Health inspection·November 30, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm including the POLST and the AD from the resident or the responsible party on the day of admission. The MDSC stated, it was the Social Services Director's responsibility to follow up on the resident's AD. The MDSC stated, she could not find follow up notes from the Social Services Director. The MDSC stated, it was important to provide the resident with information about AD, and/or the POLST to be completed so the facility will know what to do according to the resident's wishes in case a resident had a change in condition. Residents Affected - Some During an interview on 11/29/23 at 2:35 p.m. with the Social Services Director (SS), the SS stated, it was the responsibility of the nurse who admitted the resident to inquire and explain about AD and the SS would follow up. The SS stated, if there was no AD, the SS would follow up with the resident or responsible party every quarter to offer. The SS stated, the POLST should be completed so the facility will know the resident's wishes as far as medical decisions in an event of an emergency. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, revised 10/2023, the P&P indicated, Further, it is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, to formulate an advance directive. The P&P indicated, Prior to, upon, or immediately after admission, the facility staff will ask residents, and/or their family members, about the existence of any advance directives. During a review of the facility's P&P titled, Physician Orders for Life Sustaining Treatment (POLST), dated 10/2023, the P&P indicated, The admitting nurse will note the existence of the POLST form on the admission assessment and review the form for completeness. 2.During a review of Resident 32's AR dated 11/30/2023, the AR indicated Resident 32 was admitted on [DATE], with a diagnoses of acute and chronic respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body), other reduced mobility (unsteadiness while walking, difficulty getting in and out of a chair, or falls), and need for assistance with personal care. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 is cognitively intact (a participant who has sufficient judgment) for daily decision making. The MDS indicated Resident 32 required partial/moderate assistance (helper does less than half the effort) for showering. The MDS also indicated Resident 32 is independent with eating and oral hygiene. During a concurrent interview and record review on 11/28/2023 at 12:39pm., with MDS Coordinator (MDSC), the MDSC stated, the admitting nurse will ask the family and resident if they have an advance directive and the Social Services Director is the person in charge of following up. The MDS Coordinator confirmed Resident 32's Advance Directive is not signed and stated, Yes, that's not filled out, but it should be. The MDSC also stated, if a resident does not have an Advance Directive, We don't know what to do with the patient. During a review of the facility's P&P titled, Advance Directives, revised 10/2023, the P&P indicated, the facility staff will ask residents if they have an Advance Directives prior to or right after admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 2 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to ensure any abnormal vital signs for one of one sampled resident (Resident 83) was reported to the physician timely. Residents Affected - Few This failure had the potential to result in a decline in Resident 83's condition due to a delay in the delivery of treatment and services. Findings: During a review of Resident 83's admission Record (AR), the AR indicated the facility originally admitted Resident 83 on 10/1/2023 with multiple diagnoses including sepsis (body's extreme response to infection), hypovolemic shock (life-threatening condition wherein severe blood or fluid loss causes the heart's inability to pump enough blood to the body), urinary tract infection, and acute kidney failure (condition when the kidneys do not filter waste products from the blood). During a review of Resident 83's History and Physical Examination (H&P), dated 10/12/2023, the H&P indicated Resident 83 had the capacity to understand and make decisions. During a review of Resident 83's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 10/14/2023, the MDS indicated Resident 83 had moderate impairment in cognition (ability to understand and process information). During a concurrent interview and record review on 11/30/2023 at 11:20 a.m. with Registered Nurse 1 (RN 1), Resident 83's blood pressure (BP, pressure of blood against the wall of arteries with a reading of less than 90/60 millimeters of mercury [mm Hg, unit of pressure] considered as low BP) trends and progress notes were reviewed. RN 1 stated on 10/10/23, Resident 83 had a BP reading of 84/60. RN 1 stated Resident 83's BP of 84/60 was very low and required a physician notification to obtain orders for possible closer monitoring, labs, or transfer to the hospital for evaluation. RN 1 stated there were no documented evidence that the physician was notified of the change, or any new orders were received for the BP of 84/60 on 10/10/2023. During a review of the facility's policy and procedures (P&P), titled Change of Condition Reporting, dated 10/2023, the P&P indicated the facility must communicate all changes in the resident condition to the physician. The P&P indicated the resident change of condition must be documented in eInteract Change of Condition UDA and in the nursing progress notes. The P&P indicated all attempts to reach the physician and responsible party must be documented in the nursing progress notes, including the time and response. The P&P indicated the licensed nurse responsible for the resident must continue assessment and documentation every shift for at least 72 hours or until the condition is stable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 3 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure seven of seven Resident Council members (Resident 7, 15, 17, 34, 39, 48, and 61) and one alert and oriented resident (Resident 47) knew how to file a grievance (official statement of a complaint) and the identity of the facility's designated Grievance Official. The facility also failed to include the contact information of the facility's Grievance Official in the facility's policy and procedure (P&P) for grievances. These failures violated the rights of Residents 7, 15, 17, 34, 39, 48, 61 and 47, and had the potential for the residents to feel the facility did not hear or address the residents' concerns. Findings: During a review of the Resident Council Minutes (official record of a meeting), dated 8/29/2023, the Resident Council Minutes indicated the residents reviewed the topic of grievances including the right to voice grievances without discrimination (unjust treatment) and reprisal (act of returning an attack). During a review of the Resident Council Minutes, dated 9/28/2023, the Resident Council Minutes indicated the topic of grievances was discussed, including the person in charge of grievances. The Resident Council Minutes indicated the Social Services Director (SSD) oversaw grievances and the SSD's picture was presented to the resident council. During a group interview on 11/27/2023 at 2:30 PM with seven residents who attended monthly Resident Council Meetings, all seven residents did not know who the facility's Grievance Official was and how to file a grievance. During a review of Resident 34's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 9/2/2023, the MDS indicated Resident 34 was cognitively intact (able to think, understand, learn, and remember). During the group interview on 11/27/2023 at 2:30 PM, Resident 34 stated, All we do (during the meeting) is complain. Resident 34 stated the residents usually informed the Activity staff (Activity 1) of any concerns. Resident 34 stated Resident 34 had written concerns on a piece of paper which Resident 34 gave to the nurse (unknown). Resident 34 did not know of any specific form to express concerns. During a follow-up interview on 11/27/2023 at 3:12 PM, Resident 34 did not recall being informed about grievances or who to talk to. During a concurrent interview and record review on 11/28/2023 at 4:31 PM with the Activity Director (AD), the AD stated the Resident Council members were educated on how to express concerns and showed a picture of the SSD at every meeting to inform the residents of the facility's Grievance Officer. The AD reviewed the Resident Council Minutes from 4/2023 to 10/2023. The AD stated the Resident Council Minutes, dated 9/29/2023, indicated residents were provided the SSD's picture. The AD reviewed the Resident Council Minutes from 4/2023, 5/2023, 6/2023, 7/2023, and 10/2023 and stated they did not indicate the AD educated and showed the residents the picture of the SSD as the Grievance Officer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 4 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 11/29/2023 at 4:12 PM with the SSD, the SSD confirmed the SSD's role as the facility's Grievance Official. The SSD also pointed out a notice posted on a bulletin board located in the hallway which indicated the SSD was the Grievance Official. The SSD provided the Grievance/Complaint Logs (collection of monthly grievances) from 1/2023 to 11/2023. During a review of the undated notice posted on the facility's bulletin board, the notice indicated the facility's Grievance Official was the SSD and included the SSD's telephone number and location in the facility. A review of the monthly Grievance/Complaint Log included the following: 1/2023 - no grievances 2/2023 - one grievance 3/2023 - one grievance 4/2023 - two grievances 5/2023 - one grievance 6/2023 - no grievances 7/2023 - no grievances 8/2023 - two grievances 9/2023 - two grievances (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 5 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0585 10/2023 - one grievance Level of Harm - Minimal harm or potential for actual harm 11/2023 - one grievance. Residents Affected - Some During a review of the facility P&P titled, Grievances, dated 10/2023, the P&P indicated the Grievance Resolution Form was available from the SSD, the Administrator (ADM), and at the nursing stations. The P&P did not indicate the facility's Grievance Official and contact information. During a concurrent interview and review of the Grievance P&P on 11/30/23 at 9:02 AM with the ADM, the ADM stated the SSD was the Grievance Officer while the ADM was the Grievance Official. The ADM stated the ADM was the Grievance Official since the ADM evaluated and investigated the concerns and took appropriate action. The ADM stated the contact information of the Grievance Official was not included in the Grievance P&P. During a review of Resident 47's MDS, dated [DATE], the MDS indicated Resident 47 was cognitively intact. During an interview on 11/30/2023 at 9:16 AM with Resident 47, Resident 47 did not know which facility staff member handled residents' concerns. Resident 47 knew the SSD's name but did not know the SSD's role at the facility. Resident 47 knew the ADM's name but did not know the ADM's role in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 6 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the care plan for two of two sampled residents (Resident 21and 5). 