Health inspection·December 12, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some station. The MD stated all bathrooms in Residents 13, 23, 30, 32, 44, 56, 61, 75, 298, and 299's rooms need to be repaired due to cracking drywall/caulking, and peeling paint. The MD stated the door jambs and casing needed to be repaired because of chipped paint and dents in the wood. The MD stated the dust from compromised and cracked holes in the drywall can affect the residents' breathing, and the drywall should be repaired and painted. The MS stated the cracked floor tiles and base wall tile needed to be replaced because there was a potential risk for residents and visitors fall to fall from the cracked floor tiles. During a review of the facility's Maintenance Logs from 2023 to 2024, the logs indicated Residents 61, 298 and 299's room, did not have any log entries for bathroom repairs. During a review of the facility's Maintenance Logs from 2023 to 2024, the logs indicated Residents 23 and 75's room did not have any log entries for bathroom repairs. During a review of the facility's Maintenance Logs from 2023 to 2024, the logs indicated Residents 44 and 56's room did not have any log entries for bathroom repairs. During a review of the facility's Maintenance Logs from 2023 to 2024, the logs indicated no log entries for any needed repairs for Resident 13, 30, and 32's room. During a review of the facility's Policy and Procedure (P&P) titled, Physical Environment: Environmental Conditions/Environmental Rounds, dated 01/2024, the P&P indicated, Policy: It is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public through monthly environmental rounds. The P&P further indicated, Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 2 of 14 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 12/12/2024 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)

F 0641 Ensure each resident receives an accurate assessment. 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 ensure a Minimum Data Set (MDS, a standardized assessment and care-screening tool) was accurate for one of one sampled resident (Residents 90). Resident 90's MDS did not accurately reflect the resident's discharge status. Residents Affected - Few This deficient practice resulted in inaccurate assessment on Resident 90's discharge status with wrong medical information on Resident 90's MDS. Findings: During a review of Resident 90's admission Record (AR), the AR indicated Resident 90's was admitted on [DATE]. During a review of Resident 90's Physician's Discharge Summary (PDS), signed by the resident's physician on 9/23/2024, the PDS indicated Resident 90 diagnoses included Dementia (a decline in mental abilities, such as thinking, remembering, and reasoning), emphysema (damages air sacs in the lungs, making it difficult to breathe), and history of falling. The PDS indicated Resident 90's Transfer/Discharge was necessary due to: Against Medical Advice (AMA, when a patient chooses to leave the hospital before their doctor recommends discharge). During a review of Resident 90's Leaving Facility Against Medical Advice (LFAM), dated 9/15/2024, the LFAM indicated the resident voluntarily left the facility against the advice of her physician. During a review of Resident 90's Progress Notes - Discharge Summary, dated 9/15/2024, the notes indicated the resident was discharged to resident family to take to resident home. During an interview and concurrent record review of Resident 90's MDS documents, dated 9/15/2024, with the Minimum Data Set Nurse 1 (MDSN 1), on 12/12/2024 at 11:39 am, MDSN 1 stated the resident was left AMA with the resident's family. MDSN 1 stated Resident 90 went home but the MDS dated [DATE] was coded discharge to an General Acute Care Hospital (GACH). MDSN 1 stated the MDS should have been marked discharge to home and not to GACH to accurately show what happened to Resident 90. During a review of the facility's policy and procedure titled, Resident Assessment: Accuracy of Assessment (MDS 3.0), revised on 1/2024, indicated it was the policy of the facility to ensure that the assessment accurately reflect the resident's status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 3 of 14 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 12/12/2024 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)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to have a communication board easily accessible for one of two sampled residents (Resident 79) as indicated in Resident 79's care plan. Residents Affected - Few This deficient practice prevented Resident 79 from communicating with facility staff and had a potential to delay appropriate nursing care/treatment and services for Resident 79. Findings: During a review of Resident 79's admission Record (AR), the AR indicated the facility admitted Resident 79 on 9/5/2024, with diagnoses including metabolic encephalopathy (a change in how your brain works due to an underlying condition), reduced mobility and need for assistance with personal care. During a review of Resident 79's History and Physical (H&P), dated 9/5/2024, the H&P indicated Resident 79 did not have decision making capacity. During a review of Resident 79's Care Plan, dated 9/5/2024, the Care Plan indicated Resident 79 had a communication problem related to language barrier (Mandarin speaking only). The goal was for Resident 79 to be able to make basic needs know on a daily basic. The intervention was to provide Resident 79 with a communication board in Mandarin so Resident 79 would be able to communicate with staff. During a review of Resident 79's Minimum Data Set (MDS, a resident assessment tool), dated 9/10/2024, the MDS indicated Resident 79 was unable to complete the interview to assess for cognition (the ability to think and process information) . The MDS indicated Resident 79 was dependent (helper does all the effort) on staff with activities of daily living (ADL, term used in healthcare that refers to self-care activities) such as toilet transfer. During an observation and a concurrent interview on 12/9/2024 at 10:53 AM, no communication board was noted in Resident 79's room. Family Member (FM) 1, stated Resident 79 speaks Madarin, and the resident may have a language barrier when communicating his basic needs to staff. During an interview on 12/10/2024 at 2:52 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated facility staff used communication boards to provide residents with language barriers a visual method for the residents to communicate their needs and preferences. LVN 1 stated Resident 79 should always have a communication board easily accessible; and the use of the communication board should be encouraged to the resident to facilitate communication. LVN 1 stated she was unable to locate the communication board after looking around the resident's environment and bedside drawer. LVN 1 stated she would request a Mandarin communication board from the Social Services Director (SSD) as it may have been misplaced. During an interview on 12/12/2024 at 07:45 AM, with the SSD, the SSD stated the communication board should always be easily displayed within the Residents' line of sight and should be easily accessible as it allowed the residents to effectively communicate their needs, concerns, and preferences. The SSD stated the communication board packets can be easily misplaced and lost. The SSD stated the SSD will find an alternative method to avoid loss and misplacement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 4 of 14 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 12/12/2024 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)

