Health inspection·December 28, 2023

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 notify the resident ' s family member of changes in the resident ' s condition when laboratory results were received with abnormal findings for one of three sampled residents (Resident 1). This failure prevented Resident 1 and his family to express concerns, raise questions, and participate in the plan of care for Resident 1. Residents Affected - Few Findings: A review of Resident 1 ' s admission Record (AR- a document containing basic information of a resident), dated December 28, 2023, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included acute (sudden in onset) respiratory failure, adult failure to thrive (decline in older adults ' health and ability), and pancytopenia (having low levels of all three blood cell types: red blood cells, white blood cells and platelets) among others. The AR further indicated nieces, son, sister, and brother as contact persons. A review of Resident 1 ' s Physician Order, with order date December 15, 2023, indicated, May do CBC (Complete Blood Count), CMP (Complete Metabolic Panel), uric acid (a chemical created when the body breaks down substances called purines) one time only until 12/19/2023 . A review of Resident 1 ' s laboratory results for CMP and CBC, with test reported date December 19, 2023, indicated the following blood test results are outside of normal ranges: a. Glucose (amount of sugar in blood). b. Creatinine (waste product that comes from the digestion of protein in your food). c. Chloride (an electrolyte that helps maintain acid-base balance in your body). d. Carbon dioxide (measures the amount of carbon dioxide in the blood). e. AST/SGOT (aspartate aminotransferase/serum glutamic-oxaloacetic transaminase- a blood test that looks for liver damage). f. Alkaline Phosphatase (commonly used to diagnose liver damage or bone disorders). g. BUN/Creatinine ratio (an indicator of kidney health). h. WBC (White Blood Cells- cells involved in protecting the body against both infectious disease (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555108 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 12/28/2023 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)