1. For Resident 21, the facility failed to implement the care plan related to Resident 21's fluid restrictions to address the fluid imbalances related to the resident's kidney failure and hemodialysis (mechanical filtering of the blood when the kidneys are not working properly). 2. For Resident 5, the facility failed to implement the care plan related to Resident 5's oxygen therapy. These failure had the potential to result in the decline of Resident 5 and 21's physical and psychosocial well-being. Findings: 1. During a review of Resident 21's admission Record (AR), the AR indicated the facility admitted Resident 21 on 5/27/2023, with multiple diagnoses including acute kidney failure with dependence on hemodialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) and multiple sclerosis (long-lasting disease of the central nervous system). During a review of Resident 21's History and Physical Examination (H&P), dated 5/30/2023, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 11/1/2023, the MDS indicated Resident 21 had no impairment in cognition (ability to understand or process information). During a review of Resident 21's Order Summary Report (OSR), the OSR indicated the following active physician's orders for 11/2023: 1. Date Ordered: 5/29/2023 - Monitor PO (taken orally) intake after meals 2. Date Ordered: 6/9/2023 - Fluid restriction of 1,200 milliliters (ml) per day - Dietary = 480 ml (Breakfast 240 ml, Lunch - 120 ml, Dinner - 120 ml), Nursing = 720 ml (7-3 = 360 ml, 3-11 = 240 ml, 11-7 = 120 ml) every shift related to the kidney disease, requiring hemodialysis During a review of Resident 21's care plans related to fluid restrictions, the following were indicated: 1. Resident 21's need for hemodialysis related to renal failure, dated 5/29/2023, indicated interventions included 1200 ml/day fluid restriction and monitor intake and output. 2. Resident 21's preference to keep water pitcher at the bedside, dated 11/27/2023, indicated interventions included providing the resident with education on risks and benefits regarding nonadherence to fluid restriction. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 7 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 21's Change in Condition note, dated 11/27/2023 timed at 9:22 a.m., Registered Nurse 1 (RN 1) documented she notified Resident 21's sister that Resident 21 prefers to have water pitcher by bedside table. During a concurrent observation and interview on 11/27/2023 at 12:06 p.m. with Resident 21's Family Member 1 (FM 1), FM 1 stated she received a phone call from the facility nurse on 11/27/2023 (same day) regarding restricting Resident 21's fluid restrictions and Resident 21's refusal to give her water pitcher to the staff. FM 1 stated they were unaware of the reason why there was a sudden change in her fluid intake and restrictions were initiated, since Resident 21 started hemodialysis in 5/2023. FM 1 stated she was not aware of any recent change in the resident's condition, particularly the resident's fluid balance. Resident 21's water pitcher was observed on the overbed table. During an interview on 11/29/2023 at 11:17 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 21 did not have any fluid restrictions. CNA 1 stated she would give/refill Resident 21's water pitcher on the overbed table once or twice per shift when Resident 21 would request for more. During an interview on 11/29/2023 at 3:07 p.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated she documented a total of 600 ml for Resident 21's fluid intake for the 7 a.m. to 3 p.m. shift. LVN 4 stated Resident 22 had 240 ml of fluids in her meal tray during breakfast, 120 ml of fluids in her meal tray during lunch, 120 ml extra fluids during medication pass in the morning, and 120 ml extra fluids during medication pass at lunch. LVN 4 stated she documented Resident 21's fluid intake based on Resident 21's fluids on her meal tray. LVN 4 stated CNA 1 was supposed to let her know when Resident 21 would request a refill of her water pitcher. During an interview on 11/30/2023 at 9:45 a.m. with CNA 3, CNA 3 stated she was aware that the fluid intake of Resident 21 must be recorded. CNA 3 stated she would document 100 ml for apple or cranberry juice (served in 4-ounce or 120-ml cup) if Resident 21 drank it all. CNA 3 stated she would document 250 ml for the tea (served in an 8-ounce or 240-ml cup). CNA 3 stated she would not document the water intake of Resident 21 from the water pitcher. CNA 3 stated she would sometimes refill the water pitcher once per shift. During a concurrent interview and record review on 11/30/2023 at 10:27 a.m. with Registered Nurse 1 (RN 1), Resident 21's physician orders, progress notes, and care plans were reviewed. RN 1 stated the facility practice was not to allow residents on fluid restrictions to have a water pitcher at the bedside. RN 1 stated all assigned staff must be monitoring Resident 21's intake accurately and restricting the resident's fluids consistently as ordered by the physician to prevent fluid overload that would further compromise the resident's kidneys and/or heart. RN 1 stated she could offer Resident 21 some ice chips instead of water refill if Resident 21 was about to go over the fluid restrictions. During a review of the facility's policy and procedures (P&P) titled, Comprehensive Person-Centered Care Planning, dated 10/2023, the P&P indicated the Interdisciplinary Team (IDT, team members from different disciplines working collaboratively to set goals and make decisions) must develop a comprehensive person-centered care plan to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. The P&P stated the care plans must include healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 8 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0656 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedures (P&P) titled, Fluid Restriction, dated 10/2023, the P&P indicated the facility must provide fluids as specified in the physician's orders to ensure fluid needs are met while not exceeding limits established by the physician. The P&P indicated the resident must be educated regarding the benefits of compliance/risks of noncompliance with the fluid intake parameters as needed. Residents Affected - Some 2.During a review of Resident 5's AR, the AR indicated Resident 5 was readmitted to the facility on [DATE] with diagnoses that included heart failure (the inability of the heart to pump blood effectively), pneumonia (inflammation of the lungs due to a bacterial or viral infection), personal history of pulmonary embolism (blockage of the blood vessels that send blood to the lungs), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), Alzheimer's disease (a condition in which brain cells degenerate accompanied by memory loss, physical decline, confusion and dementia) and dementia (a gradual decline in mental ability). During a review of Resident 5's focused care plan for Oxygen Therapy continuously for ineffective gas exchange due to congestive heart failure (CHF - a chronic [long standing] condition in which a weakness of the heart leads to a buildup of fluid in the lungs), initiated on 11/9/2023, the care plan indicated Resident 5's oxygen settings at 2 liters via nasial cannula or mask to maintain oxygen saturation above 92%. During an observation on 11/28/2023 at 12:39 pm., and continuous observation on 11/29/2023 from 11:18 AM to 12:27 PM, at Resident 5's bedside, no oxygen therapy being administered to Resident 5. No nasal cannula or mask connected to Resident 5. During a concurrent observation and interview on 11/29/2023 at 12:17 pm., with Licensed Vocational Nurse (LVN) 2, at Resident 5's bedside, LVN 2 confirmed no oxygen therapy is being administered to Resident 5. LVN 2 stated the risks of a resident not receiving oxygen includes the resident not being able to breathe, anxiety, shortness of breath and no proper gas exchange. During an interview on 11/30/2023 at 4:36 PM with the Director of Nursing (DON), the DON stated the risks of a resident not receiving oxygen as ordered include oxygen desaturation (when the amount of oxygen in your blood drops below the normal level), respiratory distress, unnecessary hospitalizations, increased confusion and delirium (a mental state in which you are confused, disoriented, and not able to think or remember clearly). During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, (undated), the policy indicated the interdisciplinary team (IDT) will also develop and implement a baseline care plan for each resident that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, (undated), the policy indicated that the purpose of the oxygen therapy is to provide sufficient oxygen to the blood stream and tissues. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 9 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview, and record review, the facility failed to revise the care plans for bowel/bladder incontinence (inability to hold urine or stool) and skin problems for one of one sampled resident (Resident 21). This failure resulted in Resident 21's confusion and frustration of Resident 21's plan of care related to fluid intake (fluid consumed, daily) vs. fluid restriction (restriction of fluid intake consumed, daily), causing Resident 21 to become teary-eyed from the misinformation the facility was providing Resident 21. Findings: During a review of Resident 21's admission Record (AR), the AR indicated the facility readmitted Resident 21 on 5/27/2023 with multiple diagnoses including acute kidney failure with dependence on hemodialysis (mechanical filtering of the blood when the kidneys are not working properly) and multiple sclerosis (long-lasting disease of the central nervous system). During a review of Resident 21's History and Physical Examination (H&P), dated 5/30/2023, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 11/1/2023, the MDS indicated Resident 21 had no impairment in cognition (ability to understand or process information). During a review of Resident 21's Order Summary Report (OSR), the OSR indicated the following active physician's orders for 11/2023: 1. Date Ordered: 5/29/2023 - Monitor PO (taken by mouth) intake after meals 2. Date Ordered: 6/9/2023 - Fluid restriction of 1,200 milliliter (ml, unit of volume) per day - dietary 480 ml (Breakfast - 240 ml, Lunch - 120 ml, Dinner - 120 ml), Nursing - 720 ml (7-3 p.m. = 360 ml, 3-11 p.m. = 240 ml, 11-7 a.m. = 120 ml) every shift for end-stage renal disease on hemodialysis During a review of Resident 21's care plans (CPs), the following interventions were indicated: 1. Resident 21's potential for pressure sore (skin injury due resulting from limited blood flow to the skin due to pressure against it) development CP, dated 5/27/2023 - Encourage fluid intake and assist to keep skin hydrated. 