Claremont Heights: Moldy Showers, Medication Delays - CA
The resident, who has been paralyzed in both arms and legs since his April 2024 admission, returned from an eight-day hospital stay on December 15 with clear physician orders to continue receiving baclofen and diazepam for muscle spasms. The facility received the telephone orders at 12:23 a.m. on December 16.
But medication records show the resident didn't receive his baclofen until December 17 and went without diazepam until December 27. "I felt like I was withdrawing when he did not get the diazepam," the resident told inspectors on January 3. "I was really uncomfortable."
The resident's physician confirmed the medications should have been continued immediately upon his return. "Resident 1 could have experienced withdrawal symptoms when Resident 1 was not getting diazepam," the doctor said during a telephone interview with inspectors. "Withdrawal symptoms could include higher anxiety, changes in vital signs, and hallucinations."
The Director of Nursing acknowledged the resident had been taking diazepam since May 2024 and was "at risk of going through withdrawal" without it. She said withdrawal could cause "restlessness, shivering, sweating, and muscle spasms" but explained the pharmacy required additional authorization before dispensing the controlled substance.
Meanwhile, residents complained about the deteriorating condition of the facility's four shower rooms. During interviews, residents described showers that were "corroded and moldy" with grout falling out and a smell that made them "feel dirty and uncomfortable."
Inspectors confirmed the residents' complaints during walkthroughs with facility staff on January 2 and 3. In one shower room, they found missing floor tiles in the shower area and a rusted door frame pulling away from the wall. Another shower room had grout missing between tiles on the half wall, with black discoloration where dirt had built up in the gaps.
"The missing grout created a risk of bacteria to build up inside the area between the tiles," the facility's Infection Preventionist told inspectors. "Missing grout also meant staff were not able to clean the area effectively."
The Infection Preventionist confirmed that rusted door frames "could harbor germs" and that staff "were not able to clean the rusted door frame in the condition it was in." Missing shower floor tiles were identified as "a potential harboring place for bacteria."
In a third shower room, inspectors observed a rusted metal door frame and a line of black and green discoloration on the wall next to the shower area. The shower floor was missing tiles.
The Maintenance Supervisor confirmed the problems during the inspection tour, acknowledging missing floor tiles and rusted, deteriorating door frames in multiple shower rooms.
The facility's own policy requires providing residents with "a safe, clean, comfortable, and homelike environment" with attention to "cleanliness and order" and "pleasant, neutral scents." The policy emphasizes creating a "personalized, homelike atmosphere" for residents.
But residents described a different reality. One resident with diabetes and partial paralysis from a stroke said the shower rooms "smelled like mold" and had missing tiles. The quadriplegic resident, who depends entirely on staff for bathing, toileting, and personal hygiene, specifically complained about grout falling out of the showers.
The medication delay violated federal requirements for facilities to provide appropriate treatment according to physician orders. The resident had been cognitively intact throughout his stay, able to make daily decisions about his care but physically dependent on staff for all basic needs due to his paralysis and chronic pain syndrome.
Federal inspectors classified both violations as having minimal harm but potential for actual harm to residents. The shower room conditions affected multiple residents, while the medication delay specifically impacted the quadriplegic resident who experienced withdrawal symptoms during the 11-day gap in his prescribed treatment.
The inspection was conducted January 2-3, 2025, in response to a complaint about conditions at the 590 S. Indian Hill Boulevard facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Claremont Heights Post Acute from 2025-01-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
CLAREMONT HEIGHTS POST ACUTE in CLAREMONT, CA was cited for violations during a health inspection on January 3, 2025.
The facility received the telephone orders at 12:23 a.m.
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.