Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 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.
A facility failed to maintain resident dignity when staff entered multiple resident rooms without knocking and when an LPN administered insulin to a resident without fully closing the privacy curtain. Residents involved had documented cognitive abilities ranging from intact to moderately impaired, and one resident and RP stated that not knocking would be startling. The facility policy required staff to knock before entering rooms and to maintain privacy during treatment.
A resident with ESRD and DM received insulin injections in a shunt arm despite a physician order prohibiting needle sticks to that arm. Another resident with DM had a callus debrided on the heel, revealing an open diabetic foot ulcer, but staff did not complete a COC assessment or notify the MD. A third resident received an unnecessary fingerstick before a scheduled Lantus dose even though there was no physician order for that blood sugar check, and the resident said the repeated pokes were bothersome.
Incomplete and inaccurate clinical documentation was found for three residents. One resident with ESRD, dialysis, and DM had MAR entries documenting insulin injection sites on the deltoid, while another resident with ESRD, dialysis, and DM had a care plan stating no needle stick on the left arm but the MAR documented injections on the deltoid; the dialysis communication form was also missing key items such as the dialysis center name, access site location, and infection status. A third resident with a right heel ulcer had wound treatment orders and a note documenting surgical debridement, but the TAR still recorded weekly assessments as "No Skin Impairment."
Failure to Follow Care Plan for Insulin Injections: A resident with ESRD, dialysis dependence, and DM2 had a care plan stating no needle sticks in the left arm, but MAR review showed insulin injections were given in that arm multiple times. An LPN stated she was not aware of the care plan and administered the injections anyway; the DON and QA confirmed the care plan should be followed and noted left-arm injections could increase bleeding risk or cause trauma.
Failure to provide needed grooming assistance: A resident with dementia, psychotic disturbance, mood disturbance, anxiety, and dependence for ADL was observed unkempt with greasy hair, whitish flakes on the head, and chin whiskers. A CNA stated the resident needed shaving and hair washing but was combative during care, and the DON stated the resident needed grooming for health reasons and dignity. The facility policy required residents unable to carry out ADL to receive necessary grooming services.
A resident at high risk for falls with a recent fall history was found leaning toward one side of the bed, and the mattress did not have equal side borders. The resident stated the mattress caused leaning and had already contributed to a fall, while the care plan noted fall risk but did not include a goal and only identified a safe environment as an intervention. An LVN observed the mattress border on one side was not the same as the other side.
Unlabeled Oxygen Humidifier Bottle: A resident with CRF with hypoxia and COPD was observed receiving 2 L of O2 via NC with a humidifier bottle that was not labeled with a date. Staff stated the humidifier bottles and NC tubing were changed weekly and as needed, and the facility policy required the humidifier to be dated when changed.
A facility failed to maintain IPC practices when an unlabeled shaving cream can was found in a shared restroom used by two residents, despite policy requiring personal care items to be labeled and stored properly. The facility also failed to implement ordered EBP for a resident with an open diabetic foot ulcer; no EBP signage or PPE cart was observed, and staff reported the resident had not been seen with gowns during personal care. The residents involved had multiple medical conditions, including osteomyelitis, bacteremia, COPD, UTI, cellulitis, and diabetes-related wound care needs.
Kitchen 1's walk-in refrigerator had a plastic air curtain with a missing strip, leaving a six-to-eight-inch gap. The DSS stated the strip was missing and needed repair, and noted the air curtain helped keep cold air inside the refrigerator. The RD stated kitchen equipment should be functioning and in working condition, while the ADM said the unit was older than 40 years and the facility did not have the air curtain's maintenance manual.
Call light not within reach for two residents. One resident with heart failure, dementia, DM, and impaired mobility could not find the call light while sitting in a wheelchair and asking for a nurse. Another resident with reduced mobility, impaired UE strength, moderately impaired cognition, and dependence with ADLs had the touch call pad tucked under a pillow near the bed siderail and stated it was hard to call for help. The DON and LVN both stated the call light should be within the resident’s reach.
