kitchen, the RD 1 stated they do not have a planned vegetarian menu. The RD 1 further stated they just go based on the resident's preferences then modify the current menu. During a review of the facility's policy and procedure titled, Operation Manual-Dietary Menus Policy Number DS-05, dated April 1, 2014, it indicated, 1. The Dietary Manager will collaborate with the Dietitian to develop menus at least a week in advance. 2. Food served should adhere to the written menu. 055693 Page 7 of 13 055693 12/02/2022 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, record review, the facility failed to follow proper sanitization and food handling practices when: Residents Affected - Many 1. Raw thawing beef and bacon was stored on the same shelf as raw thawing chicken breast. 2. The dishwashing machine was not sanitizing the dishes. 3. The ice machine was found to have brown residue under the ice dispenser and on the ceiling of the ice storage bin. 4. A floor repair was unfinished, and the surface was not easily cleanable. These failures had the potential to expose 51 highly susceptible residents who received food from the kitchen to cause foodborne illness (illness caused by the ingestion of contaminated food or beverage) due to cross contamination (the transfer of harmful substances or disease-causing microorganisms to food). Findings: 1. An inspection of the kitchen was conducted with a Dietary Aide (DA 1), on November 29, 2022, at 8:03 AM. Inside the refrigerator, a metal container of thawing bacon was stored on top of a thawing bag of chicken breast, and a container of thawing raw beef was on the bottom shelf beside the chicken. The thawing pan of raw chicken breast was filled with raw chicken juices. During a subsequent interview with DA 1, on November 29, 2022, at 8:30 AM, DA 1 stated the raw beef and bacon should be stored above the raw chicken breast and not on the same shelf. During an interview with the Registered Dietitian (RD 1), on December 1, 2022, at 2:35 PM, the RD 1 stated the chicken should not be thawing on the same shelf as the beef. The RD 1 further stated the staff should be following the guidelines according to cooking temperature. During a review of FDA (Food and Drug Administration) Food Code 2017 3-401.11, indicated, Greater numbers and varieties of pathogens generally are found on poultry than on other raw animal foods. Therefore, a higher temperature, in combinations with the appropriate time is needed to cook these products. 2. During an observation, on November 30, 2022, at 9:12 AM, in the kitchen, DA 1 tested the dishwashing machine with a chlorine test strip (used to measure the concentration of chlorine in sanitizing solutions). The result from the test strip indicated there was no sanitizer detected or 0 parts per million (PPM- unit of measurement). Two additional tests were performed by DA 1 with the same results of no sanitizer detected. During an follow up with DA 1, on November 30, 2022, at 9:50 AM, she stated the PPM of chlorine should be 50-100 according to the manufacturer's guidelines. During a review of the facility's undated policies and procedure titled Dish Machine Temperature 055693 Page 8 of 13 055693 12/02/2022 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0812 Level of Harm - Minimal harm or potential for actual harm Recording, it indicated The dish machine will be routinely monitored during use. The concentration of the sanitary solution during the rinse cycle is 50 ppm for chlorine sanitizer. During a review of the FDA Food Code 2017 4-204.117, it indicated The presence of adequate detergents and sanitizers is necessary to effect clean and sanitized utensils and equipment. Residents Affected - Many 3. During a concurrent observation and interview, on November 29, 2022, at 8:35 AM, with the Maintenance Supervisor (MS), in the kitchen, the ice machine was found to have brown residue under the ice dispenser and on the ceiling of the ice storage bin. The MS acknowledged the finding and stated the hard water stains were difficult to remove and he has to use a brush to scrub and remove it. During an interview, with the RD 1, on November 30, 2022, at 9:37 AM, the RD 1 stated the ice machine should be kept clean, and they may need to clean it more often to ensure it remains clean. During a review of the Federal FDA 2017 Food Code 4-204.17, it indicated The potential for mold and algae growth in this area is very likely due to the high moisture environment. Molds and algae that form is difficult to remove and present a risk of contamination to the ice stored in the bin. According to the CDC's (Center for Disease Control) Guidelines for Environmental Infection Control in Health Care Facilities, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC), revised July 2019, https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf), microorganisms may be present in ice, ice-storage chests, and ice-making machines. The two main sources of microorganisms in ice are the potable water from which it is made and a transferal of organisms from hands. Ice from contaminated ice machines has been associated with .blood stream infections, pulmonary (having to do with the lungs) and gastrointestinal (having to do with the stomach and intestinal tract) illnesses. Recommendations for a regular program of maintenance and disinfection have been published. Some waterborne bacteria found in ice could potentially be a risk to immunocompromised patients if they consume ice or drink beverages with ice. 4. During an observation, on November 29, 2022, at 8:05 AM, in the kitchen, the floor near the sink drain was patched with a black substance. During an interview, the RD 1, on November 30, 2022, at 9:37 AM, the RD 1 stated they did some plumbing work and had to remove some of the tiles. She further stated the material used to patch the floor was not smooth and not easily cleanable. During a review of the FDA Food Code 2017 4-202.16 Nonfood-Contact Surfaces indicated, Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms. 055693 Page 9 of 13 055693 12/02/2022 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to ensure a copy of a completed Physician Orders for Life-Sustaining Treatment (POLST-voluntary