Claremont Heights: Vaccination Consent Failures - CA
Federal inspectors found Claremont Heights Post Acute violated vaccination protocols for multiple residents during a February inspection, creating a system where some got unwanted shots while others who wanted protection never received it.
The facility gave Resident 2 a flu vaccination on October 1, 2024, but kept no record of educating the resident about risks and benefits. No signed consent form existed in the medical record, Director of Nursing told inspectors during a February 26 interview.
"An informed consent was needed from residents to ensure the residents were aware of risks and benefits of receiving a vaccination," the nursing director said. "It was the resident's right to give an informed consent."
But the facility's own policies required exactly what didn't happen. The nursing home's influenza prevention policy, revised in September 2020, mandated that residents receive education about vaccine risks and benefits before any shot. Staff must document that education occurred and obtain written consent.
The policy also required recording vaccine lot numbers on immunization logs. Inspectors found no lot number documented for Resident 2's flu shot.
Meanwhile, other residents who wanted vaccines never got them despite signing consent forms.
Resident 4, admitted February 5 with chronic lung disease and muscle weakness, signed informed consent forms agreeing to receive both pneumonia and flu vaccinations on the day of admission. The nursing director confirmed staff never administered either vaccine.
Resident 3 faced the same problem. The resident's representative signed a pneumonia vaccine consent form on January 10, the day of admission. Staff never gave the shot.
The COVID-19 vaccination program proved equally chaotic. Resident 4 signed a COVID vaccine consent form on February 5 but never received the vaccination, inspectors found.
Resident 5 got a COVID shot on April 24, 2024, but the facility kept no documentation showing the resident received required education about vaccine benefits and risks. No signed consent form existed for that vaccination either.
Resident 2 never received an offer for the latest COVID vaccination, according to the nursing director's review of medical records. "If Resident 2's medical record did not contain documentation that Resident 2 was offered the COVID-19 vaccination then the facility staff did not offer the COVID-19 vaccination to Resident 2," the nursing director told inspectors.
The facility's March 2022 COVID vaccination policy required offering vaccines to all residents. A more recent respiratory virus prevention plan from January 2025 emphasized the importance of vaccination programs for infection control.
Staff vaccination tracking proved nonexistent. Licensed Vocational Nurse 1, hired as the facility's infection preventionist on February 11, told inspectors the nursing home "did not have a system or documentation to keep track of the COVID-19 vaccination status of the facility's staff."
This contradicted the facility's own policies requiring staff vaccination records and consent or declination forms in confidential medical files.
The vaccination failures affected residents with serious underlying conditions that made them vulnerable to respiratory infections. Resident 1 lived with paralysis from stroke, respiratory failure, and seizure disorder. Resident 2 had diabetes and high blood pressure. Resident 4 suffered from chronic lung disease and fluid buildup in the lungs.
Resident 5, who received an undocumented COVID shot, had Alzheimer's disease, spinal problems, and obesity. The resident required complete assistance from staff for basic hygiene and dressing.
Some residents also refused vaccinations, but the facility failed to document those refusals properly. Resident 1 declined the 2024-2025 flu vaccine, but staff never provided education about vaccination benefits and risks. No signed declination form existed in the medical record, violating facility policy requiring documentation of vaccine refusals.
The inspection revealed a fundamental breakdown in the nursing home's immunization program during the 2024-2025 flu season and ongoing COVID vaccination efforts. Residents who wanted protection couldn't get it. Others received shots without proper consent. Staff vaccination status remained unknown.
Federal inspectors concluded these failures created potential for COVID-19 spread among residents, staff, and visitors throughout the 590 South 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 2025-02-27 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 February 27, 2025.
The facility gave Resident 2 a flu vaccination on October 1, 2024, but kept no record of educating the resident about risks and benefits.
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.