Claremont Heights Post Acute
CLAREMONT HEIGHTS POST ACUTE in CLAREMONT, CA — inspection on February 27, 2025.
Found 4 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
During a telephone interview on 2/26/2025 at 10:45 a.m. with the Public Health Nurse (PHN), the PHN stated the PHN had been working with the facility because the facility was currently going through a covid -19 outbreak.
The PHN stated the facility's IP had quit and that the PHN did not know who would take over for the IP.
During a telephone interview on 2/26/2025 at 11:35 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated LVN 1 was the facility's previously designated IP and last worked as the IP on 2/21/2025. LVN 1 stated LVN 1 was no longer the facility's IP. LVN 1 stated LVN 1 had been assigned to pass medications to residents (in general) on 2/24/2025 and 2/25/2025.
During an interview on 2/27/2025 at 9:04 a.m. with LVN 1, LVN 1 stated the DON assigned LVN 1 to take care of residents (in general) as a charge nurse on 2/24/2025 and 2/25/2025.
The IP stated the facility management (in general) informed LVN 1 that LVN 1 would remain the facility IP until the facility found another IP to replace LVN 1.
During a concurrent interview and record review on 2/27/2025 at 9:30 a.m. with the Director of Staff Development (DSD), the facility's Daily Nursing Staffing Sign-In Log, dated 2/24/2025, and the facility's Daily Nursing Staffing Sign-In Log, dated 2/25/2025 were reviewed.
The DSD stated both Daily Nursing Staffing Sign-In Logs indicated IP was assigned to work as a charge nurse and not as IP on 2/24/2025 and2/25/2025.
During a review of the facilities job description titled, Infection Preventionist, undated, the job description indicated, The Infection Preventionist (IP) serves as the facility's Infection Prevention and Control Officer, with oversight of the facility Infection Prevention and Control program.
The IP serves as a practitioner, resource, consultant, educator, and facilitator .
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
055344 02/27/2025
Claremont Heights Post Acute 590 S.
Indian Hill Blvd.
Claremont, CA 91711
Based on the resident's pneumococcal vaccination history, offer the appropriate vaccine .
- Resident/Representative will sign the appropriate consent form.
- Administer the appropriate vaccine per the CDC/ACIP guidance .
055344 02/27/2025
Claremont Heights Post Acute 590 S.
Indian Hill Blvd.
Claremont, CA 91711
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 2/12/2025, 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.
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.
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 02/27/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Claremont Heights Post Acute 590 S.
Indian Hill Blvd.
Claremont, CA 91711
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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.