form used statewide as a physician order that converts a resident's wishes regarding life-sustaining treatment and resuscitation into physician orders.) was filed in the medical record of one of six residents (Resident 209) reviewed for advance directive (written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated), in accordance with the facility procedure. This failure has the potential to place Resident 209 at risk of unmet care needs in the event of an emergency requiring lifesaving interventions due to the POLST not being accessible. Findings: During a review of Resident 209's admission Record (contains demographic and medical information), indicated Resident 209 was admitted to facility on November 16, 2022, with diagnoses of urinary tract infection (UTI- infection caused by bacteria in the bladder), and encephalopathy (damage or disease that affects the brain). During a concurrent interview and record review, with a Licensed Vocational Nurse (LVN 3), on December 2, 2022, at 1:45 PM, LVN 3 reviewed Resident 209's medical record and stated Resident 209's POLST was not on file. During a concurrent interview and record review, with the Medical Records Director (MRD), on December 2, 2022, at 1:30 PM, the MRD reviewed Resident 209's medical record and stated Resident 209's POLST was not on file. During a review of the facility's policy and procedure titled Physician's Orders for Life-Sustaining Treatment (POLST), dated June 3, 2020, indicated .The facility will make a copy of the completed POLST from . File the copy in the Advance Directive or legal section of the medical record . 055693 Page 10 of 13 055693 12/02/2022 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement their infection control program to help prevent the spread of infections and other infectious diseases when four staff members did not complete the screening log (a log used to screen staff and visitors for COVID-19 [A highly infectious disease caused by the SARS-CoV-2 virus] symptoms and exposure upon entering the facility) on multiple occasions. Residents Affected - Few This failure had the potential to place 54 residents residing within the facility to be at risk of exposure to COVID-19 virus. Findings: During a concurrent interview and record review, on December 2, 2022, at 11:50 AM, with the Infection Preventionist Nurse (IPN), the IPN reviewed a facility document titled Daily Nursing Staffing, sign-In Log, from November 12, 2022, to November 30, 2022, which indicated the following: a. On November 12, 2022, Certified Nursing Assistant (CNA 1) signed on the night shift at 11:00 PM. b. On November 13, 2022, Licensed Vocational Nurse (LVN 2) and Certified Nursing Assistant (CNA 2) signed on the night shift, at 11:00 PM. c. On November 19, 2022, Licensed Vocational Nurse (LVN 2) and Certified Nursing Assistant (CNA 2) signed on the night shift, at 11:00 PM. d. On November 20, 2022, Licensed Vocational Nurse (LVN 2) and Certified Nursing Assistant (CNA 3) signed on the night shift, at 11:00 PM. The IPN verified the four staff members worked on those days from 11:00 PM to 7:00 AM. During further interview and record review, with the IPN, on December 2, 2022, at 12:00 PM, the IPN reviewed a facility document titled, Daily screening log of Employees, from November 12, 2022, to November 30, 2022, which indicated the following: a. On November 12, 2022, at 11:00 PM, CNA 1 was not screened for COVID-19 symptoms before entering the facility. b. On November 13, 2022, at 11:00 PM, LVN 2 and CNA 2 were not screened for COVID-19 before entering the facility. c. On November 19, 2022, at 11:00 PM, LVN 2 and CNA 2 were not screened for COVID-19 before entering the facility. d. On November 20, 2022, at 11:00 PM, LVN 2 and CNA 3 were not screened for COVID-19 before entering the facility. The IPN stated all staff members were expected to be screened for signs and symptoms of COVID-19, and to answer the screening log questions accurately before entering the facility. 055693 Page 11 of 13 055693 12/02/2022 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review, with the IPN, on December 2, 2022, at 12:12 PM, the IPN reviewed the facility's policy and procedure (P&P) titled Infection Prevention & Control Manual, revised October 11, 2022, which indicated, Practice Standards .Entrance Screening .1. Active Screening of all HCP [Healthcare Personnel] entering the Facility (such as employees, medically necessary personnel, contracted staff/vendors, and volunteers) will be done upon entry to the facility . The IPN stated that facility did not follow the policy. 055693 Page 12 of 13 055693 12/02/2022 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.unit of measurement) of livable space per resident for nine of 19 resident rooms (rooms 26, 27, 28, 29, 30, 31, 32, 33, and 34). This failure had the potential to affect the resident's health and safety and prevent the residents from maintaining their highest level of well-being by limiting the movements of these residents in their rooms. Findings: During an entrance conference interview, with the Administrator, on November 29, 2022, at 8:25 AM, the Administrator stated nine of 19 resident rooms had less than the required square footage (80 sq. ft. of livable space per resident). During an environmental tour, with the Maintenance Supervisor (MS), on November 30, 2022, at 12: 20 PM, nine of the 19 resident rooms were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements of livable space were noted as follows: 1. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) 2. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) 3. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) 4. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) 5. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) 6. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) 7. room [ROOM NUMBER] (3 beds) measured: 221.5 sq ft (74 sq. ft. per resident) 8. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) 9. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) These rooms were not crowded and did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms. The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency. 055693 Page 13 of 13