Inland Valley Care and Rehab: Respiratory Care Failures - CA
The August 22 complaint inspection turned up 27 separate deficiencies at the facility. One of them, cited under the regulatory category for respiratory care, documented a pattern of failures serious enough that inspectors determined residents faced potential for more than minimal harm. No actual injury was recorded. But for people whose lungs cannot do the work on their own, the margin between a care lapse and a crisis is narrow.
The respiratory citation was classified at Scope/Severity Level E, meaning inspectors found not an isolated incident but a pattern, something happening across more than one resident or more than one occasion. That distinction matters. A single mistake by a single aide on a single shift is one kind of problem. A pattern means the failure was built into how the facility was operating.
Inland Valley Care and Rehabilitation Center sits in Pomona, in the eastern stretch of Los Angeles County, a region where nursing home beds serve a largely working-class population with limited options for long-term care. The facility reported to inspectors that it had corrected the respiratory care deficiency by August 27, five days after the inspection closed.
Whether that correction holds is a separate question.
Twenty-seven deficiencies in a single inspection is a significant number. Inspectors working a complaint survey are already responding to a specific allegation, which means they arrived with a reason to look closely. What they found went well beyond whatever triggered the original complaint. Respiratory care was one item on a list that stretched to nearly three dozen problems across the facility's operations.
The respiratory care tag, F0695, covers a range of interventions: the proper use and maintenance of oxygen delivery systems, the management of residents on mechanical ventilation, the administration of nebulizer treatments, the monitoring of residents whose breathing requires clinical support. When inspectors cite a pattern under that tag, it means something in the facility's approach to those interventions was consistently falling short.
For residents on supplemental oxygen, an equipment failure or a care lapse does not produce a slow, visible decline. It produces a drop in blood oxygen that can trigger confusion, cardiac stress, and organ damage before a family member or a passing nurse notices anything is wrong. Residents with chronic obstructive pulmonary disease, congestive heart failure, or post-COVID lung damage have no reserve capacity to absorb that kind of gap.
The facility's five-day turnaround on the correction date is the kind of timeline that raises its own questions. Correcting a pattern, by definition, requires more than fixing a piece of equipment or retraining one employee. A pattern means the problem was systemic. Five days is enough time to write a new policy. It is rarely enough time to change how a staff consistently behaves at two in the morning when the supervisor is not on the floor.
Inland Valley Care and Rehabilitation Center will be subject to a revisit inspection to verify that the cited deficiencies have been addressed. That visit has not yet occurred, and the facility's compliance status remains open.
What the inspection record does not contain is the name of a single resident who experienced the respiratory care failures. The report documents potential for harm, a pattern of deficient practice, and a correction date. It does not say whose oxygen concentrator was malfunctioning, whose nebulizer treatment was skipped, or who spent a night breathing harder than they should have because something in the care system was not working.
Those residents are still there. The 27 deficiencies document a facility that was not operating the way it should have been in August 2025. Some of those deficiencies carry correction dates. None of them carry guarantees.
For families with a relative at Inland Valley Care and Rehabilitation Center, the inspection report is available through the Medicare Care Compare website. It is worth reading in full, not for the regulatory language, but for the shape of what inspectors found when they walked through the doors with a complaint in hand and kept finding problems long after they had answered it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Inland Valley Care and Rehabilitation Center from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 11, 2026 · Our methodology
INLAND VALLEY CARE AND REHABILITATION CENTER in POMONA, CA was cited for violations during a health inspection on August 22, 2025.
The August 22 complaint inspection turned up 27 separate deficiencies at the facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.