Other·May 10, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of California Department of Public Health during a recertification survey conducted on March 25, 2019 through March 29, 2019. Representing California Department of Public Health: Surveyors 32495, 34661, 39429, 41593 and 41459. Census: 53 Sampled Residents: 17 An Immediate Jeopardy (IJ- immediate danger of harm) situation was identified and called under 483.80 Infection Control, in the presence of the Administrator (ADMIN) and the Director of Nursing (DON) on March 27, 2019 at 11:10 AM. The Administrator and the DON were verbally notified of the IJ situation identified based on the facility's failure to ensure the glucometer (a devise to check blood sugar) was disinfected, before and after resident's use, according to the facility's policy and procedure and manufacture's guidelines. The facility submitted an acceptable corrective action plan on March 27, 2019 at 2:30 PM. After observation, staff interviews, and record reviews were conducted to ensure the inplementation of the corrective action plan, the IJ was lifted on March 28, 2019 at 2:32 PM in the presence of the ADMIN and the DON. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 1 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F578 Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/24/2019 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 2 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 2, Resident 15 and Resident 10) medical record contained a completed advance directive. This failure had the potential to result in delaying treatment in an emergency. Findings: 1. During an observation on March 25, 2019 at 3:35 PM, Resident 2 was lying in bed under the covers dressed in gown. During a record review of the clinical record on March 27, 2019 at 12:57 PM, there was no documented evidence of a completed Advance Directive or POLST (Physician Order of Life Sustaining Treatment) in the chart at the nurse's station for Resident 2. During a concurrent interview with the Medical Records Director (MRD) on March 27, 2019 at 12:57 PM for Resident 2, the MRD confirmed there was not an advance directive in the chart. During a subsequent record review on March 28, 2019, Resident 2 was admitted on November 30, 2018 with diagnoses which included: leg cast, physical deconditioning, cervical spine osteomyelitis (infection in the neck vertebra), pain management, hypertension (high blood pressure), deep vein thrombosis (blood clots in the vein) and a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 3 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE wound on the right buttock. Resident 2 had the capacity to understand and make decisions. The facility policy and procedure titled, "Advance Directives" dated 2001, indicated, "4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record." 2. During an observation on March 27, 2019 at 12:03 PM, Resident 15 was lying in bed with the bed in low position and fall mats adjacent to the bed. During a record review of the clinical record on March 27, 2019 at 12:54 PM, there was no documented evidence that the physician completed the Advance Directive Section D Information and Signatures which requires: Physician name, Physician phone number, Physician license number, Physician signature and date. During an interview on March 28, 2019 at 11:40 AM with the MRD, she stated, "I audit that too and follow up with the Social Services Director and the nurses." The MRD confirmed the physician had not signed the advance directive and completed Section D. During a subsequent record review on March 28, 2019, Resident 15's Advance Directive was signed on March 26, 2019 by her responsible party. Resident 15 was admitted on January 10, 2019 with diagnoses which included: urinary tract infection, anemia, Type 2 Diabetes Mellitus, hypertension (high blood pressure), GERD (gastro esophageal reflux disease - acid reflux from the stomach), history of falling, muscle weakness, and altered mental status. Resident 15 does not have the capacity to understand and make decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 4 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility policy and procedure titled, "Advance Directives" dated 2001, indicated, "4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record." The facility policy and procedure titled, "Record Content Subject: Documentation Principles," dated April 2010, indicated, " Resident's health record shall be current and kept in detail consistent with good medical and professional practice based on the service provided to the resident." 3. During an observation on March 26, 2019 at 3:39 PM, Resident 10 was receiving a tube feeding of Jevity at 60 cc/hour (cubic centimeters - a unit of measurement). Resident 10's head of bed was elevated and she was lying in bed on her back. During a record review of the clinical record on March 26, 2019 at 4:07 PM, there was no documented evidence of a completed Advance Directive or POLST (Physician Order of Life Sustaining Treatment) in the chart at the nurse's station for Resident 10. During an interview with the Medical Records Director (MRD) on March 28, 2019 at 11:45 AM for Resident 2, the MRD confirmed there was not an advance directive in the chart. During a subsequent record review on March 28, 2019, Resident 10 was admitted on November 30, 2018 with diagnoses which included: hemiplegia (paralysis on one side of the body) following cerebral infarction (stroke) on right non-dominant side, chronic pain syndrome, hypertension (high blood pressure), arteriosclerotic heart disease of coronary artery (plaque build-up in the major heart vessel), hyperlipidemia (high cholesterol), major FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 5 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE depressive disorder, GERD (gastro esophageal reflux disease - acid reflux from the stomach), dysphagia (difficulty swallowing), gastrostomy tube (opening in the stomach through the abdomen for food by a tube). The facility policy and procedure titled, "Advance Directives" dated 2001, indicated, "4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record."