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 Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure residents were treated with dignity when staff entered resident rooms without knocking and when privacy was not fully maintained during insulin administration. Resident 21 was admitted and readmitted with diagnoses including osteomyelitis of the thoracic vertebra and bacteremia, and was alert and oriented x4 with intact cognitive skills for daily decision making. Resident 61 was admitted with COPD with exacerbation and UTI, had capacity to understand and make decisions, and had intact cognitive skills. Resident 116 was admitted with anxiety disorder and an old MI, and Resident 117 was admitted with need for assistance with personal care and bipolar disorder; both had varying levels of assistance needs documented in their MDS assessments. During an observation on 2/10/2026, multiple staff were seen entering multiple resident rooms without knocking. During an observation on 2/11/2026 at 7:46 AM, LVN 2 entered Resident 21 and Resident 61's room without knocking to check breakfast trays, then entered Resident 116 and Resident 117's room without knocking and collected Resident 116's breakfast tray. LVN 2 later re-entered Resident 21 and Resident 61's room without knocking and collected Resident 61's breakfast tray. In an interview, LVN 2 stated staff should knock before entering resident rooms and that knocking was important to protect privacy and dignity. Resident 61 and the responsible party stated that staff not knocking would scare Resident 61, and the responsible party said staff sometimes knocked and sometimes did not. Resident 35 was admitted with type 2 DM with other specified complication and heart failure, and the MDS indicated intact cognitive skills for daily decision making. Resident 35 had an active order for Lantus insulin twice daily, and during an observation on 2/12/2026 at 8:36 AM, LVN 3 administered insulin in Resident 35's right upper quadrant abdomen while the privacy curtain was only drawn from the head of the bed to the right corner of the foot of the bed, leaving Resident 35's abdomen exposed. LVN 3 stated the curtain should have been drawn all the way around the bed for privacy and dignity. The facility policy titled Resident Rights-Dignity and Respect stated residents should be treated with kindness, dignity, and respect, that their bodies should be examined and treated in a manner that maintained privacy, and that staff should knock before entering resident rooms.
Failure to Follow Orders for Insulin Administration, Wound Change Assessment, and Blood Sugar Checks
Penalty
Summary
The facility failed to follow a physician order for a resident with end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus. The resident had an order stating that no needle stick was to be performed on the left arm, which had a shunt. Despite that order, licensed nurses administered insulin injections into the resident’s left arm on multiple occasions, including insulin glargine and NovoLOG administrations documented on the MAR. One nurse stated she was not aware of the order and acknowledged that using the left arm for injection could increase the risk of bleeding and cause trauma. The facility also failed to complete a change of condition assessment and failed to notify the physician after a resident’s planned debridement of a right heel callus revealed an open diabetic foot ulcer. The resident had diagnoses including cellulitis, pressure ulcer, and type 2 diabetes mellitus, and the record showed a nursing order and progress note related to debridement of the right heel. After the callus was debrided and an open ulcer was exposed, staff confirmed that a COC assessment was not completed. Staff stated the change from intact skin to an open wound required assessment, monitoring, new interventions, and physician notification, but there was no documented evidence that the MD was notified of the change. The facility further failed to obtain a physician order before performing a fingerstick on a resident receiving Lantus insulin. The resident’s record showed an active order for Lantus SoloStar twice daily, but no order to check blood sugar for the 9 AM dose. During medication administration, an LPN performed a fingerstick before giving the scheduled insulin and stated she liked checking the resident’s blood sugar because the resident was getting Lantus. The resident stated being poked many times a day bothered them, and the LPN and DON both acknowledged there was no order for that blood sugar check and that it was not necessary.
Incomplete and inaccurate resident clinical documentation
Penalty
Summary
The facility failed to ensure clinical records were complete and accurate for three sampled residents. Resident 2 had diagnoses including end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus. Resident 2’s MDS indicated dialysis, and the MAR for 2/2026 documented insulin administration sites on the deltoid. Resident 113 also had end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus; the MDS indicated dialysis, the care plan initiated on 2/6/2026 stated no needle stick on the left arm, and the MAR for 2/2026 documented insulin administration sites on the deltoid. During interview, LVN 3 stated the MAR documentation for Resident 113 was wrong and that she did not use the left arm for medication injections. For Resident 113, the dialysis communication form dated 2/12/2026 was incomplete. It was missing the dialysis center name, COVID-19 confirm case status, location of the dialysis access site, level of consciousness status, whether the access site had a dressing, and whether the access site had infection. RN stated the form should be complete and that facility nurses were responsible for ensuring the dialysis communication form was completed and accurate. RN also stated incomplete documentation was unacceptable and could affect communication between nurses and increase the risk of medication error. Resident 66 was admitted with diagnoses including cellulitis, pressure ulcer, and need for assistance with personal care. The MDS indicated cognition was intact and that the resident required assistance with ADLs and mobility. A progress note documented surgical debridement of a right heel ulcer and ongoing wound care, and the OSR showed an active order for daily wound treatment to the right heel diabetic ulcer. However, the TAR for 1/2026 documented weekly assessment entries under "No Skin Impairment." RN 1 stated documentation should be accurate, timely, and reflective of the resident’s actual condition, and that wound documentation should clearly show whether skin was intact or open, the status of healing, and any changes observed.
