Health inspection·October 24, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interview, record review, and facility policy review, the facility failed to refer the resident to the appropriate state-designated authority for Level II preadmission screening and resident review (PASARR) evaluation after the resident was identified to have a newly evident mental illness diagnosis for 1 (Resident #26) of 2 sample residents reviewed for PASARR. Findings included: An admission Record revealed the facility admitted Resident #26 on 07/16/2021. According to the admission Record, the resident had a medical history that included diagnoses of disorder of muscle, neuromuscular dysfunction of bladder, and functional quadriplegia. Per the admission Record, the resident received a 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. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/19/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) Score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had active diagnoses to include anxiety disorder, depression, and PTSD. Resident #26's care plan included a focus area initiated 02/27/2023 that indicated the resident was on an antidepressant due to a diagnosis of depression. Resident #26's care plan, indicated a focus area initiated 03/03/2023, that indicated the resident had PTSD. Resident #26's care plan included a focus area initiated 03/18/2024, that indicated the resident used anti-anxiety medication related to a diagnosis of anxiety disorder. Resident #26's medical record revealed no evidence to indicate the resident was referred to the appropriate state-designated authority for a Level II PASARR after the resident received a diagnosis of anxiety disorder on 03/21/2023, post-traumatic stress disorder (PTSD) on 04/19/2023, or major depressive disorder on 08/31/2023. During an interview on 10/23/2024 at 2:16 PM with the Administrator and the Director of Nursing (DON), the DON stated he was not working at the facility when Resident #26 admitted to the facility. Page 1 of 7 055707 055707 10/24/2024 Ontario Healthcare Center 1661 South Euclid Avenue Ontario, CA 91762

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the preadmission screening and resident review (PASARR) was accurate at the time of admission for 1 (Resident #15) of 2 sampled residents reviewed for PASARR. Residents Affected - Few Findings included: An admission Record revealed the facility admitted Resident #15 on 12/01/2022. According to the admission Record, the resident had a medical history that included a diagnose of anxiety disorder. Resident #15's Preadmission Screening and Resident Review Level I Screening, dated 12/02/2022, revealed the resident did not have a serious diagnosed mental disorder such as depression disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusion, and/or mood disturbance. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/02/2024, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) Score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had an active diagnosis to include anxiety disorder. During an interview on 10/23/2024 at 2:16 PM with the Administrator and the Director of Nursing (DON), the DON he was not working at the facility when Resident #15 admitted to the facility, but added the PASARR should be accurate. 055707 Page 2 of 7 055707 10/24/2024 Ontario Healthcare Center 1661 South Euclid Avenue Ontario, CA 91762

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility policy review, the facility failed to ensure all food items removed from its original container were dated and labeled. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings included: A facility policy titled, Labeling and Dating of Food, revised 01/03/2018, revealed, All food will be dated and labeled, and prepared for storage to prevent contamination, deterioration, and dehydration. During the initial tour of the kitchen on 10/21/2024 at 9:46 AM, the surveyor noted four, unlabeled and undated bags that contained corn tortillas in the dry storage. During an observation of the kitchen on 10/23/2024 at 11:04 AM, the surveyor noted a gallon size, undated bag of nine snickerdoodle cookies on a shelf in the dry storage. During an interview on 10/23/2024 at 2:36 PM, the Dietary Supervisor (DS) stated all food should be labeled with a use-by date to ensure the food was fresh. The DS acknowledged the food items should have been dated, and stated they must have gotten missed. During an interview on 10/24/2024 at 8:12 AM with the Administrator and the Director of Nursing, the Administrator stated all items should be dated when they were taken out of the box. Per the Administrator, all food should be dated to ensure it was fresh. 055707 Page 3 of 7 055707 10/24/2024 Ontario Healthcare Center 1661 South Euclid Avenue Ontario, CA 91762