2. Resident 21's need for hemodialysis related to renal failure CP, dated 5/29/2023 - 1200 ml/day fluid restriction and Monitor intake and output. 3. Resident 21's bowel/bladder incontinence CP, dated 6/7/2023 - Encourage fluids during the day to promote prompted voiding responses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 10 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Resident 21 has potential/actual impairment to skin integrity CP, dated 8/2/2023 - Encourage good nutrition and hydration in order to promote healthier skin. 5. Resident 21's Moisture-Associated Skin Damage (MASD, inflammation or skin erosion caused by prolonged exposure to a source of moisture) to left buttocks extending to inner buttocks CP, dated 9/26/2023 - Encourage good nutrition and hydration in order to promote healthier skin. 6. Resident 21's green discoloration above left antecubital (arm region in front of the elbow) CP, dated 11/15/2023 - Encourage good nutrition and hydration in order to promote healthier skin. 7. Resident 21 has right lateral malleolus (bony prominence of the ankle) deep tissue injury (localized area of tissue damage due to absent or significantly diminished blood flow) CP, dated 11/15/2023 - Encourage good nutrition and hydration. 8. Resident 21's preference to keep water pitcher at the bedside, dated 11/27/2023 - Provide with education on risks and benefits regarding nonadherence to fluid restriction. During a concurrent observation and interview on 11/27/2023 at 12:06 p.m., in Resident 21's room, Resident 21's Family Member 1 (FM 1) stated she received a phone call from the facility nurse (unspecified) on 11/27/2023 (same day) regarding restricting Resident 21's fluid restrictions and Resident 21's refusal to give her water pitcher to the staff. FM 1 stated FM 1 was unaware of the reason why there was a sudden change in Resident 21's fluid intake and why restrictions were initiated since Resident 21 started hemodialysis in 5/2023. FM 1 stated FM 1 was not aware of any recent change in Resident 21's condition, particularly Resident 21's fluid balance. Resident 21's water pitcher was observed on the overbed table. During an interview on 11/29/2023 at 11:17 a.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 21 did not have any fluid restrictions. CNA 1 stated CNA 1 would give/refill Resident 21's water pitcher on the overbed table once or twice per shift when Resident 21 would request for more. During a concurrent observation and interview on 11/29/2023 at 3:15 p.m. with Resident 21, in Resident 21's room, Resident 21's water pitcher with iced water was observed on top of Resident 21's overbed table. Resident 21 stated Resident 21 was so confused about what to do anymore because some staff told her to drink as much water to prevent dehydration and keep Resident 21's skin healthy, but the other staff (unspecified) were also telling her now Resident 21 had to restrict Resident 21's fluid intake. Resident 21 was observed teary-eyed during the interview. Resident 21 stated Resident 21 was so frustrated about the situation regarding Resident 21's fluid restrictions, especially since it was not a problem to have Resident 21's water pitcher at the bedside before. During an interview on 11/30/2023 at 9:45 a.m., CNA 2 stated CNA 2 did not include in Resident 21's intake documentation Resident 21's water intake. CNA 2 stated she would document 100 ml for apple or cranberry juice (served in 4-ounce or 120-ml cup) if Resident 21 drank it. CNA 2 stated CNA 2 would document 250 ml for the tea (served in an 8-ounce or 240-ml cup). CNA 2 stated CNA 2 would not document the water intake of Resident 21 from the water pitcher. CNA 2 stated CNA 2 would sometimes refill the water pitcher once per shift. During a concurrent interview and record review on 11/30/2023 at 10:27 a.m. with Registered Nurse 1 (RN 1), Resident 21's physician orders, progress notes, and care plans were reviewed. RN 1 stated when RN 1 did resident rounds in the morning on 11/27/2023, RN 1 saw Resident 21's water pitcher on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 11 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the overbed table, but Resident 21 verbalized wanting to keep her water pitcher at the bedside. RN 1 stated the facility practice was not to allow residents on fluid restrictions to have a water pitcher at the bedside. RN 1 stated all assigned staff must be monitoring Resident 21's intake accurately and restricting Resident 21's fluids consistently as ordered by the physician to prevent fluid overload that would further compromise Resident 21's kidneys and/or Resident 21's heart. RN 1 stated RN 1 could offer Resident 21 ice chips instead of water refills if Resident 21 was about to go over the fluid restrictions. RN 1 stated the bowel/bladder incontinence and skin care plans were not revised to address Resident 21's fluid restrictions as ordered by the physician. RN 1 stated it was important to update all the care plans to ensure all staff would consistently implement the correct plan of care for Resident 21. During a review of the facility's policy and procedures (P&P), titled Comprehensive Person-Centered Care Planning, dated 10/2023, the P&P indicated the resident care plans must be reviewed and/or revised by the interdisciplinary team (IDT, group of individuals from different disciplines that work with the resident and/or responsible party to determine the residents' plan of care) after each assessment. During a review of the facility's policy and procedure (P&P), titled Fluid Restriction, dated 10/2023, the P&P indicated the facility must provide fluids as specified in the physician's orders to ensure fluid needs are met while not exceeding limits established by the physician. The P&P indicated the resident must be educated regarding the benefits of compliance/risks of noncompliance with the fluid intake parameters as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 12 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, Licensed Vocational Nurse (LVN) 1 failed to monitor Resident 238's heart rate prior to administering blood pressure medication per the parameters indicated in the physician orders. Residents Affected - Few This deficient practice had the potential to result in Resident 238 having an increased risk for complications related to the management of blood pressure, dizziness and falls. Findings: During a review of Resident 238's Admissions Record dated 11/27/23, Admissions Record, indicated Resident 238 was admitted to the facility on [DATE] with a diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), hyperlipidemia (abnormally high concentration of fats in the blood), anemia (condition where your blood produces a lower than normal amount of healthy red blood cells), atherosclerotic heart disease (a condition characterized by the buildup of fats, cholesterol and other substances in and on the artery walls) and malignant pleural effusion (the buildup of fluid and cancer cells that collects between the chest wall and the lung). A review of Resident 238's History and Physical (H&P) dated 11/27/23, the H&P indicated Resident 238 had the capacity to understand and make decisions. A review of Resident 238's care plan for hypertension (high blood pressure) indicated to give Carvedilol (medication used to lower blood pressure) as ordered with a goal to remain free of complications related to hypertension. During an observation on 11/29/23 at 8:29 AM in Resident 238's room, LVN 1 gave Resident 238 Carvedilol 3.125 mg tablet without first measuring the heart rate to make sure the heart rate was within acceptable parameters as defined in the physician's orders. During an interview on 11/29/23 at 9:11 AM with Registered Nurse Supervisor (RN)1, RN 1 stated that prior to giving Carvedilol, the nurse should check the blood pressure and heart rate of the resident because the medication could drop the heart rate quickly and the resident could get chest pain or other heart problems. During a concurrent interview and record review on 11/29/23 at 9:35 AM with LVN 1, Resident 238's physician orders were reviewed. The physician orders indicated, Carvedilol Oral Tablet 3.125 milligram (mg) tablet. Give 1 tablet by mouth two times a day for HTN (hypertension) hold for BP (blood pressure) less than 100 MMHG (millimeters of mercury) or HR (heart rate) less than 60 BPM (beats per minute). LVN 1 stated that if physician orders are not followed it could cause harm to the resident by lowering the heart rate and make a patient dizzy and more prone to falls. During a review of the facility's policy and procedure, titled, Administration Process, undated, indicated that medications must be administered in accordance with the written orders of the attending physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 13 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 10), was provided the preferred choice of activities. Residents Affected - Few This deficient practice resulted in Resident 10 being bored and had the potential to result in a decline in Resident 10's physical, mental, and psychosocial well-being. Findings: During a review of Resident 10's admission Record (AR), the AR indicated, Resident 10 was admitted on [DATE] with multiple diagnoses including multiple pressure ulcers (also known as bedsores, are wounds that occur because of prolonged pressure on a specific area of the skin) stage 3 (involves full-thickness tissue loss), stage 4 (most severe with injuries extending to muscle, tendon, or bone) and unstageable (when stage is not clear due to base of the wound is covered by a layer of dead tissue), quadriplegia (paralysis of all four limbs), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 10's History and Physical Examination (H&P), dated 4/6/23, the H&P indicated, Resident 10 had the capacity to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/4/23, the MDS indicated, Resident 10's cognitive (ability to think and reason) status for daily decision making was intact and was dependent for activities of daily living. During a review of Resident 10's Activity - admission Evaluation AAE), dated 4/11/23, the AAE indicated, Resident 10's interests include word puzzles, cards, watching chiefs football and basketball on tv, watching the news on tv, listening to soul music, and reading who done it type books. The AAE indicated, Resident 10 will receive 1:1 in room programs to supply him with in room materials such as reading materials, word puzzles, and helping to put the tv on channels of interest. During a review of Resident 10's Care Plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan), titled Potential Alteration in diversional activities, initiated 4/11/23, the CP, indicated, one of the interventions included Resident 10's activities will be tailored to his customary routines and interests. During a review of Resident 10's Activity Participation (AP), dated 11/2023, the AP indicated, music, reminisce and leisure carts. The AP indicated, no documentation that word puzzles, card or read book were offered or provided. During an observation on 11/27/23 at 12:10 p.m. Resident 10 was observed awake and alert with a flat affect but pleasant, contracted, lying in bed on his right side on a low air loss mattress (LAL, a mattress designed to prevent and treat pressure ulcers) with a small tv on in front of him. Resident 10 stated, facility did not offer him of other activities other than washing him. Resident 10 stated, he only watches tv for activity but I be bored at that. Resident 10 stated, he was at least also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 14 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0679 listening to the radio when he was at the GACH. