Ontario, CA

Inland Christian Home

4-star overall rating with 4-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

1950 S Mountain Ave, Ontario, CA

(909) 983-2315

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

59

Certified beds

Average residents

59

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1979-02-16

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.40

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

1.23

Licensed practical nurse staffing · state 1.22 · national 0.87

Aide hours / resident day

2.59

Nurse aide staffing · state 2.64 · national 2.35

Total nurse hours

4.21

All reported nurse hours · state 4.51 · national 3.89

Licensed hours

1.63

RN + LPN hours · state 1.87 · national 1.54

Weekend hours

3.73

Weekend nurse staffing · state 4.08 · national 3.43

Weekend RN hours

0.23

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.40

CMS adjusted RN staffing hours

Adjusted total hours

4.26

CMS adjusted total nurse staffing hours

Case-mix index

1.35

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

48%

Annual nurse turnover · state 38% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,943

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

34.51

Composite VBP score used to determine payment impact.

Payment multiplier

0.9884

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.41

Performance 20.32% · Measure score 2.41 · Achievement 2.41 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

1.34

Baseline 7.21% · Performance 7.43% · Measure score 1.34 · Achievement 1.34 · Improvement 0

Total nurse turnover

6.61

Baseline 64.29% · Performance 36.67% · Measure score 6.61 · Achievement 6.61 · Improvement 6.50

Adjusted total nurse staffing

3.45

Baseline 3.76 hours · Performance 4.06 hours · Measure score 3.45 · Achievement 3.45 · Improvement 0.97

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 11.04%
10.72%
0.3 pts worse
No Different than the National Rate · Eligible stays 67 · Observed rate 11.94% · Lower 95% interval 8.15%
Discharge to community 48.47%
50.57%
2.1 pts worse
No Different than the National Rate · Eligible stays 56 · Observed rate 39.29% · Lower 95% interval 35.63%
Medicare spending per beneficiary 1.4
1.02
0.4 pts worse
Drug regimen review with follow-up 97.3%
95.27%
2 pts better
Numerator 36 · Denominator 37
Falls with major injury 2.7%
0.77%
1.9 pts worse
Numerator 1 · Denominator 37
Discharge self-care score 44.44%
53.69%
9.2 pts worse
Numerator 12 · Denominator 27
Discharge mobility score 59.26%
50.94%
8.3 pts better
Numerator 16 · Denominator 27
Pressure ulcers or injuries, new or worsened 8.11%
2.29%
5.8 pts worse
Numerator 3 · Denominator 37 · Adjusted rate 5.83%
Healthcare-associated infections requiring hospitalization 7.43%
7.12%
0.3 pts worse
No Different than the National Rate · Eligible stays 45 · Observed rate 8.89% · Lower 95% interval 3.9%
Staff COVID-19 vaccination coverage 1.27%
8.2%
6.9 pts worse
Numerator 1 · Denominator 79
Staff flu vaccination coverage 28.57%
42%
13.4 pts worse
Numerator 26 · Denominator 91
Discharge function score 44.44%
56.45%
12 pts worse
Numerator 12 · Denominator 27
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to patient 100%
96.28%
3.7 pts better
Numerator 21 · Denominator 21
Resident COVID-19 vaccinations up to date 38.1%
25.2%
12.9 pts better
Numerator 8 · Denominator 21

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.2
2.3
0.1 pts better
1.9
0.3 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.6 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 0.7
1.6
0.9 pts better
1.8
1.1 pts better
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 94.5%
98.5%
4 pts worse
93.4%
1.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 82.1% · Q3 100.0% · Q4 100.0% · 4Q avg 94.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 88.6%
98.2%
9.6 pts worse
95.5%
6.9 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.6%
Percentage of long-stay residents experiencing one or more falls with major injury 0.0%
1.6%
1.6 pts better
3.3%
3.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 0.7%
6.8%
6.1 pts better
11.4%
10.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7%
Percentage of long-stay residents who lose too much weight 7.1%
4.1%
3 pts worse
5.4%
1.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 0.0% · Q3 12.1% · Q4 9.1% · 4Q avg 7.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 12.0%
13.7%
1.7 pts better
19.6%
7.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 13.9% · Q3 11.1% · Q4 10.8% · 4Q avg 12.0%
Percentage of long-stay residents who received an antipsychotic medication 0.0%
14.2%
14.2 pts better
16.7%
16.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.4%
0.4 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened 12.5%
11.0%
1.5 pts worse
16.3%
3.8 pts better
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 23.4%
10.7%
12.7 pts worse
14.9%
8.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 39.1% · Q3 10.7% · Q4 6.7% · 4Q avg 23.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 4.8%
1.0%
3.8 pts worse
1.0%
3.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 5.4% · Q3 1.8% · Q4 4.4% · 4Q avg 4.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 7.1%
1.2%
5.9 pts worse
1.7%
5.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 7.9% · Q3 0.0% · Q4 2.9% · 4Q avg 7.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 21.8%
10.9%
10.9 pts worse
19.8%
2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 33.4% · Q2 13.8% · Q3 19.3% · Q4 17.7% · 4Q avg 21.8%
Percentage of long-stay residents with pressure ulcers 3.6%
4.7%
1.1 pts better
5.1%
1.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 6.2% · Q3 1.6% · Q4 1.7% · 4Q avg 3.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 94.6%
94.0%
0.6 pts better
81.7%
12.9 pts better
Short Stay · 2024Q4-2025Q3 · Q1 89.4% · Q2 90.5% · Q3 95.6% · Q4 100.0% · 4Q avg 94.6%
Percentage of short-stay residents who had an outpatient emergency department visit 5.2%
11.2%
6 pts better
12.0%
6.8 pts better
Short Stay · 20240701-20250630 · Adjusted 5.2% · Observed 5.0% · Expected 10.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 0.0%
1.5%
1.5 pts better
1.6%
1.6 pts better
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 93.1%
93.2%
0.1 pts worse
79.7%
13.4 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 29.6%
23.2%
6.4 pts worse
23.9%
5.7 pts worse
Short Stay · 20240701-20250630 · Adjusted 29.6% · Observed 27.5% · Expected 22.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-19 · Fire 2025-06-19