Failure to Follow Care Plan for Insulin Injections
Penalty
Summary
The facility failed to ensure Resident 2’s care plan was implemented when licensed nurses administered insulin injections in the resident’s left arm, despite the care plan stating there should be no needle sticks in that arm. Resident 2 was a [AGE]-year-old female initially admitted on 5/27/2023 and re-admitted on [DATE], with diagnoses including end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus. Her MDS dated 11/1/2025 indicated she was receiving dialysis, and her care plan initiated 2/6/2026 directed no needle stick on the left arm. The MAR for 2/2026 showed insulin glargine and NovoLOG were administered by needle injection in the left arm on multiple occasions, including 2/2/2026, 2/4/2026, 2/6/2026, 2/7/2026, 2/8/2026, and 2/9/2026. During interview and record review, LVN 5 stated she was not aware of the care plan and had administered insulin in the left arm. The DON stated nurses should follow the resident’s care plan, and QA stated the care plan needed to be implemented and that using the left arm for insulin injections would increase the risk of bleeding or could cause trauma.
Failure to Provide Needed Grooming Assistance
Penalty
Summary
The facility failed to ensure that Resident 43, who was unable to carry out activities of daily living, received the necessary services to maintain personal grooming as required by the facility's ADL policy. Resident 43 was admitted with diagnoses including need for assistance with personal care, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. The care plan identified an ADL self-care performance deficit, impaired mobility, activity intolerance, and impaired cognition related to dementia, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident's cognitive skills for daily decision making were severely impaired and that the resident was dependent and required supervision or touching assistance with ADL. During a concurrent observation and interview, Resident 43 was found lying in bed awake and was unkempt with greasy hair, whitish flakes on the head, and chin whiskers. A CNA stated the resident had little whiskers and needed to be shaved, and that the hair was a little oily and needed to be washed, but the resident was combative during care. The DON later stated the resident had oily hair and facial hair and needed grooming for health reasons and dignity. The facility's policy stated residents unable to carry out ADL would receive necessary services to maintain grooming.
Inadequate fall prevention for a high-risk resident
Penalty
Summary
The facility failed to implement appropriate fall prevention interventions for a resident who was at high risk for falls and had a recent history of falling. The resident was admitted with diagnoses including cerebral infarction, difficulty walking, and need for assistance with personal care. The record showed the resident had decision-making capacity, required partial to moderate assistance with lying, sitting, and transferring, and had a fall risk score of 11. The care plan identified the resident as at risk for falls after an actual fall in which the resident slid slowly from the bed to the floor, but the care plan did not include a goal and only noted that the resident needed a safe environment. After the fall, documentation stated the resident was found on the floor next to the bed on the left side after trying to turn in bed and sliding slowly to the ground. During a later observation, the resident was seen leaning toward the left side of the bed, and the mattress did not have equal sized side borders. The resident stated the mattress caused leaning to the left and that the resident had already fallen. The resident also stated staff had placed pillows on the left side so the resident would not fall when leaning left. An LVN observed that the left upper side of the mattress did not have a border like the right side and stated the mattress company would be called to check whether it needed repair.
Unlabeled Oxygen Humidifier Bottle
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident 25. Resident 25 was admitted with diagnoses including chronic respiratory failure with hypoxia and COPD. The resident’s MDS indicated cognition was intact, and the care plan identified oxygen therapy related to CHF and respiratory illness, with the resident at risk for respiratory distress and changes in respirations. During an observation in the resident’s room, Resident 25 was resting in bed and receiving 2 liters of oxygen via nasal cannula with a humidifier bottle. The humidifier bottle was not labeled with a date. Staff interviews indicated the humidifier bottles and nasal cannulas were changed weekly and as needed, and that the bottles should be labeled with the date they were changed. The DSD stated the tubing and humidifier bottles were changed and dated together, and confirmed Resident 25’s humidifier was not labeled with a date. The facility policy stated that when a disposable humidifier bottle is used, the person changing the water should label it with a date.
