Health inspection·December 23, 2025

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 COVID-19 (a highly infectious disease caused by a respiratory virus) when: 1. Certified Nurse Assistant 1 (CNA 1) failed to wear the required eye protection before entering a COVID-19 isolation room on December 19, 2025. 2. Certified Nurse Assistant 2 (CNA 2) did not ensure that the isolation room door was closed when exiting a COVID-19 isolation room on December 19, 2025. These failures had the potential to cause harm to the 54 residents residing within the facility by causing cross contamination of the environment and increasing the risk of exposure and spread of the COVID-19 virus.1. During an observation on December 19, 2025, at 12:10 PM, the residents inside Room [number] were under droplet isolation precautions (a safety protocol used to stop the spread of germs that travel through respiratory droplets, produced by coughing, sneezing, or talking), as shown by signage posted on the right side of the door.During an observation on December 19, 2025, at 12:15 PM, Certified Nurse Assistant 1 (CNA) 1 was observed entering Room [number] to serve a lunch tray without wearing eye protection, despite the isolation signage posted outside room [number] to inform staff and visitors to be instructed to wear appropriate personal protective equipment (PPE) including masks, gloves, gowns, and eye protection before entering the room.During an interview on December 19, 2025, at 12:15 PM, with the Director of Nursing (DON). The DON stated that residents in room [number] are under droplet isolation for Covid-19 (a virus that causes respiratory illness). Furthermore, the DON stated that eye protection must always be worn before entering a droplet isolation room, while pointing to the face shields (a type of PPE for eye protection) stored and hung in the caddy by the door of Room [number].During an interview on December 19, 2025, at 4:30 PM, with CNA 1, CNA 1 stated she was aware that eye protection is required prior to entering a droplet isolation room but stated that she forgot to put it on before entering Room [number].During a concurrent record review and interview on December 19, 2025, at 4:35 PM, with the Infection Prevention Nurse (IPN) and DON, the facility Policy and Procedure (P&P) titled, Respirator Virus Prevention & Control Plan, revised March 31, 2025, was reviewed. The P&P indicated, .This plan is based on these key focus areas for preventing and controlling the spread of respiratory viruses:. PURPOSE. The purpose of the Respiratory Virus Prevention and Control Plan is to describe our facility's approach to preparing for, preventing, responding to, and controlling the spread of respiratory infections to residents and staff who may develop signs or symptoms of respiratory viral infections by: Maintaining a safe and secure environment for residents, staff, and visitors. Initiating prompt testing and treatment of COVID-19 and influenza to reduce the risk of severe illness, hospitalization, and death. Guidance on recommended Transmission-Based Precautions and personal protective equipment (PPE) when caring for residents with COVID-19 includes N95 or higher-level respirator, eye protection, gown, and gloves. The IPN and DON stated that staff did not follow the P&P. 2. During an observation on December 19, 2025, at 12:18 PM, the residents inside Room [number] were under droplet isolation precautions, as shown by signage Residents Affected - Few Page 1 of 2 055693 055693 12/23/2025 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 posted on the right side of the door.During an interview on December 19, 2025, at 12:20 PM, with the Director of Nursing (DON). The DON stated that residents in room [number] are under droplet isolation for Covid-19.During an observation on December 19, 2025, at 12:25 PM, CNA 2 was observed leaving Room [number] after delivering a lunch tray and walking directly to the nurse's station without closing the door behind her.During an interview on December 19, 2025, at 12:30 PM, with CNA 2, CNA 2 stated that she was aware of the requirement to keep the door closed in a Covid - 19 isolation room. She acknowledged that she forgot to close the door behind her upon leaving.During a follow-up observation on December 19, 2025, at 12:35 PM, the DON engaged in a conversation with the resident in room [number] and subsequently closed the door.During an interview on December 19, 2025, at 4:35 PM with the IPN and DON, the DON stated that the staff is expected to keep the doors closed for residents under droplet isolation to limit the spread of respiratory droplets into common areas.During an interview on December 20, 2025, at 2:20 PM, the Director of Nursing (DON) stated that the facility was not able to locate a written policy and procedures (P&P) specific to door closure for residents under droplet isolation. The DON further stated that it is the facility's practice to keep doors closed for residents under droplet isolation to remain consistent with CDC infection control guidance for managing residents with suspected or confirmed COVID-19.During a concurrent record review and interview on December 20, 2025, at 3:20 PM, with the DON and Administrator, the facility's P&P titled, Testing of Residents and HCP with Signs/Symptoms of Respiratory Illness, revised May 29, 2024, was reviewed. The P&P indicated, . 23. Testing of Residents and HCP with Signs/Symptoms of Respiratory Illness. See CDC guidance on interim guidance for managing healthcare personnel with SAR-Cov-2 Infection or Exposure to SAR-Cov-2. The CDC guidance within the referenced link indicated, . Patient Placement . Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). > If cohorting, only patient with the same respiratory pathogen should be housed in the same room. The DON stated that staff did not follow the P&P. 055693 Page 2 of 2