Claremont Heights Post Acute

F-F584)

Findings:

1. During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1

on 4/18/2024, with diagnoses including quadriplegia (the condition in which both the arms and legs are paralyzed [partly or wholly incapable of movement]), chronic pain syndrome (when people have symptoms beyond pain alone, like depression and anxiety, which interfere with their daily lives), and muscle spasm (a sudden, involuntary, and forceful contraction of a muscle or group of muscles) of back.

During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/24/2024,

the MDS indicated Resident 1 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for eating, bathing, toileting and personal hygiene, and dressing.

2. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 5/2/2022, with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) and hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect

the arms, legs, and facial muscles) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to

the brain) .

During a review of Resident 3's MDS, dated [DATE REDACTED], the MDS indicated Resident 3 had no impairment in cognitive skills. The MDS indicated Resident 3 required partial/moderate assistance (helper does less than half the effort) from staff for toileting and personal hygiene, bathing, and dressing.

During an interview on 1/2/2025 at 11:11 a.m. with Resident 1, Resident 1 stated the showers at the facility were corroded (damaged by chemical action) and moldy (covered or filled with a soft green, blue, or black growth). Resident 1 stated the grout was falling out in the front shower and in the shower next to Resident 1's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 055344 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055344 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Claremont Heights Post Acute 590 S. Indian Hill Blvd. Claremont, CA 91711

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)

F 0880 During a concurrent observation and interview on 1/2/2025 at 3:05 p.m. with the Maintenance Supervisor (MS), the facility's shower rooms were observed. The MS stated the facility had four shower rooms. The MS Level of Harm - Minimal harm or confirmed shower room [ROOM NUMBER] had missing floor tiles in the shower area. The MS confirmed the potential for actual harm door frame at the entrance of shower room [ROOM NUMBER] was rusty (covered with a red-brown substance that formed as a result of decay caused by reacting with air and water). The MS confirmed the Residents Affected - Some door frame at the entrance of the shower room (unidentified) next to residents' room [ROOM NUMBER] was rusty and pulling away from the wall.

During an interview on 1/3/2025 at 9:21 a.m. with Resident 3, Resident 3 stated the facility shower rooms made Resident 3 feel dirty and uncomfortable. Resident 3 stated the shower rooms smelled like mold (a fungal growth that develops on wet materials in interior spaces). Resident 3 stated some of the shower tiles were missing in the shower rooms.

During a concurrent observation and interview on 1/3/2025 at 9:30 a.m. with the Infection Preventionist (IP),

in Shower room [ROOM NUMBER], grout (a mixture of sand, water, and cement used to seal any gaps or fill

in spaces between tiles) was missing between tiles located on the half wall between the shower area and the entry into the shower room. The area of missing grout was black. The IP stated the black area was a buildup of dirt. The IP states the missing grout created a risk of bacteria to build up inside the area between the tiles.

The IP stated missing grout also meant staff were not able to clean the area effectively.

During a concurrent observation and interview on 1/3/2025 at 9:35 a.m. with the IP, in the shower room (unidentified) next to room [ROOM NUMBER], grout was missing between tiles located on the half wall between the shower area and the entry into the shower room. Black discolorations were observed inside and around the missing grout. The metal doorframe was rusted and pulling away from the wall on both sides of

the entry into the shower room. The IP stated the condition of the rusted doorframe was an area that could harbor germs. The IP stated the facility staff were not able to clean the rusted door frame in the condition it was in.

During a concurrent observation and interview on 1/3/2025 at 9:43 a.m. with the IP, in Shower room [ROOM NUMBER], the right bottom side of the metal door frame was rusted. There was a line of black and green discoloration observed on the half wall next to the shower area. The shower floor was missing tiles. The IP stated the missing shower tiles was a potential harboring place for bacteria.

During a review of the facility's policy and procedure (P&P) titled, Infection Control - Policies & Procedures, revised 1/1/2012, the P&P indicated, The Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The P&P indicated the policy objectives included, Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 055344

F-F880)

Findings:

1. During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1

on 4/18/2024, with diagnoses including quadriplegia (the condition in which both the arms and legs are paralyzed [partly or wholly incapable of movement]), chronic pain syndrome (when people have symptoms beyond pain alone, like depression and anxiety, which interfere with their daily lives), and muscle spasm (a sudden, involuntary, and forceful contraction of a muscle or group of muscles) of back.

