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Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Claremont Care Center during CMS and state inspections, most recent first.
Nursing staff failed to assess and document blood pressure immediately before administering antihypertensive medications to two residents, despite physician orders and facility policy requiring this step. In one case, a resident received blood pressure medications without a current BP check, and in another, a resident was given isosorbide mononitrate even though their systolic BP was below the hold parameter. Staff interviews confirmed that previous BP readings were sometimes used instead of obtaining a current measurement, leading to improper medication administration.
A resident with a history of heart failure, COPD, and diabetes, who was cognitively intact and required moderate ADL assistance, disclosed a past sexual assault to the ADM following recent abuse allegations involving a CNA. The facility created a care plan for emotional distress related to the new allegations but did not promptly develop a trauma-informed care plan addressing the resident's prior trauma, as required by policy. Staff confirmed the delay in care planning, resulting in unmet individualized needs.
A resident with a history of right femur fracture, dementia, and impaired mobility did not receive appropriate pain assessment and management when reporting persistent pain. Nursing staff failed to document the pain location and did not administer or record pain medication as required by the care plan and facility policy, resulting in incomplete pain management and documentation.
A facility failed to maintain accurate and complete medical records for a resident by not properly documenting pain location in therapy and nursing notes, and by omitting the rationale for a room transfer. Physical therapists and an LVN did not accurately record the site of pain, and the MAR lacked this information during pain medication administration. Additionally, the reason for a room change was not documented, despite facility policy requiring such documentation.
A resident with a history of falls, cognitive impairment, and significant mobility limitations had multiple episodes of attempting to get up unassisted from a wheelchair. Despite these incidents, the care plan was not updated to include new interventions or increased monitoring, contrary to facility policy and regulatory requirements. Staff interviews confirmed the care plan remained unchanged after the events.
The facility failed to maintain a clean and homelike environment for several residents, with issues such as peeling paint, cracked drywall, and raised floor tiles observed in their rooms and bathrooms. Interviews revealed a lack of effective reporting and maintenance, with no entries in the maintenance logs for necessary repairs, despite the facility's policy for monthly environmental rounds.
A resident with type 2 diabetes did not receive insulin as scheduled, with doses often administered hours late or early. Staff interviews revealed that insulin should be given within an hour of the scheduled time, but the MAR showed significant deviations. The facility's policy stresses timely administration according to physician orders.
The facility failed to handle and store milk properly, leading to expired milk being found in the kitchen and served to residents. The DSS acknowledged the expired milk and disposed of it, but was unsure how it reached the residents. The facility's policy requires proper labeling and daily inspections, which were not followed.
The facility failed to adhere to its infection prevention and control program for two residents, leading to potential infection risks. A CNA entered a resident's room under contact isolation for MRSA without a gown, and housekeeping staff cleaned another resident's room under enhanced barrier precautions without a gown. Both instances violated the facility's PPE protocols, increasing the risk of infection transmission.
A facility failed to accurately document a resident's discharge status on the MDS. The resident, diagnosed with dementia and emphysema, was discharged against medical advice to their family, but the MDS incorrectly recorded the discharge as to a General Acute Care Hospital. This discrepancy was confirmed by the MDS Nurse and contradicted the facility's policy on accurate resident assessments.
A resident with a language barrier was not provided with a communication board as required by their care plan, hindering their ability to communicate needs. The resident, who only spoke Mandarin, was admitted with conditions affecting mobility and cognition. Despite facility policies mandating the availability of communication tools, staff interviews confirmed the absence of the board, which was crucial for the resident's communication.
A resident at risk for pressure injuries had their low air loss (LAL) mattress incorrectly set at 180 lbs, despite weighing 117 lbs. This setting did not comply with the physician's order to adjust the mattress based on the resident's weight, potentially worsening the resident's existing pressure ulcers. The resident was admitted with conditions including urinary tract infection and reduced mobility, and was dependent on assistance for daily activities.
A resident with cognitive impairment and multiple health conditions was at risk of falling due to staff failing to activate a pressure pad alarm and not lowering the bed as per the care plan. Observations and staff interviews confirmed these oversights, which were contrary to the facility's Fall Management System policy.