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 11/27/23 at 3:11 pm., with Resident 76 and the Emergency Contact (EC), Resident 10 was observed lying in bed on Resident 10's right side with the tv on. Resident 76 and the EC stated, they had never seen Resident 10 out of bed he just lays there, he wants to go home. The EC stated the EC had not observed staff providing Resident 10 with 1:1 activities. Residents Affected - Few During an observation on 11/28/23 at 2:10 pm., Resident 10 was observed resting in bed lying on his right side with the small tv located in front of Resident 10. During a concurrent observation and interview on 11/29/23 at 10:28 am., with Resident 10 and Certified Nursing Assistant (CNA) 7, Resident 10 was awake and alert, lying in bed lying on his right side with, the small tv was located in front of Resident 10. Resident 10 stated, Resident 10's interests included read me some books and listening to music, radio. Resident 10 stated, he had not been provided with Resident 10's preferred activities am completely bored, I want to go home. There were no books or radio observed at the bedside [in Resident 10's room]. CNA 7 stated, Resident 10 was always in bed and was only out of bed when Resident 10 had a doctor's appointment. CNA 7 stated, Resident 10 watched tv as an activity. During a concurrent observation and interview on 11/29/23 at 11:00 am., with Resident 10 in the presence of the Activity Assistant (AA), Resident 10 was awake and alert, lying on Resident 10's right side. Resident 10 stated, not yet when asked if staff had offered or provided him of his preferred interest of activity. The AA stated it was important to provide residents with their preferred activities of interest so they don't feel so bored. I know there's no place like home and we want them to feel like they're home and it was important for their mental state. During a review of the facility's policy and procedure (P&P) titled, Activity Policy and Procedure Manual, reviewed 10/2023, the P&P indicated, This facility is concerned with the needs and interests of each resident on an individual and group basis. The activity program will be designed to stimulate and support the resident's desire to use his/her physical and mental capability to their fullest extent and to enable the resident to maintain their highest attainable social, physical and emotional functioning and their usefulness and self-respect, but not necessarily correct or remedy a disability. The P&P indicated, If residents are unable to attend group activities, individual programs will be developed when appropriate. During a review of the facility's P&P titled, Accommodation of Needs, reviewed 10/2023, the P&P indicated, Staff will Review resident's preference and accommodate their needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 15 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and correctly apply a splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to one of six sampled residents (Resident 26) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] by failing to: 1. Ensure Resident 26 received passive range of motion (PROM, movement of joint through the ROM with no effort from the person) to the left arm from 11/13/2023 to 11/27/2023. 2. Provide PROM to Resident 26's left elbow prior to application of a left elbow extension splint (material used to extend or straighten the elbow as much as possible) on 11/28/23, and correctly apply a left elbow extension splint to the left elbow. These failures had the potential to further limit Resident 26's left arm ROM and promote the development of contractures (chronic joint stiffness). Findings: During a review of Resident 26's admission Record, the facility admitted Resident 26 on 9/16/2023 with diagnoses including acute respiratory failure (lungs are unable to get enough oxygen to the blood), unspecified atrial fibrillation (irregular and often very rapid heart rate), and hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area) affecting left non-dominant side. During a review of Resident 26's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 9/21/2023, the MDS indicated Resident 26 sometimes expressed ideas and wants, sometimes understood verbal content, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS also indicated Resident 26 required extensive assistance (resident involved in activity with staff providing support) for dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 26 had limited ROM in one arm. During a review of Resident 26's Occupational Therapy [OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)] Discharge summary, dated [DATE], the OT Discharge Summary included recommendations for Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) to perform exercises to both arms, application of the left elbow extension splint, and application of the left hand roll (soft splint placed in the palm of the hand to prevent fingers from closing). During a review of Resident 26's physician's orders, dated 11/13/23, the physician's orders indicated for RNA to perform right arm exercises using a two-pound (unit of measuring weight) dumbbell (hand held weight), five times per week (5x/week) as tolerated. Another physician's order, dated 11/13/23, indicated RNA for application of Resident 26's left elbow extension splint and left hand roll for four hours, 5x/week as tolerated. The physician's orders did not include any exercises for Resident 26's left arm. During a concurrent observation and interview on 11/28/2023 at 9:42 AM with Restorative Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 16 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Aide 1 (RNA 1) in Resident 26's room, Resident 26 was lying in bed wearing a hospital gown with the head-of-bed elevated. Resident 26's left elbow was in a bent position (elbow flexion) toward the body. RNA 1 performed PROM to Resident 26's left arm. RNA 1 repetitively raised the left arm to shoulder level (shoulder flexion), moved the left arm across the chest and away from the body (shoulder horizontal adduction and abduction), and attempted to straighten the fingers of the left hand. RNA 1 did not provide any PROM to the left elbow. RNA 1 stated she attempted to extend the elbow but could not straighten Resident 26's left elbow. RNA 1 was asked to demonstrate how to perform PROM of the left elbow. RNA 1 raised Resident 26's left arm to shoulder level and then moved the left arm across the chest and away from the body. During an observation on 11/28/2023 at 10:02 AM with RNA 1 in Resident 26's room, RNA 1 retrieved an elbow extension splint from Resident 26's bedside drawers. RNA 1 applied the elbow splint to Resident 26's left forearm. RNA 1 used the splint's straps to secure the splint just below Resident 26's left wrist, the middle of the left forearm, and just below Resident 26's left elbow. RNA 1 looked through Resident 26's drawers and did not locate the hand roll splint, which the RNA 1 stated may have been sent to the laundry. During a concurrent observation and interview on 11/28/2023 at 10:12 AM with Occupational Therapist 1 (OT 1) and RNA 1 in Resident 26's room, OT 1 stated Resident 26 was referred to RNA to perform two-pound dumbbell exercises to the right arm and to apply Resident 26's left elbow splint and left hand roll splint. OT 1 brought Resident 26 a new hand roll splint for the left hand. OT 1 observed the elbow extension splint applied to Resident 26's left forearm and stated it was not applied correctly. OT 1 stated recommending the left elbow splint to prevent the elbow from bending (elbow flexion). OT 1 performed PROM to Resident 26's left elbow joint into extension (straightening the elbow joint), applied the splint to the left elbow, and educated RNA 1 on proper application of the left elbow extension splint. OT 1 then performed PROM to Resident 26's fingers on the left hand and applied a left hand roll. During an interview on 11/28/2023 at 10:24 AM with RNA 1, RNA 1 stated the other RNA staff (in general) taught RNA 1 how to apply Resident 26's left elbow extension splint. RNA 1 stated, I put the splint on wrong. During an interview on 11/28/2023 at 10:26 AM with OT 1, OT 1 stated the RNA staff (in general) should be performing PROM to Resident 26's left elbow into extension prior to applying the elbow splint. The PROM exercises RNA 1 provided to Resident 26 was demonstrated on OT 1. OT 1 stated RNA 1 provided PROM exercises to the shoulder joint and did not perform PROM to the elbow joint. OT 1 stated RNA 1 applied the left elbow splint incorrectly. OT 1 stated it was important to properly apply the left elbow splint to prevent elbow flexion contractures. During a concurrent interview and record review on 11/29/2023 at 8:49 AM with the Director of Rehabilitation (DOR), the DOR reviewed Resident 26's physician's orders, RNA tasks (assigned work), and OT Discharge summary, dated [DATE]. The DOR stated Resident 26 was discharged from OT with recommendations for right arm exercises using a two-pound dumbbell and application of the left elbow extension splint and left hand splint. The DOR stated the RNA staff (in general) should provide PROM prior to applying the splints. The DOR reviewed Resident 26's physician's orders and RNA tasks. The DOR stated there was no physician's orders to provide PROM to Resident 26's left arm. The DOR reviewed the RNA tasks for Resident 26 and stated there was no documented evidence the RNAs provided PROM to the left arm. The DOR stated it was important to perform PROM to maximize Resident 26's ROM prior to applying the splints. