Health inspection·November 12, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of two sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Fall Management System, and Resident 1's care plan when facility staff failed to turn on Resident 1's pressure pad alarm (a device that alerts a caregiver when a patient or family member is getting out of bed) and return Resident 1's bed to the lowest position. These failures had the potential to increase Resident 1's risk of fall and result in Resident 1 to sustain injury and/or harm in an event of a fall. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/19/2023, and readmitted Resident 1 on 2/19/2024, with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), heart failure (condition in which the heart cannot pump enough blood to all parts of the body), and acute cerebrovascular insufficiency (brain does not receive enough blood flow). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/22/2024, the MDS indicated Resident 1 was moderately impaired in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting, dressing, eating, and bathing. During a review of Resident 1's care plan titled, (Resident 1) At risk for falls ., dated 10/16/2024, the care plan indicated the goal of the care plan was that Resident 1 would be free of falls. The care plan indicated the interventions used to meet the goal included for staff to provide Resident 1 with a low bed and a pad alarm in wheelchair and bed to alert staff of Resident 1's attempt to get up unassisted. During a concurrent observation and interview on 11/8/2024 at 3:25 p.m. with Certified Nursing Assistant (CNA) 1, Resident 1 was lying in her bed with the head of the bed elevated. The bed was not at the lowest position to the floor. CNA 1 stated CNA 1 and the treatment nurse (TN) had just been in the room and that the bed was raised during the care of Resident 1. CNA 1 stated the bed was not returned to the lowest position after the TN and CNA 1 had finished providing care to Resident 1. CNA 1 stated the bed needed to be at the lowest position to prevent injury if Resident 1 fell out of the bed. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055394 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 11/12/2024 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)