8 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2024-05-10 · Fire 2024-05-10

14 health deficiencies

Top issue: Environmental (3 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2022-03-03 · Fire 2022-03-03

5 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

6 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-06-19

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2025-07-01

F · Potential for more than minimal harm 2025-06-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-07-10

F · Potential for more than minimal harm 2025-06-19

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-07-09

E · Potential for more than minimal harm 2025-06-19

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-07-10

D · Potential for more than minimal harm 2025-06-19

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-07-10

D · Potential for more than minimal harm 2025-06-19

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-07-01

D · Potential for more than minimal harm 2025-06-19

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-07-10

F · Potential for more than minimal harm 2024-05-10

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-05-22

F · Potential for more than minimal harm 2024-05-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-22

D · Potential for more than minimal harm 2024-05-10

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-05-22

D · Potential for more than minimal harm 2024-05-10

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-05-22

D · Potential for more than minimal harm 2024-05-10

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-05-22

F · Potential for more than minimal harm 2022-03-03

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-03-29

D · Potential for more than minimal harm 2022-03-03

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2022-03-29

D · Potential for more than minimal harm 2022-03-03

E35 · Emergency Preparedness Deficiencies

Fire Safety

Provide family notifications of emergency plan.

Corrected 2022-03-29

D · Potential for more than minimal harm 2022-03-03

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2022-03-29

D · Potential for more than minimal harm 2022-03-03

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2022-03-29

D · Potential for more than minimal harm 2022-03-03

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-03-29

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-06-19

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-07-09

E · Potential for more than minimal harm 2025-06-19

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-07-09

E · Potential for more than minimal harm 2025-06-19

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2025-07-09

D · Potential for more than minimal harm 2025-06-19

F638 · Resident Assessment and Care Planning Deficiencies

Health

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected 2025-07-09

D · Potential for more than minimal harm 2025-06-19

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2025-07-09

D · Potential for more than minimal harm 2025-06-19

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-07-09

D · Potential for more than minimal harm 2025-06-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-09

D · Potential for more than minimal harm 2025-06-19

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-07-09

F · Potential for more than minimal harm 2024-05-10

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-06-10

F · Potential for more than minimal harm 2024-05-10

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-06-10

F · Potential for more than minimal harm 2024-05-10

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2024-06-10

E · Potential for more than minimal harm 2024-05-10

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-06-10

E · Potential for more than minimal harm 2024-05-10

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2024-06-10

E · Potential for more than minimal harm 2024-05-10

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2024-06-10

D · Potential for more than minimal harm 2024-05-10

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-06-10

D · Potential for more than minimal harm 2024-05-10

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-06-10

D · Potential for more than minimal harm 2024-05-10

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-06-10

D · Potential for more than minimal harm 2024-05-10

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-06-10

D · Potential for more than minimal harm 2024-05-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-10

D · Potential for more than minimal harm 2024-05-10

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2024-06-10

C · Minimal harm 2024-05-10

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-06-10

C · Minimal harm 2024-05-10

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-06-10

D · Potential for more than minimal harm 2023-12-28

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-01-16

D · Potential for more than minimal harm 2023-04-05

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-04-12

D · Potential for more than minimal harm 2023-04-05

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-04-12

D · Potential for more than minimal harm 2022-03-03

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2022-03-22

D · Potential for more than minimal harm 2022-03-03

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2022-03-22

Penalties and ownership

What sits behind the stars

Ownership

Davis, Susan

Corporate Officer · Individual

0% 2 facilities 2018-05-22
De Hoog, Joe

Corporate Officer · Individual

0% 1 facilities 2015-05-19
Dehaan, Henry

Corporate Officer · Individual

0% 1 facilities 2015-06-06
Groen, Don

Corporate Officer · Individual

0% 1 facilities 2017-05-16
Huizenga, Paul

Corporate Officer · Individual

0% 1 facilities 2017-05-16
Klein, Lois

Corporate Officer · Individual

0% 1 facilities 2015-05-19
Ligtenberg, Georgene

Corporate Officer · Individual

0% 1 facilities 2015-05-19
Stienstra, David

Corporate Director · Individual

0% 1 facilities 1990-09-01
Stienstra, David

W-2 Managing Employee · Individual

0% 1 facilities 1990-09-01
Weide, Henry

Corporate Officer · Individual

0% 1 facilities 2015-06-06
Westra, Joan

Corporate Officer · Individual

0% 1 facilities 2015-05-19
Wiersma, Vince

Corporate Officer · Individual

0% 1 facilities 2016-05-24
Wilson, Helen

Corporate Officer · Individual

0% 1 facilities 2015-05-19
Wolff, Mary

Operational/Managerial Control · Individual

0% 1 facilities 2010-05-01
Wolff, Mary

W-2 Managing Employee · Individual

0% 1 facilities 2007-06-13

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Staffing
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Staffing
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Fines
$2,098

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