During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/24/2024,

the MDS indicated Resident 1 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for eating, bathing, toileting and personal hygiene, and dressing.

2. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 5/2/2022, with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) and hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect

the arms, legs, and facial muscles) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to

the brain).

During a review of Resident 3's MDS, dated [DATE REDACTED], the MDS indicated Resident 3 had no impairment in cognitive skills. The MDS indicated Resident 3 required partial/moderate assistance (helper does less than half the effort) from staff for toileting and personal hygiene, bathing, and dressing.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 7 055344 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055344 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Claremont Heights Post Acute 590 S. Indian Hill Blvd. Claremont, CA 91711

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)

F 0584 During an interview on 1/2/2025 at 11:11 a.m. with Resident 1, Resident 1 stated the showers at the facility were corroded (damaged by chemical action) and moldy (covered or filled with a soft green, blue, or black Level of Harm - Minimal harm or growth). Resident 1 stated the grout was falling out in the front shower and in the shower next to Resident potential for actual harm 1's room.

Residents Affected - Some During a concurrent observation and interview on 1/2/2025 at 3:05 p.m. with the Maintenance Supervisor (MS), the facility's shower rooms were observed. The MS stated the facility had four shower rooms. The MS confirmed shower room [ROOM NUMBER] had missing floor tiles in the shower area. The MS confirmed the door frame at the entrance of shower room [ROOM NUMBER] was rusty (covered with a red-brown substance that formed as a result of decay caused by reacting with air and water). The MS confirmed the door frame at the entrance of the shower room (unidentified) next to residents' room [ROOM NUMBER] was rusty and pulling away from the wall.

During an interview on 1/3/2025 at 9:21 a.m. with Resident 3, Resident 3 stated the facility shower rooms made Resident 3 feel dirty and uncomfortable. Resident 3 stated the shower rooms smelled like mold (a fungal growth that develops on wet materials in interior spaces). Resident 3 stated some of the shower tiles were missing in the shower rooms (unidentified).

During a concurrent observation and interview on 1/3/2025 at 9:30 a.m. with the Infection Preventionist (IP),

in Shower room [ROOM NUMBER], grout (a mixture of sand, water, and cement used to seal any gaps or fill

in spaces between tiles) was missing between tiles located on the half wall between the shower area and the entry into the shower room. The area of missing grout was black. The IP stated the black area was a buildup of dirt. The IP stated the missing grout created a risk of bacteria to build up inside the area between the tiles.

The IP stated missing grout also meant staff were not able to clean the area effectively.

During a concurrent observation and interview on 1/3/2025 at 9:35 a.m. with the IP, in the shower room (unidentified) next to room [ROOM NUMBER], grout was missing between tiles located on the half wall between the shower area and the entry into the shower room. Black discolorations were observed inside and around the missing grout. The metal doorframe was rusted and pulling away from the wall on both sides of

the entry into the shower room. The IP stated the condition of the rusted doorframe was an area that could harbor germs. The IP stated the facility staff were not able to clean the rusted door frame in the condition it was in.

During a concurrent observation and interview on 1/3/2025 at 9:43 a.m. with the IP, in Shower room [ROOM NUMBER], the right bottom side of the metal door frame was rusted. There was a line of black and green discoloration observed on the half wall next to the shower area. The shower floor was missing tiles. The IP stated the missing shower tiles was a potential harboring place for bacteria.

During a review of the facility's policy and procedure (P&P) titled, Resident Rooms and Environment, revised 1/1/2012, the P&P indicated, The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. The P&P indicated, Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following:

A. Cleanliness and order;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 7 055344 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055344 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Claremont Heights Post Acute 590 S. Indian Hill Blvd. Claremont, CA 91711

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)

F 0584 B. Lighting that is comfortable (minimum glare) yet adequate (suitable to the task);

Level of Harm - Minimal harm or C. Personalized furniture and room arrangements; potential for actual harm D. Pleasant, neutral scents; . Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 055344 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055344 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Claremont Heights Post Acute 590 S. Indian Hill Blvd. Claremont, CA 91711

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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 44027 potential for actual harm Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident Residents Affected - Few 1), received medications as ordered by Resident 1's physician.

This failure resulted in Resident 1 to feel uncomfortable and had the potential for Resident 1 to experience a decline in his health and well-being.

