Health inspection·April 5, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete plan for each resident. 2. The care plan interventions are derived through analysis of the information gathered as part of the comprehensive assessment .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change . The facility policy and procedure (P&P) titled Falls and Fall Risk, Managing dated March 2018 Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Documentation: when a resident falls, the following information should be recorded in the resident's medical record: .Interventions, first aid or treatment administered. 4. Notification of the physician and family, as indicated .6. Appropriate interventions taken to prevent future falls. Event ID: Facility ID: 555108 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inland Christian Home 1950 S Mountain Ave Ontario, CA 91762 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to document a change of condition to include revised interventions to decrease further falls for one of three residents (Resident 3 ). This failure resulted in the incomplete documentation of Resident 3 ' s clinical record. Residents Affected - Few Findings: An abbreviated survey was conducted on March 28, 2023, at 10:12 AM, to investigate a complaint regarding Accidents. A review of Resident 3's face sheet (contains demographic information and diagnoses) indicated that Resident 3 was admitted to the facility on [DATE], with diagnoses which included: fracture of left Femur (broken thigh bone), osteoarthritis (degenerative joint disease), and dementia (memory impairment). During a review of the clinical record for Resident 3, the Nurses Note, dated March 5, 2023, at 1:09 PM indicated After lunch, resident noted attempting to ambulate to the bathroom without assistance. Resident suddenly lost balance. Staff were able to guide the resident down to the floor safely. Multiple staff members assisted resident into his wheelchair. Licensed staff member assessed resident. No complaint of pain. Will continue to closely monitor . This Nurses note was signed by Licensed Vocational Nurse (LVN 1). During a review of the clinical record for Resident 3 with Licensed Vocational Nurse (LVN 1), on March 28, 2023, at 12:46 PM, LVN 1 stated, The note on March 5, 2023, that should have been documented as a fall. He was my resident. That was my note. The SBAR (change in condition) was not done. The clinical record did not indicate that a Change of Condition was documented for the fall to include notification of the physician and the responsible party. The facility did not provide documentation that the Change in Condition and or Fall protocol were documented in Resident 3 ' s chart for this fall. During an interview with the Director of Nursing on March 28, 2023, at 1:25 PM, the DON stated, A Change in Condition should have been done for the fall on March 5, 2023. The facility policy and procedure (P&P) titled Falls and Fall Risk, Managing dated March 2018 Based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Definition: According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is stall a fall .Documentation: when a resident falls, the following information should be recorded in the resident ' s medical record: 1. The condition in which the resident was found. 2. Assessment data, including vital signs and any obvious injuries. 3. Interventions, first aid or treatment administered. 4. Notification of the physician and family, as indicated. 5. Completion of a falls risk assessment. 6. Appropriate interventions taken to prevent future falls. The signature and title of the person recording data. Reporting: 1. Notify the following individuals when a resident falls: a. Residents family; b. The attending Physician c. The Director of Nursing Services; and d. The Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555108 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inland Christian Home 1950 S Mountain Ave Ontario, CA 91762 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Supervisor on duty. 2. Report other information in accordance with facility policy and procedure and professional standards of practice. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555108 If continuation sheet Page 4 of 4