Claremont Heights Post Acute

F-F887)

Findings:

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

on 1/25/2022, with diagnoses including 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), respiratory failure (when the lungs can't get enough oxygen into

the blood), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures).

During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/6/2025, the MDS indicated Resident 1 was severely impaired (never/rarely made decisions) impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from staff for toileting, oral, and personal hygiene and dressing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 8 055344 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025

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 0883 During a concurrent interview and record review on 2/26/2025, at 3:41 p.m. with the Director of Nursing (DON), Resident 1's Immunization Report, dated 2/26/2025 was reviewed. The Immunization Report Level of Harm - Minimal harm or indicated Resident 1 refused to receive a flu vaccination from the facility for the 2024/2025 Influenza season. potential for actual harm The DON stated Resident 1's medical record indicated no documentation that education was provided to Resident 1 regarding risks and benefits of receiving a flu vaccination. The DON stated Resident 1's medical Residents Affected - Some record did not contain a signed declination for the flu vaccination for the 2024/2025 flu season.

b. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 11/18/2018, and readmitted Resident 2 on 7/13/2024, with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), hypertension (high blood pressure), and difficulty in walking.

During a review of Resident 2's MDS, dated [DATE REDACTED], the MDS indicated Resident 2 was moderately impaired

in cognitive skills (decisions poor; cues/supervision required). The MDS indicated Resident 2 required partial/moderate (helper does less than half the effort) from staff for toileting and personal hygiene and dressing.

During a concurrent interview and record review on 2/26/2025, at 3:45 p.m. with the DON, Resident 2's Progress Notes (PN), dated 10/1/2024, timed at 4:49 p.m. was reviewed. The PN indicated facility staff administered a flu vaccination to Resident 2 on 10/1/2024. The DON stated Resident 2's medical record indicated no documentation that education was provided to Resident 1 regarding risks and benefits of receiving the flu vaccination. The DON stated Resident 1's medical record did not contain a signed consent for Resident 2 to receive the flu vaccination on 10/1/2024. The DON stated Resident 2's medical record did not indicate the flu vaccine's lot number. The DON stated an informed consent was needed from residents (in general) to ensure the residents (in general) were aware of risks and benefits of receiving a vaccination.

The DON stated it was the resident's (in general) right to give an informed consent.

c. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 1/10/2025, with diagnoses including fracture of right femur (broken bone in right leg), lack of coordination, and difficulty in walking.

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 from staff for toileting hygiene, bathing, and lower body dressing.

During a concurrent interview and record review on 2/26/2025, at 3:48 p.m. with the DON, Resident 3's PCV13 Informed Consent, dated 1/10/2025 was reviewed. The PCV13 Informed Consent indicated Resident 3's RR agreed for Resident 3 to receive the PCV. The DON stated facility staff did not administer the PCV to Resident 3.

d. During a review of Resident 4's AR, the AR indicated the facility admitted Resident 4 on 2/5/2025, with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), acute pulmonary edema (swelling caused by too much fluid trapped in the body's tissues), and muscle weakness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 8 055344 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025

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 0883 During a review of Resident 4's MDS, dated [DATE REDACTED], the MDS indicated Resident 4 was moderately impaired

in cognitive skills. The MDS indicated Resident 4 was dependent (helper does all the effort) on staff for Level of Harm - Minimal harm or toileting hygiene and lower body dressing. The MDS indicated Resident 4 required substantial/maximal potential for actual harm assistance from staff for bathing.

Residents Affected - Some During a concurrent interview and record review on 2/26/2025, at 3:55 p.m. with the DON, Resident 4's PCV Informed Consent, dated 2/5/2025 and Resident 4's Resident Influenza Vaccine Informed Consent (Flu Informed Consent), dated 2/5/2025 were reviewed. Both the PCV Informed Consent and Flu Informed Consent indicated Resident 4 agreed to receive the PCV and the flu vaccination. The DON stated facility staff did not administer the PCV or the flu vaccination to Resident 4.

During a review of the facility's policy and procedure (P&P) titled, Influenza Prevention and Control, revised September 10, 2020, the P&P indicated:

A. Before offering the influenza vaccine, each Resident or the Resident's representative will be given education regarding the risk and benefits and potential side effects of the immunization. The CDC Vaccination Information Statement (VIS) will be used as part of the Resident's (representative's) education

B. Residents are offered an influenza immunization every year during flu season, unless the immunization is medically contraindicated, or the Resident has already been immunized during the current flu season

C. The Resident or representative must give consent prior to receiving the vaccine. They can refuse the immunization-with such refusal being noted in the Resident's medical record

D. The Resident's medical record will include documentation that indicates, at a minimum, the following:

i. The Resident or the Resident's representative was provided education regarding the risk and benefits and potential side effects of the influenza vaccination

ii. The Resident was given a copy of IC - 14 - Form A - Influenza Vaccination, Informed Consent or Refusal

iii. There is a physician order to administer the influenza vaccine

iv. Whether the Resident received the influenza vaccine, could not receive the vaccine due to a medical contraindication or refused the vaccine

v. The medical contraindication will be documented by the healthcare provider. If the medical contraindication is resolved, the Resident or representative will be approached to obtain consent for immunization

vi. The vaccine type, dose, route and nurse administrating the vaccine will be documented on the medication administration record

vii. The vaccine lot number will be recorded on the immunization log

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 055344 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025

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 0883 During a review of the facility's P&P titled, IPC601 Pneumococcal Vaccination, revised 9/26/2023, the P&P indicated: Level of Harm - Minimal harm or potential for actual harm 1. Upon admission, obtain the pneumococcal history of all residents.

