Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ontario Healthcare Center during CMS and state inspections, most recent first.
The facility did not adhere to its policy of dating and labeling food items removed from their original containers, as observed by surveyors. Unlabeled and undated bags of corn tortillas and cookies were found in the dry storage. Interviews with the Dietary Supervisor and Administrator confirmed that these items should have been dated to ensure freshness, but were missed.
A facility failed to refer a resident for a Level II PASARR evaluation after the resident was diagnosed with anxiety disorder, PTSD, and major depressive disorder. Despite having intact cognition and active diagnoses, there was no evidence of referral in the medical record. The DON, who was not employed at the time of admission, acknowledged the oversight during an interview.
A facility failed to ensure the accuracy of the PASARR for a resident admitted with an anxiety disorder. The PASARR Level I Screening incorrectly indicated the absence of a serious mental disorder, despite the resident's medical history and MDS assessment showing an active diagnosis of anxiety disorder. The DON acknowledged the PASARR should have been accurate.
A facility failed to implement enhanced barrier precautions for a resident with a G-tube, as required by their infection control policy. An LVN administered medications without wearing a gown, despite the policy mandating gown and glove use during high-contact activities. Staff interviews confirmed the policy requirements, and the Administrator acknowledged the expectation for staff to follow procedures.
The facility did not meet the required room size of 80 sq ft per resident in 11 rooms, with sizes ranging from 69.35 to 78.75 sq ft. Despite this, a CNA reported no impact on care, and the Administrator and DON noted no care issues related to room size.
Failure to Date and Label Food Items
Penalty
Summary
The facility failed to ensure that all food items removed from their original containers were properly dated and labeled, as required by their policy titled 'Labeling and Dating of Food,' revised on 01/03/2018. This policy mandates that all food be dated and labeled to prevent contamination, deterioration, and dehydration. During an initial tour of the kitchen, the surveyor observed four unlabeled and undated bags of corn tortillas in the dry storage. Additionally, a gallon-sized undated bag containing nine snickerdoodle cookies was noted on a shelf in the dry storage during a subsequent kitchen observation. Interviews with the Dietary Supervisor (DS) and the Administrator revealed that all food should be labeled with a use-by date to ensure freshness. The DS acknowledged that the food items should have been dated and labeled, admitting that they must have been missed. The Administrator confirmed that all items should be dated when removed from their original packaging to ensure freshness.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation after the resident was diagnosed with a newly evident mental illness. The resident, admitted on 07/16/2021, had a medical history that included disorders of muscle, neuromuscular dysfunction of the bladder, and functional quadriplegia. The resident received 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. Despite these diagnoses, there was no evidence in the medical record indicating that the resident was referred for a Level II PASARR evaluation. The resident's quarterly Minimum Data Set (MDS) assessment, dated 09/19/2024, showed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, and listed active diagnoses of anxiety disorder, depression, and PTSD. The resident's care plan included focus areas for depression, PTSD, and anxiety disorder, with corresponding medication use. During an interview, the Director of Nursing (DON) stated he was not employed at the facility when the resident was admitted, suggesting a possible gap in continuity of care or oversight regarding the PASARR referral process.
Inaccurate PASARR Screening for Resident with Anxiety Disorder
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) for a resident at the time of admission. The resident was admitted with a medical history that included an anxiety disorder. However, the PASARR Level I Screening conducted the day after admission incorrectly indicated that the resident did not have a serious diagnosed mental disorder, such as an anxiety disorder. This discrepancy was identified during a review of the resident's records, which included an annual Minimum Data Set (MDS) assessment showing an active diagnosis of anxiety disorder. During an interview, the Director of Nursing, who was not employed at the facility at the time of the resident's admission, acknowledged that the PASARR should have been accurate.
Failure to Implement Enhanced Barrier Precautions for Resident with G-tube
Penalty
Summary
The facility failed to ensure staff implemented enhanced barrier precautions (EBP) for a resident with a gastrostomy tube (G-tube), as required by their infection prevention and control program. The facility's policy, dated April 2024, mandates the use of gowns and gloves during high-contact resident care activities, including medication administration for residents with indwelling medical devices like G-tubes. However, during an observation, a Licensed Vocational Nurse (LVN) was noted administering medications to the resident via enteral route while only wearing gloves, contrary to the policy that required both gown and gloves. Interviews with various staff members, including a Registered Nurse, the Director of Staff Development, the Infection Preventionist, and the Director of Nursing, confirmed that the facility's policy required the use of gowns during such procedures. The LVN's failure to adhere to the policy was acknowledged by the Administrator, who stated that the expectation was for staff to follow the facility's procedures to ensure resident safety. The resident involved had a medical history of conditions requiring a G-tube, and the care plan specifically directed staff to use enhanced barrier precautions.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum size of 80 square feet per resident in multiple occupancy rooms. Specifically, 11 out of 24 resident rooms were found to be below this standard, with room sizes ranging from 69.35 to 78.75 square feet per resident. This deficiency was identified through a Client Accommodations Analysis signed by the Administrator. Despite the room size issue, a Certified Nursing Aide reported that the room sizes did not hinder the provision of proper care. Additionally, during an interview, the Administrator and the Director of Nursing stated that there had been no issues with care related to the room sizes.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ontario
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Inland Christian Home | 1.2 mi | — | 0 | 0 |
| Trellis Chino | 2.6 mi | — | 1 | 0 |
| Las Colinas Post Acute | 2.7 mi | — | 3 | 0 |
| Montclair Manor Care Center | 2.7 mi | — | 0 | 0 |
| Ontario Grove Healthcare & Wellness Centre, Lp | 3 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.