F641 SS=E Accuracy of Assessments CFR(s): 483.20(g)

F641 04/24/2019 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the accuracy of resident assessment were completed for three of 17 sampled residents (Residents 2, 25, and 35) as evidenced by: 1. Resident 2's MDS (Minimum Data Set-a comprehensive assessment of a resident's needs), Section J (Health Conditions) was coded inaccurately and the PASRR (Preadmission Screening and Resident Review-an assessment for mental illness or intellectual disability) assessment was incomplete. 2. Resident 25's pre-dialysis care assessment was incomplete. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 6 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3. Resident 35's MDS Section N (medication) was coded inaccurately These failures had the potential of resulting in inaccurate development of resident care plans and not meeting the needs of the residents. Findings: 1a. During an observation on March 25, 2019 at 3:19 PM, Resident 2 laid in bed dressed in a gown under the covers. A wheelchair and front wheeled walker were near the bedside. During an interview on March 25, 2019 at 3:21 PM, Resident 2 stated she had a fall on November 27, 2018 at 5:30 AM in the smoking area near the red bench because she flipped over and broke her ankle. During a review of the clinical record on March 25, 2019 for Resident 2, Resident 2 was admitted on November 30, 2018 with diagnoses which included: leg cast, physical deconditioning due to left trimalleolar (ankle) fracture from a mechanical fall (resident lost balance and fell), cervical spine (neck) osteomyelitis (infection of bone), pain management, hypertension (high blood pressure), deep vein thrombosis (DVT- blood clot in the leg) prophylaxis (prevention of blood clots). Resident 2 had the capacity to understand and make decisions. During a review of the clinical record on March 28, 2019, the reentry MDS (Minimum Data Seta comprehensive assessment of a resident's needs), Section J (Health Conditions) dated November 30, 2018 was coded inaccurately in: a. Section J1700 Fall History on Admission Part A, B, and C was left blank. These parts to Section J1700 should have been coded 1 as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 7 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Yes. b. Section J1800 was left blank. This section should have been coded 1 as Yes. c. Section J1900 C was left blank. This section should have been coded 1 as Yes. During an interview on March 28, 2019 at 3:21 PM, the MDS nurse stated the entries were made by the prior MDS nurse who is no longer employed by the facility and should have been coded yes. The facility policy and procedure titled, "Resident Assessment Instrument," dated October 2010, indicated, "2. The Interdisciplinary Assessment Team must use the MDS form currently mandated by Federal and State regulations to conduct the resident assessment ...3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity ...7. All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information." 1b. During an observation on March 25, 2019 at 3:19 PM, Resident 2 laid in bed dressed in a gown under the covers. During a review of the clinical record on March 25, 2019 for Resident 2, Resident 2 was admitted on November 30, 2018 with diagnoses which included: leg cast, physical deconditioning due to left trimalleolar (ankle) fracture from a mechanical fall (resident lost balance and fell), cervical spine (neck) osteomyelitis (infection of bone), pain management, hypertension (high blood pressure), deep vein thrombosis (DVT- blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 8 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE clot in the leg) prophylaxis (prevention of blood clots). Resident 2 had the capacity to understand and make decisions. During a clinical record review for Resident 2 on March 27, 2019 at 12:56 PM, a PASRR (Preadmission Screening and Resident Review) level one assessment dated November 5, 2018, was found in the chart and indicated in Section V Mental illness, question 27 suspected mental illness was left blank. By not completing question 27 the PASRR system inaccurately gave a negative assessment (not needing mental health services) for Resident 2. During an interview on March 28, 2019 at 11:06 AM, the MDS nurse stated the PASRR level one was transmitted by the previous administrator and confirmed question 27 was blank. The MDS nurse stated he remembered seeing a diagnosis of psychosis on the medication administration record and the last hospital admission record. During a subsequent clinical record review for Resident 2 on March 28, 2019, a quarterly MDS assessment dated December 12, 2019, indicated in Section A1500 the resident did not have a serious mental illness requiring a PASRR level two evaluation and in Section I Active diagnoses indicated Resident 2 had a psychotic disorder (abnormal thinking and perceptions causing the person to lose touch with reality) other than schizophrenia (chronic, severe mental illness that affects how people think, feel and behave). During an observation on March 28, 2019 at 3:31 PM, Resident 2 was yelling at the staff. During an interview on March 29, 2019 at 9:35 AM, an interview was attempted with Resident 2. Resident 2 became agitated and refused to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 9 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE answer any questions. The facility document titled, "Guide to Completing the PASRR Level I Screening," dated May 2018, indicated, "Level I - Positive if there is a diagnosed or suspected mental illness identified on the Level I Screening (at least one YES for questions 260-28 and at least one UNKNOWN or YES for questions 2930), the case will be coded as "Positive." The case state, resolution, and reason code fields will be blank on the Level 1 Screening for Positive cases. The Level I Screening will automatically be sent to the DHCS Contractor for a Level II prescreening call. Please periodically check the Level I Case list online for an update." 