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 17 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0688 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Policy and Procedure (P&P) titled, ROM and Contracture Prevention, dated 10/2023, the P&P indicated the facility ensured residents receive services, care and equipment to assure that: every resident maintains, and/or improves his/her highest level of range of motion (ROM) and mobility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 18 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory services were provided for two of two sampled residents (Residents 19 and 5). The facility did not follow the physician's orders to provide continuous oxygen therapy (administration of oxygen with the intent of treating or preventing the symptoms and manifestations of decreased level oxygen in tissues) for Residents 19 and 5. Residents Affected - Some This failure resulted in incomplete respiratory care and had the potential to result in respiratory distress to Residents 19 and 5. Findings: a.During a review of Resident 19's admission Record (AR), dated, the AR indicated the facility initially admitted Resident 19 on 10/8/2023 with multiple diagnoses including epilepsy (seizure disorder due to abnormal nerve cell activity in the brain), dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), sepsis (body's extreme response to infection), and acute upper respiratory infection (URI, short-term infections of the nose and throat caused by viruses and bacteria). During a review of Resident 19's History and Physical Examination (H&P), dated 10/10/2023, the H&P indicated Resident 19 did not have the capacity to understand and make decisions. During a review of Resident 19's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 10/13/2023, the MDS indicated Resident 19 had severe impairment in cognition (ability to understand and process information). The MDS indicated Resident 19 had impairment on one side of the upper extremities (arms). The MDS indicated Resident 19 required substantial/maximal assistance with rolling to the left and right while in bed and sitting-to-lying down positions. During a review of Resident 19's Order Summary Report (OSR) for 11/2023, the OSR included a physician's active order, dated 10/8/2023, to administer oxygen at 2 liters (L, unit of volume) per minute (LPM) by nasal cannula (NC, tubing device placed in the nares [openings of the nose] and used to deliver supplemental oxygen) continuously to keep the oxygen saturation (oxygen level in the blood) above 92% (percent) every shift. During an observation on 11/29/2023 at 9:08 a.m., Resident 19 did not have the NC connected to Resident 19 's nares. Resident 19 did not appear restless or in any distress. During an observation on 11/29/2023 at 9:29 a.m., Resident 19 did not have the NC connected to Resident 19 's nares. Resident 19 did not appear to be restless or in any distress. Certified Nursing Assistant 1 (CNA 1) was observed assisting Resident 19's roommate in the same room. During an observation on 11/29/2023 at 10:01 am., Resident 19 did not have the NC connected to Resident 19 's nares. Resident 19 did not appear restless or in any distress. Two staff were observed in the same room assisting Resident 19's roommate during rehabilitation therapy. During an observation on 11/29/2023 at 10:23 am., Resident 19 did not have the NC on connected to Resident 19 's nares. Resident 19 did not appear restless or in any distress. Resident 19's call light (visual cue indicating a resident needs assistance) was observed to be activated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 19 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 11/29/2023 at 10:26 am., Registered Nurse 1 (RN 1) responded to the call light. Immediate observation after RN 1 left the Resident 19's room indicated Resident 19 did not have the NC connected to Resident 19 's nares. Resident 19 did not appear restless or in any distress. During an interview on 11/29/2023 at 10:27 am., RN 1 was unable to state if Resident 19's physician's order indicated continuous oxygen therapy. RN 1 stated Resident 19's oxygen saturation was okay without oxygen. During a concurrent observation and interview on 11/29/2023 at 10:29 am. with CNA 1, Resident 19 did not have the NC on Resident 19's nares. Resident 19 did not appear restless or in distress. CNA 1 immediately put back the nasal cannula on Resident 19. Resident 19 initially resisted CNA 1, with further prompting, Resident 19 allowed CNA 1 connected the NC on Resident 19's nares. CNA 1 stated Resident 19 sometimes takes it (nasal cannula) off. CNA 1 stated Resident 19 would get angry when you initially put the NC back on, but Resident 19 would let CNA 1 connected the NC back on Resident 19's nares and Resident 19 kept the NC in place. During a concurrent observation and interview on 11/29/2023 at 10:40 am. with RN 1, Resident 19's oxygen saturation fluctuated between 97% to 98% while on room air (without oxygen therapy). RN 1 stated RN 1 verified the physician's order for Resident 19's oxygen therapy was continuous, but RN 1 was unable to state the reason Resident 19's oxygen therapy was ordered to be administered continuously by the physician. During a concurrent interview and record review on 11/30/2023 at 11:03 am., with RN 1, Resident 19's diagnoses, physician's orders, and care plans were reviewed. RN 1 stated Resident 19's oxygen therapy must be administered continuously to prevent potential immediate respiratory distress. RN 1 stated there was a care plan, dated 10/24/2023, regarding episodes of Resident 19 removing Resident 19's NC. RN 1 stated the frequency of visual checks for Resident 19 must be no less than every 30 minutes due to Resident 19's behavior of removing Resident 19's NC. RN 1 stated during the start-of-shift huddles, the licensed nurses should remind all staff to monitor Resident 19's NC placement, in case the assigned CNA was [busy] assisting another resident. b. During a review of Resident 5's AR, the AR indicated Resident 5 was readmitted to the facility on [DATE] with diagnoses that included heart failure (the inability of the heart to pump blood effectively), pneumonia (inflammation of the lungs due to a bacterial or viral infection), personal history of pulmonary embolism (blockage of the blood vessels that send blood to the lungs), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), Alzheimer's disease (a condition in which brain cells degenerate accompanied by memory loss, physical decline, confusion and dementia) and dementia (a gradual decline in mental ability). During a review of Resident 5's OSR, dated 11/26/2023, the OSR indicated an order for oxygen at 2 liters by NC continuously to maintain oxygen saturation above 92% every shift for ineffective gas exchange due to congestive heart failure (CHF - a chronic [long standing] condition in which a weakness of the heart leads to a buildup of fluid in the lungs). During an observation on 11/28/2023 at 12:39 pm., and continuous observation on 11/29/2023 from 11:18 AM to 12:27 PM, at Resident 5's bedside, no oxygen therapy was administered to Resident 5. No NC was connected to Resident 5. During a concurrent observation, interview, and record review on 11/29/2023 at 12:17pm., with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 20 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0695 Level of Harm - Minimal harm or potential for actual harm Licensed Vocational Nurse (LVN) 2, at Resident 5's bedside, Resident 5's current order for oxygen at 2 liters via nasal cannula continuously to maintain 02 saturation above 92% was reviewed. LVN 2 confirmed no oxygen therapy is being administered to Resident 5. LVN 2 stated the risks of a resident not receiving oxygen therapy includes the resident not being able to breathe, anxiety, shortness of breath and no proper gas exchange. Residents Affected - Some During an interview on 11/30/2023 at 4:36 pm., with the Director of Nursing (DON) stated?if a resident (in general) has an order for continuous oxygen at 2 liters, there should be a continuous flow rate of 2 liters and oxygen should always be given to the resident. The DON stated the risks of a resident not receiving oxygen as ordered [by the physician] included oxygen desaturation (when the amount of oxygen in your blood drops below the normal level), respiratory distress, unnecessary hospitalizations, increased confusion, and delirium (a mental state in which you are confused, disoriented, and not able to think or?remember clearly).? During a review of the facility's undated policy and procedure (P&P) titled, Oxygen Administration, (undated), the policy indicated that the purpose of the oxygen therapy is to provide sufficient oxygen to the blood stream and tissues. The Oxygen Administration P&P also indicated that oxygen therapy is administered must be administered by the licensed nurse as ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 21 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary care and services for one of one sampled resident (Resident 236) in accordance with Resident 236's physician's order to follow up with a urologist (a medical doctor that treat bladder issues) for Resident 236's urinary retention (unable to empty the bladder) Residents Affected - Few This failure had the potential to result in Resident 236 to experience a delay in treatment and had the potential to result in a physical decline to Resident 236 and affect the resident's overall well-being. Findings: During a review of the admission Record (AR), the AR indicated Resident 236 was admitted to the facility on [DATE] with diagnosis that included overactive bladder (sudden need to urinate) and major laceration (cut) of the spleen (an organ part of the immune system). During a review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 11/15/2023, indicated Resident 236's cognition (ability to understand and process information) was intact, had clear speech, had the ability to understand (clear comprehension) and be understood. The MDS also indicated Resident 236 was dependent (helper does all effort), when rolling from right to left, sit to lying, sit to stand, and toilet transfers. During a review of Resident 236's Order Summary Report, the report included a physician's order, dated 11/15/2023, and indicated an indwelling catheter (tube that drains urine from the bladder into a bag outside of the body) for diagnosis of urinary retention. During a review of Resident 236's Order Summary Report, the report included a physician's order, dated 11/21/2023, and indicated to schedule a urology consult for urinary retention. During a review of Resident 236's Care Plan (CP), created on 