Health inspection·March 3, 2022

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that preventative maintenance was performed by the due date as detailed on one out of five oxygen concentrators (an electrically powered medical device that uses environmental air and delivers it to a patient in the form of supplemental oxygen) being used within the facility. Residents Affected - Few This failure had the potential to cause harm to residents due to inadequate oxygen levels being produced by the machine. Findings: During an observation on February 28, 2022, at 1:18 PM, in resident room [ROOM NUMBER]-B, an oxygen concentrator was noted to be present with a label detailing that preventative maintenance was last performed on [DATE], and was due by April, 3, 2021. During an interview on [DATE], at 3:22 PM, with a certified nursing assistant (CNA 1), she stated that preventative maintenance should have been completed by [DATE]. During an interview on [DATE], at 3:28 PM, with a licensed vocational nurse (LVN 1), she stated that she did not know why the machine was in use when the preventative maintenance should have been completed before [DATE]. During an interview on [DATE], at 4:23 PM, with the Director of Staff Development (DSD), she stated that the machine should not be in use with expired preventative maintenance. During a record review of a facility provided document titled, [Name of manufacturer, undated, it outlines the following, Chapter 6: Maintenance .6.0.4 Oxygen concentration verification, [Name of manufacturer] recommends verifying the oxygen concentration level a minimum of every two (2) years . 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 03/03/2022 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)