Claremont Care Center: Pain Assessment Failures - CA
The resident at Claremont Care Center had been admitted with a history of falling and a fractured right thigh bone that required surgical repair. During physical therapy sessions in April, the patient consistently complained of leg pain despite being pre-medicated with hydrocodone.
On April 7, physical therapist PT 1 documented that the resident "complained of discomfort on Resident 1's left lower extremity despite being pre-medicated." The therapist informed the licensed nurse and agreed to monitor the patient.
But medication records show no evidence the resident received hydrocodone before or after that therapy session. The licensed nurse made no assessment of the patient's pain that day.
Over the following weeks, nurses administered hydrocodone-acetaminophen to the resident five times for severe pain — rating 7 or 8 out of 10 — but never recorded where the pain was located.
The medication was given on April 9 at 10:32 AM for pain level 8, April 14 at 8:56 AM for pain level 8, April 14 at 8:09 PM for pain level 7, April 16 at 8:20 AM for pain level 7, and April 17 at 8:18 AM for pain level 7.
During a therapy session on April 14, PT 2 noted the resident "was pre-medicated prior to the therapy session and Resident 1 continued to complain of pain on left hip and left lower extremity during bed mobility exercises."
When inspectors reviewed the medication records with the facility's MDS nurse, she acknowledged the documentation failures. The nurse stated "it was important for licensed nurses to document thoroughly such as the location of resident's pain to provide appropriate care, treatment, and notify the doctor if necessary."
Licensed nurse LVN 1, who administered the hydrocodone on four of the five occasions, told inspectors she failed to document the pain location despite knowing proper protocol. She said when residents report pain, nurses "should ask the location, intensity, and onset of the pain, and what triggered the resident's pain."
LVN 1 acknowledged the documentation failure "put Resident 1 at risk for missed or delayed diagnosis, inappropriate treatment, ineffective pain relief, and delay in timely interventions which can further worsen any injury residents may have."
She could not recall where the resident's pain was located during any of the medication administrations.
The physical therapist who worked with the resident on April 7 later told inspectors the patient "refused to attempt standing or getting out of bed and began to exhibit agitation." The resident "wanted to go back to bed as Resident 1 complained of discomfort on his left lower extremity" and "was guarding his left leg due to complaints of persistent pain."
PT 1 said she walked to the nurses' station to inform LVN 4 about the resident's left leg discomfort, and the nurse "agreed to monitor Resident 1." But LVN 4 later told inspectors she "could not remember being informed by PT 1 about Resident 1 having pain and giving Resident 1 pain medication."
Adding to the confusion, both physical therapists later submitted written statements claiming they had documented the wrong leg. They said the patient's pain was actually in the right leg, not the left leg as originally recorded.
The resident was moved from one room to another on April 7, the same day as the first documented therapy pain complaint. The facility's social services director wrote down the transfer date but failed to document the reason for the move.
The social services director told inspectors she "could not recall by memory why the facility decided to move Resident 1 to another room." The admissions coordinator said the facility failed to document a rationale for the room transfer, and neither she nor the social services director could remember why the move occurred.
The assistant director of nursing told inspectors that proper pain assessment requires "rating pain level, asking pain location, aggravating and relieving factors, onset of pain, duration, characteristics, and treatment."
Failure to properly assess and document pain complaints "could result in untreated pain, delayed or missed interventions, decline in physical function, and complications from over or under medication," she said.
The facility's own documentation policy requires comprehensive clinical records that include "treatment, care, response to care, signs, symptoms and progress of the residents' condition."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Claremont Care Center from 2025-05-07 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 21, 2026 · Our methodology
CLAREMONT CARE CENTER in POMONA, CA was cited for violations during a health inspection on May 7, 2025.
The resident at Claremont Care Center had been admitted with a history of falling and a fractured right thigh bone that required surgical repair.
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.