Failure to Assess and Document Blood Pressure Prior to Administration of Antihypertensive Medications
Penalty
Summary
The facility failed to accurately administer blood pressure (BP) medications to two residents by not following physician orders and facility policy regarding assessment and documentation of vital signs prior to medication administration. For one resident with hypertensive heart disease, heart failure, and chronic kidney disease, multiple nurses did not assess or document BP immediately prior to administering carvedilol and nifedipine, as required by the medication orders which specified to hold the medication if systolic BP was less than 100 or heart rate was less than 60. Instead, nurses often relied on BP readings taken hours earlier or for unrelated assessments, such as COVID-19 screening, rather than obtaining a current BP immediately before giving the medication. Interviews with nursing staff confirmed that they sometimes used previous BP readings rather than checking at the time of administration, acknowledging the risk of adverse reactions if the resident's BP had changed since the last measurement. Another resident, with a history of hypotension, hypertensive heart disease, and end stage renal disease, was administered isosorbide mononitrate despite a BP reading of 92/54, which was below the ordered hold parameter of systolic BP less than 100. The nurse responsible for administering the medication stated that BP and heart rate should be checked prior to giving BP medications and that medications should be held if the parameters are not met. The Director of Nursing confirmed that the purpose of hold parameters is to prevent injury or hospitalization due to hypotension and that BP should be checked within a couple of minutes, but not more than an hour before or after medication administration. Review of the facility's policy and procedure on medication administration indicated that vital signs must be taken and medications held if indicated by the order. Despite this, documentation and interviews revealed that nurses did not consistently follow these requirements, resulting in medications being given without proper assessment or documentation of BP immediately prior to administration. This failure to follow established protocols and physician orders had the potential to cause harm to residents with complex medical conditions.
Failure to Timely Develop Trauma-Informed Care Plan After Resident Disclosure
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan with measurable objectives and timeframes to address a resident's reported history of past trauma. After the resident disclosed a previous rape to the administrator, this information was not promptly incorporated into the resident's care plan. Although a care plan addressing emotional distress related to recent abuse allegations was created, a trauma-informed care plan specific to the resident's history of sexual assault was not initiated on the same day as the disclosure. Interviews with facility staff, including the Social Services Director and Director of Nursing, confirmed that the trauma-related care plan was not developed in a timely manner, despite the recognition that such planning is essential for addressing emotional and psychological needs. The resident, who had diagnoses including heart failure, COPD, and diabetes mellitus, was cognitively intact and required partial to moderate assistance with activities of daily living. The resident reported never having shared the history of sexual assault with the facility prior to the recent abuse allegation involving a staff member. The facility's policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, including measurable objectives and timeframes to meet identified needs. However, the lack of timely trauma-informed care planning resulted in a deficiency in meeting the resident's individualized needs.
Failure to Assess and Document Pain Management for Resident with Fracture and Dementia
Penalty
Summary
A deficiency occurred when the facility failed to properly assess and manage pain for a resident with a history of right femur fracture, dementia, osteoarthritis, and impaired mobility. The resident's care plan required staff to administer analgesic medication as ordered, anticipate pain relief needs, and respond immediately to any complaints of pain. Physician orders specified that licensed staff should monitor the resident's pain level using a 0-10 scale every shift and administer Hydrocodone-Acetaminophen as needed for moderate to severe pain. On one occasion, the resident complained of persistent pain in the right lower extremity during a physical therapy session. The physical therapist documented the complaint and informed the licensed nurse, who agreed to monitor the resident. However, there was no evidence in the Medication Administration Record (MAR) that the resident received pain medication before or after the therapy session, nor was there documentation of a pain assessment on that day. Additionally, when pain medication was administered on subsequent dates for moderate to severe pain, the location of the pain was not documented by the licensed nurse, contrary to facility policy and care plan requirements. Interviews with nursing staff confirmed that pain location and assessment details were not consistently documented, and the responsible nurse acknowledged failing to record the pain location when administering medication. The facility's policies required thorough pain assessment, including location, intensity, and onset, as well as documentation and follow-up. The lack of assessment and documentation had the potential to result in unrelieved or uncontrolled pain for the resident.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident by not ensuring that physical therapists and nursing staff accurately documented the resident's pain location in both physical therapy encounter notes and the medical record. Specifically, two physical therapists documented the resident's pain as being in the left lower extremity, but later clarified that the pain was actually in the right lower extremity. Additionally, the licensed vocational nurse did not assess or document the pain location when administering pain medication on multiple occasions, and the medication administration record lacked this critical information. Further, the facility did not document the rationale for a room transfer for the resident. While the social services director and admissions coordinator acknowledged that the resident was moved to another room and that the family was notified, neither could recall or provide documentation of the reason for the transfer. The facility's policy required comprehensive documentation of social service assessments and interventions, including reasons for room changes, but this was not followed in this instance. The resident involved had a complex medical history, including a recent right femur fracture, dementia, osteoarthritis, and generalized muscle weakness. The resident required significant assistance with activities of daily living and had a history of falls and pain management needs. The lack of accurate and complete documentation in the resident's medical record resulted in incomplete information that could affect the resident's care, as noted by staff during interviews and record reviews.