11/17/2023, the focus of the CP indicated Resident 236 was admitted to the facility with an indwelling catheter to support a diagnosis of urinary retention and the catheter was discontinued but Resident 236 was noted with bladder retention after the removal of the catheter and the catheter was re-inserted. The CP's interventions indicated a urology consult as ordered [by the physician]. During an interview and concurrent review of Resident 236's electronic and paper medical record, with the Minimum Data Set Coordinator (MDSC) on 11/29/2023 at 1:24 pm., the MDSC stated there was no documentation in Resident 236's medical record to indicate a follow up appointment was made with Resident 236's urologist. The MDSC stated it was the responsibility of social service staff or the case manager to obtain the authorization [for the appointment], schedule an appointment, and arrange transportation for medical consultations. The MDSC stated it was important for the physician's orders to be carried out to ensure interventions were applied to prevent worsening of Resident 236's urinary retention and for the benefit of Resident 236. During an interview and concurrent review of Resident 236's electronic and paper medical record, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 22 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with the Case Manager (CM) on 11/29/2023 at 10:45 am., the CM stated the CM attempted to follow up and set up an appointment for a urology consult for Resident 236 but the CM was busy with different tasks. The CM stated physicians' orders should be carried out as soon as possible to provide the best possible care for Resident 236. The CM stated Resident 236 was a short term (a short amount of time) resident, these residents were usually discharge within a few days and following orders in a timely manner was important. During a review of the facility's Case Manager Job Description, signed by the CM on 6/1/2023, indicated part of the CM duties and responsibilities included to provide case management services to provide case management services to sub-acute (skilled nursing care needed)/post-acute (return home) care to residents. Care Plan Assessment Functions included to review nurses' notes to determine if the care plan was being followed, Review and revise care plans and assessments as necessary, but at least quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 23 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the signed binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by an arbitrator [third party decision-maker] instead of a judge or jury in court) for one of one sampled residents (Resident 136) provided a selection of a convenient venue (location to carry out arbitration proceedings agreed upon and suitable to both parties). Residents Affected - Few This failure had a potential to result in a decline in Resident 136's physical and psychosocial wellbeing due to possible hardships related to arbitration proceedings. Findings: During a review of Resident 136's admission Record (AR), the AR indicated the facility initially admitted Resident 136 on 11/19/2023 with multiple diagnoses including heart failure, chronic (long standing) kidney disease, generalized osteoarthritis (joint tissues break down over time), and difficulty in walking. During a review of Resident 136's History and Physical Examination (H&P), dated 11/21/2023, the H&P indicated Resident 136 had the capacity to understand and make decisions. During an interview and concurrent review on 11/30/2023 at 1:59 pm., with Admissions Coordinator 1 (AC 1), Resident 136's BAA forms were reviewed. AC 1 stated Resident 136's signed BAA forms, titled Arbitration of Medical Malpractice Disputes, dated 11/24/2023 and Arbitration of Dispute Other Than Medical Malpractice, dated 11/24/2023 did not provide for a selection of a venue that was convenient to both the facility and Resident 136. AC 1 stated the facility did not have a specific policy and procedure on Binding Arbitration Agreements, but provided a facility document, titled Agreement to Arbitrate Disputes Not Related to Medical Malpractice, dated 11/24/2023. The facility document indicated the parties must agree upon the location of the arbitration and must consider the needs of the resident to get to the venue where the arbitration would be held. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 24 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to designate a staff representative to coordinate and ensure hospice services (a type of care and philosophy of care that focuses on the relief and comfort of a terminally ill patient's pain and symptoms and attends to their emotional and spiritual needs) and visits were given as ordered for one of one sampled resident (Resident 3). This failure had the potential to result in Resident 3 not receiving well-coordinated and comprehensive hospice services. Findings: A review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE]. Resident's 3 current diagnoses include, but are not limited to, a primary diagnosis as an encounter for palliative care (treatment that relieves the symptoms of a disorder without curing it) as of 7/18/2023, hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (the inability of the heart to pump blood effectively) , atherosclerotic heart disease (blockage of blood supply to the heart muscle due to buildup of plaque in the arteries- large blood vessels that carries blood from the heart to tissues and organs in the body) of native coronary artery (the artery that branch off from the aorta and supply oxygen-rich blood to the heart muscle), peripheral vascular disease (the reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), and occlusion (the blocking) and stenosis (the narrowing) of unspecified carotid artery (main blood vessel that carries blood to the head and neck). A review of Resident 3's Order Summary Report, dated 7/10/2023, the report indicated Resident 3 was admitted to Hospice Agency (HA) 1 with a terminal diagnosis of hypertensive heart disease without heart failure, with home health aide (HHA) visits three times per week. During a review of Resident 3's Physician Certification for Hospice Benefit, dated 9/24/2023, the benefit indicated Resident 3 will receive a visit from a certified home health aide (CHHA) three times a week from 10/8/2023 to 1/5/2024. During an interview on 11/30/2023 at 8:01 am., Certified Nurse Assistant (CNA) 2, CNA 2 stated she is familiar with the hospice staff that work with Resident 3 and they provide visits to Resident 3 on Tuesdays and Thursdays since hospice services started. During an interview on 11/30/2023 at 8:44 am., with the Case Manager (CM), the CM stated she does not know Resident 3's current hospice care or how often hospice staff visit. The CM stated hospice staff will coordinate with the charge nurse for any new or change in orders. During a concurrent interview on and record review on 11/30/2023 at 8:56 am., with the Social Services (SS), Resident 3's hospice binder including hospice calendars and flow sheets from 7/2023 to 10/2023 were reviewed. The SS confirmed hospice calendars indicate incomplete scheduling visits for CHHAs and nursing flow sheets indicate SN visits only. The SS stated she is not the hospice coordinator for the facility and her role with hospice services is to ensure the hospice benefit recertifications are up to date for residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 25 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0849 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 3's hospice calendar, dated November 2023, the calendar indicated 2 visits per week from a CHHA. During an interview on 11/30/23 at 1:48 pm., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated facility staff used the calendars in the hospice binder to know when hospice staff were to visit. Residents Affected - Few During an interview on 11/30/2023 at 4:36 pm., with the Director of Nursing (DON), DON stated regarding residents with hospice care, Typically, I'm not really involved, and hospice care is a collaboration between the CM, SS, floor nurses and the resident's family. DON stated CM and SS coordinate with hospice staff. During a concurrent interview on 11/30/2023 at 4:40 pm., with the DON, Resident 3's Physician Certification for Hospice Benefit dated 9/24/2023 was reviewed. The DON verified Physician Certification for Hospice Benefit indicated for a CHHA to visit three times a week from 10/8/2023 to 1/5/2024. During a concurrent interview on 11/30/2023 at 4:43 pm., with the DON, Resident 3's hospice care Monthly Calendars for 7/2023 to 11/2023 were reviewed. The DON confirmed the calendars indicated for CHHA visits three times per week and scheduled visits documented on calendars are incomplete. The DON unable to identify any CHHA documentation to verify completed visits. DON stated there is no designated person for communicating with hospice staff, any facility staff can do it. During a review of the facility contract with HA 1, Hospice-Skilled Nursing Facility Contract , dated 7/10/2023, the contract indicated the nursing home is responsible for designating a staff member who will coordinate care with hospice. During a review of the facility's policy and procedure titled, Hospice Admission, indicated the facility's written contract will include the DON/Designee as the member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care. The policy also indicated the duties of the Assisting Director of Nursing (ADON) must include communicating with hospice representatives and other health care providers in caring for the patient's terminal illness, related conditions, and other conditions to ensure quality care for the resident and family. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 26 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow infection control practices and implement interventions to prevent and control the spread of infections in the facility in accordance with the facility policy and procedures (P&P) and national health guidelines for five of five sampled residents (Residents 22, 3, 32, 238, and 76) when, Residents Affected - Some 1. For Resident 22, the facility failed to follow the Centers for Disease Control and Prevention (CDC, national public health agency of the United States) recommendations when the indwelling urinary catheter (IUC, flexible tube used to empty the bladder and collect urine in a drainage bag) was not maintained sterile (free from bacteria or other living microorganisms) or as a closed system (free of disconnections or dislodgements to prevent entry of contaminants) when frequent IUC irrigations (flushing fluid to maintain patency) must be done. 2 & 3. For Residents 32 and 3, the facility failed to ensure the Nasal cannula ([NC], a device consisting of lightweight tubing used to deliver supplemental oxygen) tubing did not touch the floor. 