Residents Affected - Some a. Resident or resident representative may self-report vaccination history

b. Document pneumococcal vaccination history in medical record

2. Based on the resident's pneumococcal vaccination history, offer the appropriate vaccine .

3. Resident/Representative will sign the appropriate consent form.

4. Administer the appropriate vaccine per the CDC/ACIP guidance .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 055344 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025

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 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44027

Residents Affected - Some Based on interview and record review, the facility failed to implement the facility's Covid-19 (a respiratory illness caused by a virus that easily spreads from person to person) immunization (Covid vaccination, a vaccine intended to provide immunity against Covid-19) program for three of seven sampled residents (Resident 2, 4, and 5) and all facility staff when:

a. The facility failed to offer the latest covid vaccination to Resident 2.

b. The facility failed to administer a covid vaccination to Resident 4 after Resident 4 signed an informed consent on 2/5/2025 to receive the covid vaccination.

c. For Resident 5, who received a covid vaccination on 4/24/2024, the facility failed to document if Resident 5 was provided education regarding the benefits and potential risks associated with the covid vaccination.

d. The facility failed to maintain documentation of screening, education, offering, and current Covid-19 vaccination status for the facility's staff.

These failures had the potential for residents and staff to not be vaccinated for Covid-19 which could result in

the spread of Covid-19 to residents, staff, and visitors in the facility.

Findings:

a. During a review of Resident 2's Admission Record (AR), the AR indicated the facility admitted Resident 2

on 11/18/2018, and readmitted Resident 2 on 7/13/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), hypertension (high blood pressure), and difficulty in walking.

During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 11/27/2024,

the MDS indicated Resident 2 was moderately impaired in cognitive skills (decisions poor; cues/supervision required). The MDS indicated Resident 2 required partial/moderate (helper does less than half the effort) from staff for toileting and personal hygiene and dressing.

During a concurrent interview and record review on 2/26/2025, at 3:45 p.m. with the DON, Resident 2's medical record was reviewed. The DON stated Resident 2's medical records indicated no documentation that Resident 2 was offered the latest Covid-19 vaccination. The DON stated 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.

b. During a review of Resident 4's AR, the AR indicated the facility admitted Resident 4 on 2/5/2025 with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), acute pulmonary edema (swelling caused by too much fluid trapped in the body's tissues), and muscle weakness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 055344 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025

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 0887 During a review of Resident 4's MDS, dated [DATE REDACTED], the MDS indicated Resident 4 was moderately impaired

in cognitive skills. The MDS indicated Resident 4 was dependent (helper does all the effort) on staff for Level of Harm - Minimal harm or toileting hygiene and lower body dressing. The MDS indicated Resident 4 required substantial/maximal potential for actual harm assistance from staff for bathing.

Residents Affected - Some During a concurrent interview and record review on 2/26/2025, at 3:55 p.m. with the DON, Resident 4's COVID-19 Vaccination, Informed Consent or Refusal (Covid Informed Consent), dated 2/5/2025 was reviewed. The Covid Informed Consent indicated Resident 4 agreed to receive the Covid-19 vaccination. The DON stated facility staff did not administer the Covid-19 vaccination to Resident 4.

c. During a review of Resident 5's AR, the AR indicated the facility admitted Resident 5 on 12/6/2020 with diagnoses including spinal stenosis (the spaces in the spine narrow and create pressure on the spinal cord and nerve roots), morbid obesity, and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).

During a review of Resident 5's MDS, dated [DATE REDACTED], the MDS indicated Resident 5 was moderately impaired

in cognitive skills. The MDS indicated Resident 5 was dependent on staff for toileting hygiene, lower body dressing, and bathing.

During a concurrent interview and record review on 2/26/2025, at 3:59 p.m. with the DON, Resident 5's PN, dated 4/24/2024, timed at 6:39 p.m., was reviewed. The PN indicated facility staff administered the Covid-19 vaccination to Resident 5 on 4/24/2024. The DON stated Resident 5's medical record indicated no documentation that education was provided to Resident 5 regarding risks and benefits of receiving the Covid-19 vaccination. The DON stated Resident 5's medical record did not contain a signed consent for Resident 5 to receive the Covid-19 vaccination on 4/24/2024.

d. During a telephone interview on 2/26/2025 at 11:35 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated LVN 1 had been hired to be the facility's Infection Preventionist (IP) on 2/11/2025. LVN 1 stated the facility did not have a system or documentation to keep track of the Covid-19 vaccination status of the facility's staff.

During a review of the facility's policy and procedure (P&P) titled, COVID-19 Vaccination Program, revised March 15, 2022, the P&P indicated, The Facility will offer SARS-CoV-2 vaccinations (including additional and booster doses) to all Residents .

During a review of the facility's Respiratory Virus Prevention & Control Plan (Plan), revised January 10, 2025,

the Plan indicated, Facility employees will be educated and offered COVID-19 and Influenza vaccines and strongly encouraged to get vaccinated. A consent or declination form will be signed by the employee and the form will be placed in their confidential medical record. Upon hire, a copy of any immunization records for vaccines received outside of the facility will be requested and reviewed by the Director of Staff Development and/or Infection Preventionist, not as a contingency for hire, but to include in the vaccination rates as for the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 055344