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Complaint Investigation

Claremont Heights Post Acute

February 19, 2025 · Claremont, CA · 590 S. Indian Hill Blvd.
Citations 6
CMS Rating 2/5
Beds 99
Provider ID 055344
Healthcare Facility
Claremont Heights Post Acute
Claremont, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

CLAREMONT HEIGHTS POST ACUTE in CLAREMONT, CA — inspection on February 19, 2025.

Found 6 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0622
Not transfer or discharge a resident without an adequate reason; and must provide documentation and

During a review of Resident 2's Medication Administration Record (MAR) for January 2025, the

1/24/25 through 1/31/25.

During a review of Resident 2's Treatment Administration Record (TAR) for January 2025, the treatment order for Resident 2's right shin scratch was not transcribed in the TAR as ordered from 1/24/25 through 1/31/25.

During a review of Resident 2's clinical record, there was no documented evidence wound treatment was provided to Resident 2's right leg wound as ordered by the physician.

During a review of Resident 2's Discharge Summary (DS) created by LVN 5, dated 2/4/25 and timed 1:06 am, the DS indicated Resident 2 was discharged to a group home on 2/3/25 at 6 pm.

The DS indicated Resident 2 was picked up by a staff member of the group home where Resident 2 was discharged to.

The DS indicated no documented assessment of Resident 2's skin condition upon discharge and no documented evidence Resident 2's skin condition was communicated to the group home staff member who picked up Resident 2.

During an interview on 2/19/25 at 12:15 pm with LVN 4, LVN 4 stated licensed nurses must do a skin assessment upon resident's discharge and document the skin assessment in the resident's clinical record.

During an interview and concurrent record review on 2/19/25 at 2:02 pm with the Director of Nursing (DON), the DON reviewed Resident 2's clinical record.

The DON stated there was no documented skin assessment for Resident 2 upon Resident 2's discharge.

During an interview on 2/19/25 at 3 pm with LVN 3, LVN 3 stated a body skin check must be done prior to resident's discharge just like on a resident's admission.

During an interview on 2/19/25 at 5:57 pm with the DON, the DON stated a skin assessment must be done before a resident's discharge so a treatment order could be obtained from the physician prior to discharge and/or keep the resident in the facility if needed.

During a review of the facility's policy and procedure (P&P) titled, Discharge and Transfer of Residents, dated 1/3/24, the P&P indicated, residents have rights that are intended to prevent inappropriate, unnecessary, and untimely transfers and discharges.

The P&P indicated the purpose of the P&P was to ensure that discharge planning is complete and appropriate, and that necessary information is communicated to the continuing care provider.

055344 02/19/2025

Claremont Heights Post Acute 590 S.

Indian Hill Blvd.

Claremont, CA 91711

During a review of the facility's policy and procedure (P&P) titled, Completion & Correction, dated 1/1/12, the P&P indicated entries in the resident's medical record will be recorded promptly as the events or observations occur and will be complete, legible, descriptive, and accurate.

The P&P also indicated, treatments, observations during treatments and effectiveness of treatments and the date and time noting physician orders must be documented in the resident's medical record.

During a review of the facility's P&P titled, Change of Condition Notification, 4/1/15, the P&P indicated, a licensed nurse will notify the resident's attending physician and legal representative or an appropriate family member when there is an incident involving the resident.

The P&P indicated, a licensed nurse will document the following: date, time and pertinent details of the incident and the subsequent assessment in the nursing notes; the time the attending physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received; the time the family/responsible person was contacted; update the care plan to reflect the resident's current status .a licensed nurse will document each shift for at least seventy-two hours (72) hours .

055344 02/19/2025

Claremont Heights Post Acute 590 S.

Indian Hill Blvd.

Claremont, CA 91711

appropriate family member when there is an incident involving the resident.

The P&P indicated, a

method by which he was contacted, the response time, and whether or not orders were received; the

current status .a licensed nurse will document each shift for at least seventy-two hours (72) hours .

055344 02/19/2025

Claremont Heights Post Acute 590 S.

Indian Hill Blvd.

Claremont, CA 91711

During an interview on 2/19/25 at 9:26 am with CNA 4, CNA 4 stated CNA 4 must sanitize or wash

During an interview on 2/19/25 at 5:57 pm with the Director of Nursing (DON), the DON stated staff (in general) must be educated on proper N95 donning procedure and proper fit to prevent the spread of infection and to control the COVID-19 OB.

The DON stated hand hygiene must be done before and after resident care, and before and after glove use, to prevent the spread of infection and to control the COVID-19 OB.

During a review of the facility's policy and procedure (P&P) titled, Respiratory Protection, dated 7/14/17, the P&P indicated employees must wear an N95 mask during any infectious respiratory disease emergency to prevent employee exposure to infectious agents in the workplace.

The P&P indicated it is the employee's responsibility to know the respiratory protection requirements for their work areas and to wear the appropriate respiratory protective equipment according to proper instructions.

During a review of the facility's P&P titled, Hand Hygiene, dated 9/1/20, the P&P indicated facility staff must perform hand hygiene before eating, after using the bathroom, after contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, wound drainage and soiled dressing, before and after food preparation, before and after assisting a resident with dining if direct contact with food is anticipated or occurs, before donning and after doffing personal protective equipment, and immediately upon entering and exiting a resident room.

During a review of Resident 2's Admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (brain disease, damage, or malfunction caused by an illness or organs that are not working as well as they should).

During a review of Resident 2's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 1/16/25, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.

055344

Form Approved OMB

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 02/19/2025

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

Claremont Heights Post Acute 590 S.

Indian Hill Blvd.

Claremont, CA 91711

During a review of Resident 2's Admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (brain disease, damage, or malfunction caused by an illness or organs that are not working as well as they should).

During a review of Resident 2's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 1/16/25, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.

055344

Form Approved OMB

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 02/19/2025

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

Claremont Heights Post Acute 590 S.

Indian Hill Blvd.

Claremont, CA 91711

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CLAREMONT, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CLAREMONT HEIGHTS POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.