4. For Resident 238, the facility staff failed to remove their gloves and sanitize their hands after performing a Coronavirus-19 (COVID-19, highly contagious virus that can affect lungs and airways and spreads form person to person) nasal swab test. 5. For Resident 76, the facility failed to properly store a used resident care item. 6. The facility failed to establish a facility wide systems and water safety management program based on national standards of practice and the facility assessment for the prevention, identification, investigation and control to prevent the growth of Legionella (a bacteria that causes Legionnaires [a severe form of pneumonia - lung infection/inflammation usually caused by infection] and other opportunistic waterborne infections. These failures had the potential to result in the spread of infections throughout the facility, result in contamination of resident care equipment, place all residents at risk for infections, and result in the development and transmission of infections and the growth of infectious agents such as Legionella and other opportunistic waterborne pathogens which could compromise the health and safety of all residents and all staff. Findings: 1. During a review of Resident 22's admission Record (AR), the AR indicated the facility initially admitted Resident 22 on 2/12/2021 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), end-stage renal disease (kidneys lose the ability to remove waste and balance fluids in the body), and obstructive and reflux uropathy (inability to drain urine through the urinary tract, causing urine backup into the kidney). During a review of Resident 22's History and Physical Examination (H&P), dated 7/13/2023, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. During a review of Resident 22's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 11/3/2023, the MDS indicated Resident 22 had moderately impaired cognitive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 27 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0880 skills (ability to understand and process information) for daily decision-making. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 22's Order Summary Report (OSR), the OSR indicated the following active physician's orders for 11/2023: Residents Affected - Some 1. Order date: 2/12/2021 - IUC care every shift. 2. Order date: 2/12/2021 - Change IUC bag as needed. 3. Order date: 9/8/2021 - May change IUC 16 Fr/10 milliliters (mL) for obstruction or malfunction as needed. 4. Order date: 4/26/2022 - Flush IUC with 60 ml of normal saline (NS, sterile salt solution) every day shift for chronic sediments (particles floating in the urine). During a treatment observation on 11/30/2023 at 9:03 a.m. with Treatment Nurse 1 (TN 1), the daily IUC irrigation procedure was observed. TN 1 cleaned and disinfected the overbed table. TN 1 washed her hands, donned clean gloves (non-sterile gloves), set up the sterile field on the overbed table, and placed an unopened sterile NS solution bottle and two unopened IUC irrigation trays on top of the sterile field. TN 1 and Certified Nursing Assistant 2 (CNA 2) proceeded to the bedside and explained the procedure to Resident 22. TN 1 opened the irrigation tray and brought out the 60-ml irrigation syringe container. TN 1 opened the new NS bottle and poured NS into the 60-ml irrigation syringe container. TN 1 disconnected the two-way IUC (tubing with a drainage port and a non-return valve for balloon inflation to keep the IUC in place) from the tubing of the IUC collection bag. TN 1 proceeded to clean the end of the tubing with an alcohol swab. TN 1 washed her hands and donned new clean gloves. TN 1 flushed the sterile NS into the catheter as ordered and re-connected the tubing. During an interview on 11/30/2023 at 9:36 a.m., TN 1 stated she has always utilized clean gloves and disconnected the two-way IUC when irrigating Resident 22's IUC. During a concurrent interview and record review on 11/30/2023 at 11:20 a.m. with Registered Nurse 1 (RN 1), Resident 22's physician's orders were reviewed. RN 1 stated the sterile procedure must be utilized when disconnecting the IUC closed system and irrigating Resident 22's IUC to prevent any contamination that would lead to a urinary tract infection (UTI). RN 1 stated maintaining a sterile procedure required the use of sterile gloves. During a review of the facility's policy and procedures (P&P), titled, Infection Prevention and Control Plan (undated), the P&P indicated the facility's Infection Prevention and Control Program (IPCP) must be based upon information from the Facility Assessment and follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. During a review of the CDC recommendations, titled Indwelling Urinary Catheter Insertion and Maintenance, dated 8/14/2023, the CDC recommendations indicated the following: 1. Proper catheter maintenance included maintaining a sterile closed drainage system. 2. If there are breaks in aseptic technique or disconnection, the catheter must be replaced using aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms) technique and sterile equipment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 28 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0880 Level of Harm - Minimal harm or potential for actual harm 3. To maintain a closed system, urinary catheters with pre-connected, sealed catheter tubing junctions must be considered. 4. If a resident requires a single irrigation, the entire system must be changed after or inserting a 3-way IUC must be considered. Residents Affected - Some 5. A pre-connected three-way IUC must be used if frequent flushing is required. [Source: https://www.cdc.gov/infectioncontrol/pdf/strive/CAUTI104-508.pdf] [Source: https://www.cdc.gov/infectioncontrol/training/strive.html] 5.During a review of Resident 76's AR, the AR indicated, Resident 76 was admitted to the facility on [DATE] with multiple diagnoses including heart failure, presence of cardiac pacemaker (a small, battery-powered device implanted under the skin that prevents the heart from beating too slowly) and end stage renal disease (ESRD, the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own). During a review of Resident 76's H&P, dated 10/24/23, the H&P indicated, Resident 76 was recently diagnosed with ESRD and on dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) and had the capacity to understand and make decisions. During a review of Resident 76 's MDS, dated 10/31/23, the MDS indicated, Resident 76's cognitive (ability to think and process information) status was intact, had pressure ulcer (also known as bedsores, are wounds that occur because of prolonged pressure on a specific area of the skin), open lesion(s) on the foot and was on antibiotic (medication to treat bacterial infections) treatment. During a review of Resident 76's Care Plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan), titled, [Resident 76] at risk for infection, initiated 10/25/23, the CP indicated the goal was for Resident 76 to be free from complications related to infections. During a concurrent observation and interview on 11/27/23 at 12:18 pm., with Certified Nursing Assistant (CNA) 1, in Resident 10 and Resident 76's shared restroom, a mauve colored wash basin labeled with Resident 76's name was observed stored on top of the toilet tank. CNA 1 stated, the wash basin should not be [stored] on top of the toilet tank. CNA 1 stated, the wash basin should have been washed and put away in the closet after use. CNA 1 stated, the facility was supposed to keep the toilet clean since the residents used it, so no infection [no infections for he residents]. During an interview on 11/30/2023 at 12:36 pm., with the Infection Preventionist Nurse (IPN), the IPN stated, the wash basins should not be [stored] on top of the toilet tank and should be kept in resident's (in general) bedside drawers or closet or thrown away for infection control [purposes]. The IPN stated, it was definitely a contamination issue. 6. During an interview on 11/30/2023 at 9:31 am., with the Administrator (ADM), the ADM stated, the facility did not have a binder (document/record) for a water management program for Legionella and other opportunistic waterborne pathogens. The ADM stated, the facility did not have standing water (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 29 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some like pools, water fountains or whirpools and the ADM stated that based on the literature the ADM read, Legionella was a [result] from standing water. The ADM stated the hot water was constantly running and refilling the water heater and the cold water came from the city source. The ADM was asked what preventative measures were in place that addressed microbial growth in the facility's water systems. The ADM replied and stated, the ADM would reach out to the Public Health Nurse if and when there was an outbreak (more cases of a disease than expected in a specific location over a specific time period). The ADM stated, it was the IP [IPN] or maintenance staff who could answer questions regarding water safety management. During an interview on 11/30/2023 at 10:02 am., with the IPN, the IPN stated, the IPN could not provide a water management plan [program] but had a policy and procedure and would have to ask the Maintenance Supervisor (MS) regarding the facility's water management program. During an interview on 11/30/2023 at 10:08 am., with the MS, the MS stated, Legionella could grow in standing (stagnant) water. The MS stated, the facility did not have measures or an assessment plan in place, could not provide any documents for a water management program, the MS stated, it was important to have one [a water management program] for the safety of the residents and the staff. The MS stated, the water management requirement was new to the MS and the MS was not interviewed about this program during the last recertification survey and had to google (Google, an online internet search engine) what Legionella was. During an interview on 11/30/2023 at 12:36 pm., with the IPN, the IPN stated based on the facility's P&P, routine testing for Legionella was not required and the facility [monitored] the waterlogs [to keep track of temperatures] and temperature logs. During a review of the facility's undated policy and procedure (P&P) titled, Infection Prevention Surveillance of Infections and Reporting, the P&P indicated, It is the Policy of the facility to maintain an ongoing system of surveillance designed to identify possible communicable diseases or infections to ensure that measures are taken to prevent any potential outbreak. During a review of the facility's undated P&P titled, Infection Prevention - Control of Transmission of Infection the P&P indicated, It is