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, record review, facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) for 1 (Resident #150) of 5 sampled residents reviewed for infection control. Residents Affected - Few Findings included: A facility policy titled, Enhanced Barrier Precautions, dated 04/2024, revealed Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions are used an as infection prevention and control intervention to reduce the spread of multi-drug resistant organisms to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity. b. Personal protective equipment is changed before caring for another resident. c. Face protections may be used if there is also a risk of splash or spray. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care. An admission Record revealed the facility admitted Resident #150 on 10/07/2024. According to the admission Record, the resident had a medical history that included diagnoses of encounter for attention to gastronomy dysphagia, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/11//2024, revealed Resident #150 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for eating and had a feeding tube. Resident #150's care plan included a focus area, initiated 10/22/2024, that indicated the resident required enhanced barrier precautions (EBP) related to gastrostomy tube (G-tube) placement. Interventions directed staff to use gown and gloves during high-contact resident care activities. Resident #150's Order Summary Report that contained active orders as of 10/23/2024, revealed an order dated 10/10/2024 for EBP related to G-tube every shift. During a concurrent observation and interview on 10/22/2024 at 8:19 AM, Licensed Vocational Nurse (LVN) #1 entered Resident #150's room to administer medications to the resident via enteral route. LVN #1 wore gloves and no other personal protective equipment (PPE). The surveyor noted a sign posted on the resident's door that specified the staff wear a gown and gloves during high-contact resident activities when a resident had a central line, urinary catheter, feeding tube, or tracheostomy. LVN #1 stated gowns were necessary only for direct care like showering or changing the resident. During an interview on 10/22/2024 at 11:41 AM, Registered Nurse #3 stated nurses must wear PPE for medication administration if a resident had G-tube. During an interview on 10/22/2024 at 12:17 PM, the Director of Staff Development (DSD) stated there 055707 Page 4 of 7 055707 10/24/2024 Ontario Healthcare Center 1661 South Euclid Avenue Ontario, CA 91762

F 0880 Level of Harm - Minimal harm or potential for actual harm was verbiage posted on residents' doors when on EBP should be implemented and this guided the staff on what PPE to wear. The DSD stated the purpose of EBP was to protect residents at higher risk for infection because of opened areas such as enteral feeding, wounds, intravenous port, and a dialysis catheter. The DSD stated nurses must wear a gown when they administered medications to a resident who had a G-tube as required on the post listed on the resident's door. Residents Affected - Few During an interview on 10/22/2024 at 1:25 PM, the Infection Preventionist stated the staff was required to wear PPE during high contact activities such as changing of a resident's linens, showering a resident, resident transfers, wound care, G-tube feedings, and administration of medications for residents with indwelling medical devices such as a catheter, peripherally inserted central catheters lines, feeding tubes, and chronic wounds. During an interview on 10/23/2024 at 10:52 AM, the Director of Nursing stated the administration of medication through a G-tube was a closed contact activity, and LVN #1 should have worn a gown. During an interview on 10/24/2024 at 8:29 AM, the Administrator said LVN #1 should have worn a gown during the enteral medication administration for Resident #150. The Administrator stated the expectation was for the staff to follow the facility policy and procedure for the safety of the residents. 055707 Page 5 of 7 055707 10/24/2024 Ontario Healthcare Center 1661 South Euclid Avenue Ontario, CA 91762

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, document review, and interview, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 11 (Rooms 1 - 4, Rooms 6 - 9, room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]) of 24 resident rooms in the facility. Findings included: The Client Accommodations Analysis, signed by the Administrator and dated 10/23/2024, revealed: In room [ROOM NUMBER], there was 77.9 sq ft for each resident. In room [ROOM NUMBER], there was 77.5 sq f for each resident. In room [ROOM NUMBER], there was 77 sq ft for each resident. In room [ROOM NUMBER], there was 76.2 sq ft for each resident. In room [ROOM NUMBER], there was 76.78 sq ft for each resident. In room [ROOM NUMBER], there was 78.65 sq ft for each resident. In room [ROOM NUMBER], there was 78.75 sq ft for each resident. In room [ROOM NUMBER], there was 72 sq ft for each resident. In room [ROOM NUMBER], there was 77.7 sq ft for each resident. 055707 Page 6 of 7 055707 10/24/2024 Ontario Healthcare Center 1661 South Euclid Avenue Ontario, CA 91762

F 0912 In room [ROOM NUMBER], there was 78.39 sq ft for each resident. Level of Harm - Potential for minimal harm In room [ROOM NUMBER], there was 69.35 sq ft for each resident. Residents Affected - Some During an interview with on 10/23/2024 at 1:14 PM, Certified Nursing Aide #7 stated the size of the rooms had not prevented her from providing proper care. During an interview on 10/23/2024 at 2:42 PM with the Administrator and the Director of Nursing, the Administrator stated there had been no issues with care in relation to the size of some resident rooms. 055707 Page 7 of 7