2. During an observation on March 25, 2019 at 11:23 AM Resident 25 was lying in bed. A fall mat was located adjacent to the bed on the right side. During a concurrent interview with Resident 25, he stated, "I do not understand you." During a review of the clinical record for Resident 25, Resident 25 was admitted on January 5, 2018 with diagnoses which included end stage renal disease (kidney failure), dependence on dialysis (the process of removing waste products and excess fluids from the body when the kidneys are not able to adequately filter the blood) , Type 2 Diabetes Mellitus with diabetic neuropathy (loss of peripheral nerve sensation), hyperlipidemia (high cholesterol), and cerebral infarction (stroke) with hemiplegia (paralysis on one side) on the left non dominant side. During an interview on March 28, 2019 at 8:27 AM with Resident 25's responsible party (RPperson who has legal authority to make health FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 10 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care decisions), the RP stated, "He goes to dialysis on Tuesday, Thursday and Saturday. I go with him and follow him there. The dialysis staff asks me about his medications and blood pressure because it is not on the form." During a review of the clinical record on March 28, 2019 at 9:15 AM, the document titled, "Dialysis Communication Record" indicated the pain assessment was missing on the document for the following days: March 5, 2019, March 7, 2019, March 12, 2019, March 14, 2019 and March 19, 2019. The vital signs for March 2, 2019 were left blank on the document. The assessment for the arterial venous shunt (AVa surgical grafting of a vein and artery) site for a bruit and thrill was not documented on March 7, 2019, March 14, 2019, and March 19, 2019. During an interview on March 28, 2019 at 9:21 AM, a Licensed Vocational Nurse (LVN 4) was asked about the assessment of the resident prior to dialysis. LVN 4 stated, "Check for bruits/thrills (abnormal sound generated by turbuklent flow of blood in an artery), check for bleeding, check for redness, take vital signs (temperature, pulse, blood pressure, respirations and pain). When the LVN 4 was asked if the assessment would be complete if the pain or bruits/thrills were not filled out, LVN 4 stated, "No, not completed." During an interview on March 28, 2019 at 9:32 AM, the Director of Nurses (DON) confirmed the missing entries for vital signs, pain, thrills/bruits. The DON stated the nurse assesses the resident by checking for a bruit/thrill, site access, check blood pressure and vital signs - temperature, respirations, pulse, pain and checks oxygen saturation if on oxygen. The DON acknowledged the nurses were not following the policy if the pain, vital signs, or bruit/thrill were not assessed and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 11 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE documented. During a review of the clinical record for Resident 25, the care plan titled, "[name of resident] has renal insufficiency and requires hemodialysis (process of prurifying the blood when kidneys aqre not functioning propery)" indicated under interventions, "Monitor vital signs pre and post dialysis." The facility policy and procedure titled, "Renal Dialysis, Care of Residents" dated December 2013, indicated in, "Standard 2. Access site care (fistula/graft) is checked for condition and patency every shift except on return from the dialysis unit ...Routine Access Site Care Guidelines 2. Inspect total access site for color, warmth, redness, edema, pain and drainage once per shift. 3. Routine access checks for a bruit (a pulsation felt of blood flowing through the arteriovenous anastomosis) once per shift. If bruit changes in regularity and depth, NOTIFY PHYSICIAN IMMEDIATELY ...." The facility policy and procedure titled, "Documentation Principles," dated April 2010, indicated, "Resident's health record shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each resident." 3. During an observation of Resident 35 on March 25, 2019 at 8:59 AM, she was lying in bed, awake and responded verbally to greetings. A review of Resident 35's clinical record indicated she was admitted on February 12, 2019 with diagnoses of chronic kidney disease (kidneys are damaged and cannot filter blood leading to renal failure), anxiety disorder (feelings of worry or fear), and hypertension (high blood pressure). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 12 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Admission MDS, with ARD (assessment reference date) of February 19, 2019, indicated that section N0410 (medication received) was coded (0) zero to reflect that Resident 35 did not receive antipsychotic (medication for treating psychosis) in the past seven days. A review of MDS, Section N0450 (antipsychotic medication review) was coded as one (1) to reflect response as in "Yes" which indicated antipsychotics were received on a routine basis only. During an interview with MDS Nurse on March 28, 2019 at 9:50 AM, the admission MDS was reviewed. MDS Nurse confirmed Resident 35 had no antipsychotic medication ordered. Section N0450 (medication) was coded as "YES." MDS Nurse stated that was an error and should have been coded as "NO." During a review of Resident 35's February 2019 recapitulation (summary of physician orders) with MDS Nurse, he confirmed that Resident 35 was not on any antipsychotic medication ordered since admission. A review of the MDS Section Z (Assessment Administration) was signed as completed by a licensed vocational nurse, on February 25, 2019 certifying the information entered in the MDS accurately reflected resident assessment. A review of the facility policy and procedure titled, "Resident assessment Instrument," revised October 2010 indicated, "Purpose of Assessment: . . .4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her the highest practicable level of functioning. . . 7. Certifying Accuracy: All persons who have completed any portion of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 13 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE MDS Resident Assessment Instrument form must sign such document attesting to the accuracy of such information."