Findings:

During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/18/2024, with diagnoses including quadriplegia (the condition in which both the arms and legs are paralyzed [partly or wholly incapable of movement]), chronic pain syndrome (when people have symptoms beyond pain alone, like depression and anxiety, which interfere with their daily lives), and muscle spasm (a sudden, involuntary, and forceful contraction of a muscle or group of muscles) of back.

During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/24/2024,

the MDS indicated Resident 1 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for eating, bathing, toileting and personal hygiene, and dressing.

During a review of Resident 1's After Visit Summary (AVS) from General Acute Care Hospital (GACH) 1 dated 12/15/2024, the AVS included physician transfer orders that indicated to continue baclofen (a medication used to treat muscle spasms) 10 milligrams (mg, unit of measurement), take two (2) tablets by mouth every six (6) hours as needed for muscle spasms and diazepam (a medication used to treat anxiety, muscle spasms, and seizures) 2 mg, take one (1) tablet by mouth every 12 hours as needed for anxiety.

During a review of Resident 1's physician orders (PO) dated 12/16/2024, timed at 12:23 a.m., the PO indicated orders for baclofen oral tablet 10 mg, give 2 tablets by mouth every 6 hours as needed for muscle spasms and diazepam oral tablet 2 mg, give 1 tablet every 12 hours as needed for muscle spasm as evidenced by involuntary contractions and muscle rigidity.

During an interview on 1/2/2025 at 11:11 a.m. with Resident 1, Resident 1 stated Resident 1 recently spent eight days in the hospital and when Resident 1 returned to the facility, Resident 1 was not able to get Resident 1's baclofen and Valium (brand name for diazepam). Resident 1 stated Resident 1 had been taking

the baclofen and Valium at the facility before Resident 1 went to the hospital and while Resident 1 was at the hospital.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 055344 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055344 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Claremont Heights Post Acute 590 S. Indian Hill Blvd. Claremont, CA 91711

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)

F 0684 During a concurrent interview and record review on 1/3/2025 at 1:17 p.m. with the Director of Nursing (DON), Resident 1's Medication Administration Record (MAR), dated December 2024 and Resident 1's physician Level of Harm - Minimal harm or orders, untitled, for baclofen and diazepam dated 12/16/2024 were reviewed. The DON stated Resident 1 potential for actual harm was readmitted from the hospital late on 12/15/2024. The DON confirmed a telephone order was received on 12/16/2024 at 12:23 a.m. for Resident 1 to continue receiving baclofen and diazepam for muscle spasms. Residents Affected - Few The MAR indicated Resident 1 did not receive any baclofen on 12/16/2025. The MAR indicated Resident 1 did not receive baclofen until 12/17/2024 at 8 a.m. The MAR indicated Resident 1 did not receive diazepam from 12/16/2024 until 12/27/2024. The DON stated the pharmacy needed Resident 1's Doctor (DR 1) to sign

an authorization before the pharmacy would dispense the diazepam. The DON confirmed Resident 1 had been on the two medications before being hospitalized . The DON stated Resident 1 had been on diazepam since 5/11/2024. The DON stated Resident 1 was at risk of going through withdrawal if he did not receive the diazepam. The DON stated going through withdrawal could negatively affect Resident 1's health. The DON stated Resident 1 could experience, restlessness, shivering, sweating, and muscle spasms.

During an interview on 1/3/2025 at 2:45 p.m. with Resident 1, Resident 1 stated Resident 1 felt like I was withdrawing when he did not get the diazepam. Resident 1 stated Resident 1 was really uncomfortable.

During a telephone interview on 1/3/2025 at 3:03 p.m. with DR 1, DR 1 stated DR 1 was not aware Resident 1 did not receive diazepam from 12/16/2024 until 12/27/2024. DR 1 stated Resident 1 should have received

the medications that were on Resident 1's transfer orders. DR 1 stated Resident 1 could have experienced withdrawal symptoms when Resident 1 was not getting diazepam. DR 1 stated withdrawal symptoms could include higher anxiety, changes in vital signs, and hallucinations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 055344 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055344 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Claremont Heights Post Acute 590 S. Indian Hill Blvd. Claremont, CA 91711

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44027 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure three of four shower rooms Residents Affected - Some (Shower Rooms 3, 7, and shower room next to room [ROOM NUMBER]) were clean and in good repair.

This failure had the potential for the shower rooms to harbor growth of bacteria (microscopic organisms, some can make a person sick) and had the potential to cause residents to become sick with bacterial infections.

(Cross Reference