Infection Control Lapses With Unlabeled Personal Item and Missing EBP
Penalty
Summary
The facility failed to maintain infection prevention and control practices for four sampled residents by not properly labeling and storing a personal care item in a shared restroom and by not implementing an ordered Enhanced Barrier Precautions (EBP) protocol for a resident with an open wound. The deficient practice was identified through observation, interview, and record review and involved Resident 21, Resident 61, Resident 66, and Resident 120. Resident 21 was admitted and later readmitted with diagnoses including osteomyelitis of the thoracic vertebrae and bacteremia. The resident’s H&P described the resident as alert and oriented x4, and the MDS indicated intact cognitive skills and independence with personal hygiene. Resident 61 was admitted with COPD with exacerbation and UTI; the H&P stated the resident had capacity to understand and make decisions, and the MDS indicated intact cognitive skills with supervision or touching assistance needed for personal hygiene. During observation of their shared restroom, an unlabeled 1.5 oz can of shaving cream was found on the sink. The housekeeper stated it was not labeled and was going to be thrown away. Resident 61 stated the shaving cream had been there a while. CNA 1 and the Infection Preventionist stated shaving cream was a personal item that should be labeled with the resident’s name and stored at the bedside, and the facility policy required personal care items to be labeled and stored in designated personal storage areas. Resident 66 was admitted with cellulitis, pressure ulcer, and need for assistance with personal care. The MDS indicated intact cognition, partial/moderate assistance with ADL, and substantial/maximal assistance with mobility. The resident had an active physician order for EBP for high resident contact care activities related to a diabetic wound, and the record showed a right heel diabetic foot ulcer that remained open after debridement and continued daily wound care. During observation, no EBP signage was posted at the entrance or on the door of the shared room, and no EBP or PPE cart was visible. Resident 66 stated staff had not been observed wearing gowns when assisting with personal care. The Infection Preventionist stated residents with open wounds automatically required EBP, that a diabetic foot ulcer was an open wound, and that EBP should have been implemented immediately upon discovery and after debridement. LVN 7 confirmed the ulcer remained open and stated EBP should have been implemented and followed to prevent spread of infection and protect residents and staff.
Kitchen Refrigerator Air Curtain Missing Strip
Penalty
Summary
The facility failed to ensure the plastic strip air curtain on the walk-in refrigerator in Kitchen 1 was intact and in working condition. During an initial tour of Kitchen 1, the walk-in refrigerator door leading into the walk-in freezer and located next to the kitchen exit door was observed with a plastic air curtain that had a missing strip, leaving a six-to-eight-inch gap. The Dietary Services Supervisor stated the strip was missing and needed repair, and explained that the air curtain helped maintain cold air inside the refrigerator. During interviews, the Registered Dietician stated kitchen equipment, whether used or not, should be functioning and in working condition. The Administrator stated the walk-in refrigerator was older than 40 years, the air curtain was in use, and the facility did not have a copy of the air curtain's maintenance manual. The Maintenance Director stated he was informed of the missing air curtain strip on 2/12/2026. Facility policy stated equipment should remain in good working order for resident and staff safety, and that equipment instructions and manuals would be kept in the Maintenance Supervisor's Office.
Call Light Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that the call light was within reach for two sampled residents, Resident 3 and Resident 115, despite care plan interventions directing staff to keep the call light accessible and encourage its use for assistance. The deficiency was identified through observation, interview, and record review, and the facility policy titled Call Light stated that the call device should be within the resident’s reach before staff leave the room and that staff should not leave a resident unattended if the resident cannot reach the call light. Resident 3 was admitted with diagnoses including heart failure, dementia, Type 2 diabetes mellitus, difficulty walking, and need for assistance with personal care. The care plan identified Resident 3 as at risk for falls related to impaired balance and mobility and directed staff to ensure the call light was within reach. During observation, Resident 3 was sitting in a wheelchair and stated wanting a nurse, but was unable to find the call light to call for assistance. The DON stated the importance of having a call light within reach was for residents to use it when they had a need and have their needs met. Resident 115 was admitted with diagnoses including reduced mobility and need for assistance with personal care. The care plan for falls directed staff to ensure the call light was within reach, and the H&P indicated Resident 115 could make needs known but could not make medical decisions. The OT evaluation noted impaired strength in both upper extremities, and the MDS showed moderately impaired cognitive skills, dependence with ADLs, and total incontinence. During observation, Resident 115 was lying in bed with moderate contractures in both upper extremities, and the touch call pad was tucked underneath a pillow by the left bed siderail near the shoulder. Resident 115 stated being unable to use and press the call light and said it was hard to call for help. The LVN also observed the call pad tucked under the pillow and stated it should be within reach so needs could be answered promptly.
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 | ★★★★★ | 26 | 0 |
| Woods Health Services | 1.7 mi | ★★★★★ | 25 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.