Failure to Update Care Plan After Unassisted Transfer Attempts in High Fall Risk Resident
Penalty
Summary
The facility failed to revise the care plan for a resident at high risk for falls after the resident experienced episodes of attempting to get up unassisted. The resident, who had a history of falling, a right femur fracture, dementia, osteoarthritis, abnormal gait, and generalized muscle weakness, was admitted with significant mobility and cognitive impairments. The Minimum Data Set assessment indicated the resident required varying levels of assistance for daily activities and had not attempted transfers or walking due to safety concerns. Despite these risks and a documented fall prior to admission, the care plan, which included interventions such as call light accessibility, low bed, floor mats, and pressure pad alarms, was not updated after the resident attempted to get up unassisted from a wheelchair on two occasions. Interviews with facility staff confirmed that the care plan had not been revised following these incidents to include additional interventions, such as more frequent monitoring. The facility's policy required individualized care plans for residents at high risk for falls, with updates as new issues arose. However, the lack of timely care plan revision after the resident's unassisted transfer attempts represented a failure to address the resident's changing needs and risk factors as required by facility policy and regulatory standards.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for ten sampled residents, as observed during a survey. The deficiencies included peeling paint, cracked drywall, and loosely fitting pipe escutcheons in the bathrooms of several residents' rooms. Additionally, cracked caulking, chipped paint, and raised floor tiles were noted, which could potentially expose residents to dirt, mold, and drywall dust. These conditions were observed in the bathrooms and rooms of the residents, indicating a lack of maintenance and repair. Interviews with the housekeeping staff and the Maintenance Director (MD) revealed that there was a process for reporting maintenance issues, but it was not effectively utilized. The MD acknowledged the need for repairs in the affected rooms and bathrooms, citing potential health risks from dust and the risk of falls due to cracked tiles. A review of the facility's maintenance logs showed no entries for the necessary repairs in the affected rooms, despite the facility's policy requiring monthly environmental rounds to ensure a safe and comfortable environment.
Failure to Administer Insulin Timely
Penalty
Summary
The facility failed to administer insulin as ordered for a resident with multiple diagnoses, including type 2 diabetes, dementia, and adult failure to thrive. The resident's Medication Administration Record (MAR) indicated that insulin was not administered at the scheduled times on numerous occasions throughout November and December 2024. The insulin was often given several hours past the scheduled time, and in one instance, it was administered before the scheduled time. This failure to adhere to the prescribed schedule for insulin administration could lead to inaccurate blood sugar readings and inappropriate insulin dosing. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed that the staff generally administers medication within an hour before or after the scheduled time. However, the MAR showed significant deviations from this practice. The LVN highlighted the importance of checking blood sugar levels before meals to ensure accurate insulin dosing, while the DON acknowledged that administering insulin without a meal or snack could result in hypoglycemia. The facility's policy on medication administration emphasizes the necessity of accurate and timely administration according to physician orders.
Expired Milk Handling Deficiency
Penalty
Summary
The facility failed to ensure proper handling, preparation, and storage of food, specifically milk, which could lead to foodborne illness. During an initial kitchen tour, eleven cartons of 2% fat milk with expired dates were found in the reach-in refrigerator. The Dietetic Service Supervisor (DSS) acknowledged the expired milk and disposed of it. Additionally, during a tray line observation, seven more expired milk cartons were found on a tray of drinks intended for residents. The DSS, upon being informed, discarded these cartons as well, although he was unsure of their origin since he had previously checked the tray in the refrigerator. Furthermore, a Certified Nursing Assistant (CNA) was observed returning a food tray to the kitchen with a half-empty milk carton that was also expired. This milk was intended for a specific resident, and the DSS expressed uncertainty about how the expired milk reached the resident. The facility's policy and procedure on labeling and dating foods require that all food items be labeled and dated, with perishable items discarded according to the manufacturer expiration date or seven days after opening. The policy also mandates daily inspections of refrigerators to ensure food safety, which was evidently not adhered to in this instance.
Failure to Follow Infection Control Protocols for Two Residents
Penalty
Summary
The facility failed to adhere to its infection prevention and control program for two residents, leading to potential risks of infection transmission. For Resident 78, who was on contact isolation due to Methicillin-Resistant Staphylococcus Aureus (MRSA) in the urine, a Certified Nursing Assistant (CNA) entered the resident's room without donning a gown, which is a requirement under contact precautions. The CNA acknowledged the mistake and stated that proper personal protective equipment (PPE) should have been worn to prevent cross-contamination and ensure safety. The Infection Preventionist Nurse (IPN) confirmed that the expectation was for staff to always don and doff appropriate PPE, including gowns and gloves, when entering rooms under contact isolation. In another instance, the facility did not follow enhanced barrier precautions for Resident 20, who required PPE for high-contact care activities. A housekeeping staff member was observed cleaning Resident 20's room while wearing only a surgical mask and gloves, without a protective gown, despite signage indicating the need for gown and gloves due to enhanced standard precautions. The housekeeping staff admitted to forgetting to wear a gown, and the Maintenance Director emphasized the importance of wearing a gown to prevent the spread of germs, as it is not always known if residents have infections or what they have touched in the room. The facility's policy and procedure documents, revised in October 2024, outlined the necessity of using PPE based on predicted staff interaction with residents and potential exposure to pathogens. The policy specified that for enhanced barrier precautions, signage should clearly indicate the high-contact resident care activities requiring gown and gloves. The failure to follow these protocols for both residents had the potential to transmit infectious microorganisms and increase the risk of infection for all residents and staff in the facility.