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 04/24/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure: a. Hardened brown food residue was cleaned off the top of the steam table b. Grey sticky residue was cleaned off the base FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 14 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of the food blender c. Brown and black particles of residue was cleaned off the top of the dishwasher machine These failures had the potential to contaminate food prepared in the kitchen or contaminate cleaned dishware that lead to a food borne illness. Findings: a. During an initial tour of the kitchen observation on March 25, 2019 at 8:18 AM, a brown, hard food residue was seen on the top of the steam table near the edges. During a concurrent interview with the Dietary Services Supervisor (DSS), she acknowledged the unclean equipment and stated, "I will clean it off." b. During an initial tour of the kitchen observation on March 25, 2019 at 8:18 AM, a grey sticky substance was seen and felt on the base of the blender. During a concurrent interview with the Dietary Services Supervisor (DSS), she acknowledged the unclean equipment and stated, "I will clean it off." c. During an observation on March 27, 2019 at 5:32 AM, black and brown particles of residue were on the top of the dishwasher machine. An air vent was directly above the dishwasher machine. During a concurrent interview with the DSS, when asked what was on top of the dishwasher machine, the DSS replied, "It is from the vent they cleaned yesterday, we will clean it up." The DSS acknowledged black and brown FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 15 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residue was on top of the dishwasher machine. The facility policy and procedure titled, "Cleaning Instructions: Food Preparation Appliances" dated 2010, indicated, "6. Clean the outer surface of the appliance with a clean cloth that has been moistened with hot, soapy water. Follow with a hot water rinse. Do not immerse the base of the appliance in water."

F836 SS=D License/Comply w/ Fed/State/Locl Law/Prof Std CFR(s): 483.70(a)-(c)

F836 04/24/2019 §483.70(a) Licensure. A facility must be licensed under applicable State and local law. §483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. §483.70(c) Relationship to Other HHS Regulations. In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 16 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to report to the California Department of Public Health a fall resulting in major injury affecting the health and safety of one sampled resident (Resident 2). This failure to report an incident resulted in a violation of Title 22 which requires facilities to report unusual occurrences to CDPH within 24 hours. During an observation on March 25, 2019 at 3:21 PM, Resident 2 laid in her bed in a gown. A wheelchair and front wheel walker (FWW) were in the room near her bedside. During an interview on March 25, 2019 at 3:50 PM, Resident 2 stated she quit smoking because she had a fall in the smoking area. During an observation of the smoking area on March 28, 2019 at 2:12 PM, the smoking area had a tent covering (a veranda), a metal object for cigarette butts, four yellow parking curb marking the area, and a red picnic bench down a slope from the tented area. During a review of the clinical record on March 28, 2019 at 3:24 PM, the document titled, "Nursing Progress Note," dated November 27, 2019 indicated Resident 2 went out to the smoking area at 4:45 AM accompanied by CNA 2. RN 2 noted CNA 2 came to her 10 minutes later reporting the fall. RN 2 assessed Resident 2 noting, "the resident was in pain, a cut was on the left side of the forehead with a little bleeding and the left foot was under her." The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 17 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE progress note indicated 911 was called at 5 AM, Resident 2's responsible party and physician was notified at 6:30 AM. Another document titled, "Nursing Progress Note," dated November 30, 2019 indicated Resident 2 was readmitted from [hospital name] after a fall with a diagnosis of right ankle fracture. Resident 2 was in a cast. During an observation on March 28, 2019 at 3:49 PM, the Director of Nurses sat at her computer reviewing the risk management and progress notes in the computer software application of an electronic health care record system. During a concurrent interview on March 28, 2019 at 3:49 PM, with the DON, she confirmed she could not locate any report to CDPH (California Department of Public Health) regarding Resident's 2 fall resulting in injury. When asked how the facility tracks reporting of incidents, the DON replied, "I would put them under the action tab under risk management where we also put our IDT meeting notes." The DON stated she did not see anything in electronic health record about reporting the fall and would have to check with the Administrator to see what he had in his records." During an interview on March 28, 2019 at 4:06 PM, the Administrator stated, "I have no record of a report to CDPH. I did not report it because it was a witnessed fall."

