Health inspection·June 20, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to maintain a safe and hazard free environment when a fire incident occurred on May 22, 2023. One of the facility's employee's battery pack caught on fire while it was stored in one of two oxygen storage rooms. This failure had the potential to cause smoke inhalation, burns, explosion, and even death to 133 residents in the facility. Findings: During an observation on May 31, 2023, at 10:17 AM, in the Oxygen Storage Room, by the Sub-Acute Unit (inpatient unit for residents needing services more intensive than typically provided in a skilled nursing facility), fifty-eight portable oxygen tanks were inside the storage room. The tile where the fire had occurred had black residue. During an interview, on May 31, 2023, at 10:31 AM, with Respiratory Therapist (RT 1), RT 1 stated he was checking on his patients, when he heard the fire alarm, he saw smoke coming from the oxygen storage room in the sub-acute unit . RT 1 further stated he grabbed a fire extinguisher and attempted to put out the fire, but the sprinkler system had already been activated. RT 1 stated his next step was to close the door to the oxygen storage room and start closing all the resident rooms doors. During an interview with the Sub-Acute RN, on May 31, 2023, at 10:42 AM, the Sub-acute RN stated the fire department came to the facility and asked the staff to step outside the facility. Sub-acute RN further stated the fire department stated that there was no need to evacuate the ventilated residents. Sub-acute RN stated she was informed by the fire department that the cause of the fire was a battery pack inside of an employee's backpack stored inside the oxygen storage room. During an interview with Respiratory Therapist 2 (RT 2), on June 2, 2023, at 3:55 PM, the RT 2 stated he left his backpack inside the oxygen storage room. RT 2 further stated he should not have left his backpack in the oxygen storage room. During an interview with the Director of Nursing (DON), on May 31, 2023, at 11:53 AM, the DON stated the expectation for employees is to store their belongings in the facility provided lockers. The DON further stated an oxygen storage room is not the expected location for employees to store their personal belongings. The DON stated there was no policy and procedure for the storage of employee's personal belongings. During a concurrent interview and record review on May 31, 2023, at 11:53 AM, of the facility's (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: 056444 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 056444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Extended Care Hospital of Montclair 9620 Fremont Ave Montclair, CA 91763 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)