Ontario Healthcare Center

In the surveyor’s words

From the most serious findings on record at Ontario Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF925Feb 20, 2026

  Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 55 out of 55 residents when a live roach was observed in kitchen food preparation area.This failure had the potential to contaminate food, food preparing surfaces, and equipment which will place residents at risk for food borne illness and infections.During a concurrent observation and interview on February 17, 2026, at 12:28 PM, with Dietary Supervisor (DS- a person who oversees food services in the facility), in the kitchen, a live roach was observed crawling on the wall above the kitchen sink. The DS caught the roach with a piece of aluminum foil. The DS stated she was not sure how the roach came inside the kitchen. […]

• No harm, potential for more than minimal, widespreadF812Oct 24, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF812Feb 14, 2022

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices in the kitchen when: 1. One table mounted can opener was observed with rust (a reddish-brown brittle coating form on iron when is exposed to air and moisture) in the slide bar (used to adjust different can sizes) near the knife, and in the washer inside the slide bar. 2. The ice machine had a hard deposit of white-greenish-black buildup inside the ice machine. These failures had the potential to contaminate residents' food and cause foodborne illnesses to a population 49 of 51 medically compromised residents who received food from the kitchen. […]

• No harm, potential for more than minimal, widespreadF814Feb 14, 2022

  Based on observation, interview, and record review, the facility failed to ensure proper disposal of garbage and refuse when one of two lids on garbage receptacles, was not closed and there was trash on the ground. This failure had the potential to attracts pests. Findings: During a concurrent observation and interview on February 9, 2022, at 1:11 PM, with the Supervisor of Maintenance Service (SMS), in the garbage storage area, located outside the facility, one of two garbage containers was not closed, and there was trash on the ground between the containers. […]

• No harm, potential for more than minimal, patternF880Feb 14, 2022

  Based on observation, interview, and record review, the facility failed to ensure staff followed safe infection control practice as evidenced by staff did not perform hand hygiene (cleaning hand) after touching contaminated (dirty) areas and before handling a resident's meal tray for one of 20 sampled residents (Resident 9). This failure had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to a vulnerable resident whose health conditions are already compromised. Findings: During a review of Resident 9's Admission Record (Patient demographic), not dated, the Admission Record indicated, Resident 9 was admitted into the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]