the Policy of this facility to implement infection control measures to prevent the spread of communicable diseases and condition. During a review of the facility's P&P titled, Water Safety Management Program (Legionella), revised 10/2023, the P&P indicated, It is the policy of this facility to provide facility maintenance protocol guidelines for plant operations related to water safety management to ensure the reduction in potential growth of Legionella organisms in the water system of the facility. The P&P indicated, procedures that included describing facility water systems using narrative (text) that included the following: water entry, cold water distribution, cold water heating, hot water distribution and hot, cold, and tempered waste water discard pathway, describing facility water systems using diagram and include on the diagram the following: identify areas where Legionella can grow and spread. The P&P indicated, examples of internal sources where Legionella can grow and/or spread may include: hot and cold water storage tanks, water filters, showerheads, ice machines and medical devices such as CPAP (continuous positive airway pressure, a machine that uses mild air pressure to keep breathing airways open for sleep apnea [a potentially serious sleep disorder in which breathing repeatedly stops and starts]) machines. During a review of the Center for Clinical Standards and Quality/Survey & Certification Group, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 30 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dated 6/2/2017, revised 6/9/2017, from the Department of Health & Human Services-Centers for Medicare& Medicaid Services (CMS), the document indicated Legionella Infections can cause a serious type of pneumonia (infection that inflames the air sacs of the lungs) called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic [long standing] lung disease or immunocompromised (suppressed immune system, defenses). Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs. Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water. The skilled nursing facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The expectations for health care facilities included, CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. 3. A review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE]. Resident's 3 current diagnoses include, but are not limited to, a primary diagnosis as an encounter for palliative care (treatment that relieves the symptoms of a disorder without curing it) as of 7/18/2023, hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (the inability of the heart to pump blood effectively), atherosclerotic heart disease (blockage of blood supply to the heart muscle due to buildup of plaque in the arteries- large blood vessels that carries blood from the heart to tissues and organs in the body) of native coronary artery (the artery that branch off from the aorta and supply oxygen-rich blood to the heart muscle), peripheral vascular disease (the reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), and occlusion (the blocking) and stenosis (the narrowing) of unspecified carotid artery (main blood vessel that carries blood to the head and neck). During a review of Resident 3's Order Summary Report, dated 2/11/2023, the report indicated continuous oxygen via nasal cannula at 2 liters per minute to keep oxygen saturation at or above 90%. During multiple observations on 11/27/2023 at 11:48 am., 12:44 pm., 2:02 PM and 3:24 pm., at Resident 3's bedside, Resident 3's nasal cannula tubing was touching the floor. During a concurrent observation and interview on 11/27/2023 at 3:27 pm., with LVN 3 at Resident 3's bedside, LVN 3 confirmed Resident 3's nasal cannula tubing was touching the floor. LVN 3 stated the nasal cannula tubing should not be touching the floor because it could get contaminated. During an interview on 11/30/2023 at 4:36 PM with the DON, the DON stated oxygen tubing cannot be touching the floor and when oxygen tubing is touching the floor, the risks to residents include pneumonia (infection of the lungs due to a bacteria or virus) and upper respiratory infections. The DON stated the facility does have residents who are immunocompromised (a weakened ability of the body to fight off infections). During a review of the facility's undated policy and procedure (P&P) titled Infection Prevention and Control Plan, (undated), the policy indicated that standard and transmission-based precautions are to be followed to prevent the spread of infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 31 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During a review of Resident 32's AR, dated 11/30/2023, the AR indicated the resident was admitted on [DATE], with a diagnoses of acute and chronic respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body), other reduced mobility (unsteadiness while walking, difficulty getting in and out of a chair, or falls), and need for assistance with personal care. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 is cognitively intact (a participant who has sufficient judgment) for daily decision making. The MDS indicated Resident 32 required partial/moderate assistance (helper does less than half the effort) for showering. The MDS also indicated Resident 32 is independent with eating and oral hygiene. During an observation on 11/28/2023 at 8:35AM in Resident 32's room, Resident 32's nasal cannula tubing was touching the floor. During an observation on 11/30/2023 at 7:45AM in Resident 32's room, Resident 32's nasal cannula tubing was touching the floor. During an interview on 11/28/2023 at 9:57AM with CNA 5, CNA 5 confirmed Resident 32's oxygen tubing was touching the floor and stated, It can cause contamination if it's on the ground. During an interview on 11/30/2023 at 7:46AM with the Case Manager (CM), the CM confirmed Resident 32's oxygen tubing was touching the floor and stated, It shouldn't be on the floor because of infection. 4. During a review of Resident 238's AR, dated 11/27/23, the AR indicated Resident 238 was admitted to the facility on [DATE] with a diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), hyperlipidemia (abnormally high concentration of fats in the blood), anemia (condition where your blood produces a lower than normal amount of healthy red blood cells), atherosclerotic heart disease (a condition characterized by the buildup of fats, cholesterol and other substances in and on the artery walls) and malignant pleural effusion (the buildup of fluid and cancer cells that collects between the chest wall and the lung). A review of Resident 238's History and Physical (H&P) dated 11/27/23, the H&P indicated Resident 238 had the capacity to understand and make decisions. During an observation on 11/29/23 at 8:29 am., in Resident 238's room, Licensed Vocational Nurse (LVN) 1 performed a COVID-19 (an infectious disease caused by SARS-CoV-2 virus) nasal swab on Resident 238. After the testing was completed, LVN 1 failed to remove their gloves and sanitize their hands after handling the swab and continued to provide resident care. During an interview on 11/29/23 at 9:35 am., with LVN 1, LVN 1 stated that gloves should be changed after performing a COVID-19 test because you don't know yet if the resident is positive and you could spread infection. During an interview on 11/30/23 at 12:26 pm., with IPN, IPN stated nurses should change gloves after swabbing for COVID-19 because if one is touching other things after testing, the safety of the residents and the families is compromised, and it could contaminate the other objects in the room. During a review of the facility's policy and procedure, titled, Infection Control and Prevention (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 32 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0880 Level of Harm - Minimal harm or potential for actual harm Policy, Emerging Infectious Disease (EID): Coronavirus Disease 2019 (Covid-19) dated 3/9/2020, indicated that health care providers should perform hand hygiene before and after all patient contact, and contact with potentially infectious material. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 33 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the physician that one of three sampled residents (Resident 486) did not qualify for antibiotic use based on the facility's guide (McGreer's Criteria) used to review true infections. Residents Affected - Few This deficient practice had the potential for the resident to develop adverse effects related to antibiotic use and antibiotic resistance. Findings: During a review of Resident 486's Admissions Record, dated 11/15/23, the Admissions Record indicated Resident 486 was admitted to the facility on [DATE] with a diagnosis of acute osteomyelitis (bone infection) of left ankle and foot, sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection), methicillin resistant staphylococcus aureus infection (MRSA - an infection caused by a type of staph bacteria that has become resistant to many antibiotics), and Type 2 diabetes (a disease that occurs when your blood sugar is too high). During a review of Resident 486's History and Physical (H&P), dated 11/15/23, the H&P indicated, Resident 486 had the capacity to understand and make decisions. During a review of Resident 486's Order Summary Report dated 11/30/23, the Order Summary Report indicated two antibiotics to be given until 12/12/2023. Cefepime 2 grams every 12 hours intravenously (by the vein) for MRSA of the left foot wound and Vancomycin 1 gram one time a day intravenously for MRSA of the left foot wound. During a concurrent interview and record review on 11/30/23 at 11:05 AM with Infection Preventionist Nurse (IPN), Infection Surveillance - V2 (ISV2) form dated 11/15/23 was reviewed. The ISV2 indicated, a resident must meet one of three McGreer's constitutional criteria (symptoms or manifestations indicating a systemic or general effect of a disease) to qualify for antibiotic use. IPN stated Resident 486 did not meet the measure for antibiotic use based on McGreer's criteria and did not have documentation that the physician was notified. IPN further stated she did not complete infection surveillance for Resident 486 prior to starting antibiotics because IPN was behind for the month of November. IPN stated delay of completing infection surveillance could lead to increased chance of creating antibiotics resistance or creating adverse reactions that could harm the resident. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program: Antibiotic Stewardship dated 10/23, the P&P indicated, that the facility may implement antibiotic review processes also known as an antibiotic time-out to provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer, and more information is available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 34 of 34