F880 SS=K Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 04/24/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 18 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 19 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the glucometer (device used to check blood sugar) was disinfected, before and after residents' use, according to the facility policy and procedure and manufacturer's maintenance guidelines for five out of 17 sampled residents (Residents 4, 15, 18, 25, and 49) in the universe of 19 residents, when; A. Registered Nurse 1 (RN 1) did not disinfect the glucometer used between Residents 4,15, and 49. B. Licensed Vocational Nurse 1 (LVN 1) did not disinfect the glucometer used between Residents 18 and 25. These failures created an overall danger of transmission of blood borne infection (disease FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 20 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE that can be spread through contaminated blood and other body fluids) to all residents who shared potentially contaminated glucometer. Findings: A. During a medication pass observation on March 27, 2019 at 5:41 AM, Registered Nurse (RN 1) was preparing to perform a blood glucose test to Resident 4. RN 1 did not disinfect the glucometer before and after testing Resident 4's blood sugar. A review of Resident 4's admission record indicated Resident 4 was admitted to the facility on December 12, 2018 with a diagnosis of Type 2 Diabetes Mellitus (high blood sugar). During an interview with RN 1 on March 27, 2019 at 5:56 AM, RN 1 stated he was going to do the blood sugar test of Resident 15. RN 1 went to Resident 15's room and proceeded to use the glucometer machine. RN 1 did not disinfect the glucometer device before and after use. RN 1 stated there was only one glucometer device on the medication care he was using. A review of Resident 15's admission record indicated Resident 15 was admitted to the facility on January 10, 2019 with a diagnosis of Type 2 Diabetes Mellitus. RN 1 then proceeded to go to Resident 49's room. RN 1 used the same glucometer device to test the blood sugar. RN 1 did not disinfect the glucometer device before and after use. A review of Resident 49's admission record indicated Resident 49 was admitted on September 8, 2016 with a diagnosis of Type 2 Diabetes mellitus. During an interview with RN 1, on March 27, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 21 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2019, at 7:00 AM, he stated that upon start of his work shift he cleaned the glucometer machine with "Super Sani cloth Wipes" (EPA Environmental Protection Agency) approved disinfectant/anti-microbial agent (a chemical that destroys bacteria). RN 1 stated that the glucometer machine will be cleaned before the end of the shift. RN 1 confirmed he did not disinfect the glucometer machine before and after in between resident uses. B. During a medication pass observation with Licensed Vocational Nurse (LVN 1) on March 27, 2019 at 6:06 AM, LVN 1 proceeded to do blood sugar test of Resident 18. LVN 1 did not disinfect before and after use of the glucometer. After use, LVN 1 placed the glucometer device on top of the medication cart. A review of Resident 18's admission record indicated Resident 18 was admitted to the facility on January 15, 2019 with a diagnosis of Type 2 Diabetes Mellitus. During an observation on March 27, 2019 at 6:16 AM, LVN 1 proceeded to Resident 25's room. LVN 1 used the same glucometer machine that was used for Resident 18, to check Resident 25's blood sugar. LVN 1 did not disinfect the machine before and after use. A review of Resident 25's admission record indicated Resident 25 was admitted to the facility on January 5, 2018 with a diagnosis of Type 2 Diabetes Mellitus. During an interview with LVN 1, on March 27, 2019 at 7:03 AM, she stated she used Super Sani Cloth to sanitize the glucometer machine. LVN 1 further stated that she never sanitized the glucometer device in between residents use because she only had two residents that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 22 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE use glucometer device. During an interview with Director of Nursing on March 27, 2019 at 7:29 AM, she stated the staff were required to disinfect the glucometer machine before and after use and between residents with disinfectant wipes. A review of the facility's policy and procedure titled, "Obtaining a Finger stick Glucose Level," revised December 2011 indicated, "Procedure: . . . 