Inaccurate MDS Documentation of Resident Discharge Status
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, resulting in an inaccurate assessment of the resident's discharge status. The resident, who had been diagnosed with dementia, emphysema, and a history of falling, was discharged against medical advice (AMA) to their family. However, the MDS inaccurately recorded the discharge as being to a General Acute Care Hospital (GACH) instead of to the resident's home. This discrepancy was identified during a review of the resident's records, including the Admission Record, Physician's Discharge Summary, and Progress Notes, which all indicated the resident left AMA to go home. During an interview with the Minimum Data Set Nurse (MDSN 1), it was confirmed that the MDS should have been marked as a discharge to home rather than to a GACH. The facility's policy on Resident Assessment: Accuracy of Assessment (MDS 3.0) requires that assessments accurately reflect the resident's status, which was not adhered to in this case. This oversight led to the inaccurate documentation of the resident's discharge status on the MDS.
Failure to Provide Communication Board for Resident with Language Barrier
Penalty
Summary
The facility failed to provide a communication board for a resident who had a language barrier, as indicated in the resident's care plan. The resident, who was admitted with diagnoses including metabolic encephalopathy and reduced mobility, was unable to communicate effectively due to a language barrier, as they only spoke Mandarin. The care plan specified the need for a communication board in Mandarin to help the resident communicate basic needs to the staff. However, during an observation, it was noted that no communication board was present in the resident's room, which was confirmed by a family member who stated the resident might have difficulty communicating their needs. Interviews with facility staff, including an LVN and the Social Services Director (SSD), revealed that the communication board was not easily accessible as required. The LVN acknowledged the importance of the communication board for residents with language barriers and noted its absence in the resident's environment. The SSD admitted that communication boards could be misplaced and emphasized the need for them to be within the resident's line of sight to facilitate effective communication. The facility's policies and procedures indicated that communication tools should be provided and kept at the resident's bedside, but this was not adhered to in this case.
Incorrect LAL Mattress Setting for Resident
Penalty
Summary
The facility failed to ensure that a resident at risk for skin breakdown and pressure injuries received appropriate treatment and services to prevent skin breakdown. The deficiency was identified when it was observed that the low air loss (LAL) mattress for a resident was incorrectly set at 180 pounds, while the resident's actual weight was 117 pounds. This incorrect setting was not in accordance with the physician's order, which specified that the LAL mattress should be set based on the resident's weight. The incorrect setting of the LAL mattress could lead to increased pressure on the resident's existing pressure ulcers, potentially worsening their condition. The resident in question was admitted with diagnoses including urinary tract infection, metabolic encephalopathy, and reduced mobility, and was dependent on assistance for activities of daily living. The resident's care plan indicated the use of a LAL mattress with bolsters for tissue load management due to the presence of pressure ulcers and the potential for further development. The facility's policy on pressure ulcers emphasized the need for necessary treatment and services to promote healing and prevent new sores. However, the failure to adjust the LAL mattress according to the resident's weight compromised the therapeutic benefits intended by the mattress, placing the resident at higher risk for further skin breakdown.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to adhere to its Fall Management System policy and Resident 1's care plan, which aimed to prevent falls. Specifically, the staff did not activate Resident 1's pressure pad alarm and did not return the bed to its lowest position after providing care. These actions were contrary to the care plan interventions designed to alert staff if Resident 1 attempted to get up unassisted, thereby increasing the risk of falls. Resident 1, who was admitted with conditions including type 2 diabetes mellitus, heart failure, and acute cerebrovascular insufficiency, was moderately impaired in cognitive skills and dependent on staff for daily activities. During observations, it was noted that the bed was not in the lowest position, and the pad alarm was turned off, despite the care plan's requirements. Staff interviews confirmed these oversights, acknowledging the potential risk of injury if Resident 1 were to fall.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pomona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mount San Antonio Gardens | 0.8 mi | — | 1 | 0 |
| Pilgrim Place Health Services Center | 1.3 mi | — | 20 | 0 |
| Claremont Manor Care Center | 1.4 mi | — | 18 | 0 |
| Landmark Medical Center | 1.6 mi | — | 5 | 0 |
| Woods Health Services | 1.7 mi | — | 7 | 0 |
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