3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses." A review of the Manufacturer's Guidelines of (Brand Name) Machine Monitoring System under Section Maintenance/Cleaning, dated June 2009 indicated, "Healthcare professionals should wear gloves when cleaning the (Brand Name) Pro Meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. Suggest cleaning the meter between patients." These failures to follow and implement the policies and procedures and manufacturer's guideline resulted in an Immediate Jeopardy (IJ immediate danger of harm) situation. An IJ was identified and called on March 27, 2019 at 11:10 AM, in the presence of the Administrator (ADMIN) and the Director of Nursing (DON). The ADMIN and the DON were informed of the observations, interviews, and record reviews with the facility staff. The facility submitted an acceptable corrective action plan on March 27, 2019 at 2:30 PM as follows: The facility's corrective action plan included in service training of all staff in proper cleaning FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 23 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and disinfecting of the glucometer machine before and after use between resident, use of appropriate disinfectant to clean glucometer, replaced with new glucometers in all medication carts, reassessed all identified residents on blood glucose monitoring for any complication or possible infection and notification of physician of any change in condition, revised the policy and procedure in obtaining finger stick glucose level. The DON and Pharmacy Nurse Consultant will conduct medication pass observation with emphasis of proper technique and proper cleaning and disinfecting of the glucometer machine based on manufacturer guideline. The skills check will be conducted monthly 3 times and quarterly thereafter. The DON and Designee will conduct random daily observation on proper technique in obtaining the finger stick glucose. The DON will report in the QAPI meeting any negative finding and /or concerns related to Licensed Nurse skills and competency related to blood glucose monitoring technique, cleaning, and disinfecting. The IJ was lifted on March 28, 2019 at 2:32 PM in the presence of the ADMIN and the DON after submission of an acceptable corrective action plan. Observation, staff interviews, and record reviews were conducted to ensure the corrective action plan was implemented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 24 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F912 Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) SS=B ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/24/2019 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain the required square footage (sq./ft.) for 11 of 24 rooms. This failure had the potential to limit the freedom of movement and affect the health and safety of the residents who occupied the rooms. Findings: During an interview with the Administrator (Admin) on March 25, 2019 at 8:30 AM, he stated that a letter was sent out to request for room waiver on December 18, 2018. During the observation on March 28, 2019 at 2:40 PM, with the Maintenance Supervisor (MS) the following rooms were measured: Room 1(2 beds) measured 14 x 11 (154 sq./ft.) (77 sq./ft. per person) Room 2 (2 beds) measured 14 x 11 (154 sq./ft.) (77 sq./ft. per person) Room 3 (2 beds) measured 14 x 11 (154 sq./ft.) (77 sq./ft. per person) Room 4 (2 beds) measured 14 x 11 (154 sq./ft.) (77 sq./ft. per person) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 25 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055707 (X3) DATE SURVEY COMPLETED 03/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ONTARIO HEALTHCARE CENTER 1661 S Euclid Ave Ontario, CA 91762 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Room 6 (2 beds) measured 14 x 11 (154 sq./ft.) (77 sq./ft. per person) Room 7 (2 beds) measured 14 x 11 (154 sq./ft.) (77 sq./ft. per person) Room 8 (2 beds) measured 14 x 11 (154 sq./ft.) (77 sq./ft. per person) Room 9 (4 beds) measured 15 x 19 (285 sq./ft.) (71.25 sq./ft. per person) Room 11 (3 beds) measured 9.5 x 13.6 , 10x10 (229.2 sq./ft.) (76.4 sq./ft. per person) Room 14 (3 beds) measured 9.5 x 13.3, 10x10 (226.35 sq./ft.) (75.45 sq./ft. per person) Room 21 (2 beds) measured 14 x 9 (126 sq./ft.) (63 sq./ft. per person) During an observation on March 28, 2019 at 3:30 PM, the were no issues or concerns with resident transfer and use of device in the rooms. There were no complaints or issues in the lack of space from the residents. The devices used by residents in the rooms did not impose safety hazards. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WMD311 Facility ID: CA240000090 If continuation sheet 26 of 26