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's Policy and Procedure (P&P) titled, Communication for Non-English, revision dated 10/2024, the P&P indicated the facility will provide interpreter services for non-English speaking residents. 1. Social Services will supply residents and/or family members with the use of a communication board that has universally known drawings, whenever desired. All attempts will be made to write, in the resident's native tongue, the name of each pictured item, using available staff, family members, and community resources, as appropriate. 2. Resident, family, and staff caring for the resident will be familiarized with the communication tool. The tool will be kept at the resident's bedside for use. During a review of the facility's P&P titled, Accommodations of Needs, revision dated 10/2024, the P&P indicated that the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being. The P&P indicated that in order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. a. Staff shall interact with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 5 of 14 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 12/12/2024 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 administer insulin as ordered for one of one sampled resident (Resident 19) in a timely manner. Residents Affected - Some This deficient practice had the potential to make Resident 19 become lethargic, experience an altered level of consciousness or unresponsive to external stimuli. Findings: During a review of Resident 19's admission Record, (AR), the AR indicated Resident 19 was admitted on [DATE] with multiple diagnoses including type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities) and adult failure to thrive ( a state of decline that is manifested by weight loss, decreased appetite, poor nutrition and inactivity). During a review of Resident 19's Minimum Data Set (MDS - a resident assessment tool) dated 10/2/2024, indicated Resident 19 did not have intact cognition (ability to think and process information). The MDS indicated Resident 20 was dependent (helper does all of the effort) on staff for toileting, bathing and required supervision for eating. During a review of Resident 19's Medication Administration Record (MAR), dated with active orders from 11/1/2024 - 11/30/2024, the MAR indicated Resident 19 had a physician order with start date of 8/6/2024 to administer insulin Lispro injection solution 100 unit/milliliter (ml) based on a sliding scale, scheduled every day at 6:30 AM and 5:00 PM. The MAR indicated Resident 19's insulin was given past the scheduled times on the following days and times: 1. 11/1/2024 dose scheduled at 5:00 PM and given at 7:55 PM. 2. 11/2/2024 dose scheduled at 5:00 PM and given at 7:51 PM. 3. 11/6/2024 dose scheduled at 5:00 PM and given at 7:42 PM. 4. 11/9/2024 dose scheduled at 6:30 AM and given at 8:23 AM. 5. 11/12/2024 dose scheduled at 5:00 PM and given at 6:20 PM. 6. 11/17/2024 dose scheduled at 5:00 PM and given at 7:51 PM. 7. 11/18/2024 dose scheduled at 5:00 PM and given at 6:30 PM. 8. 11/20/2024 dose scheduled at 6:30 AM and given at 7:56 AM. 9. 11/21/2024 dose scheduled at 5:00 PM and given at 7:42 PM. 10. 11/22/2024 dose scheduled at 6:30 AM and given at 8:00 AM. 11. 11/22/2024 dose scheduled at 5:00 PM and given at 10:45 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 6 of 14 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 12/12/2024 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)

F 0684 12. 11/24/2024 dose scheduled at 6:30 AM and given at 8:15 AM Level of Harm - Minimal harm or potential for actual harm 13. 11/24/2024 dose scheduled at 5:00 PM and given at 9:47 PM. 14. 11/27/2024 dose scheduled at 6:30 AM and given at 9:15 AM. Residents Affected - Some 15. 11/27/2024 dose scheduled at 5:00 PM and given at 7:43 PM. 16. 11/29/2024 dose scheduled at 5:00 PM and given at 6:51 PM. During a review of Resident 19's MAR, with active orders dated from 12/1/2024 - 12/31/2024, the MAR indicated Resident 19 had a physician order with start date of 8/6/2024 to administer insulin Lispro injection solution 100 unit/ml based on a sliding scale scheduled every day at 6:30 AM and 5:00 PM. The MAR indicated Resident 19's insulin was given prior to and past the scheduled times on the following days and times: 1. 12/1/2024 scheduled dose at 6:30 AM and given at 3:17 AM. 2. 12/4/2024 scheduled dose at 5:00 PM and given at 9:48 PM. 3. 12/9/2024 scheduled dose at 5:00 PM and given at 6:21 PM. During an interview on 12/12/2024 at 11:17 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated in general, staff administer medication an hour prior and up to an hour after the scheduled time on the Medication Administration Record (MAR). LVN 1 stated Resident 19's blood sugar is scheduled to be checked at 6:30 AM and 5:00 PM. LVN 1 further stated staff could check the blood sugar up until Resident 19 gets the resident's meal. LVN 1 stated blood sugar should be checked prior to Resident 19 eating to ensure accuracy. LVN 1 also stated if the blood sugar is checked after eating, a staff member could give more insulin than needed and the resident could become lethargic, sweaty, unresponsive or have an altered level of consciousness. LVN 1 stated Resident 19's doctor would also have an inaccurate trend of the resident's blood sugars potentially affecting Resident 19's perceived need for medication. During a concurrent interview and record review on 12/12/2024 at 11:50 AM with the Director of Nursing (DON), Resident 19's MAR dated 12/1/2024 - 12/31/2024 was reviewed. The MAR indicated the days and times Resident 19's insulin was not administered according to the schedule. The DON stated nurses should be documenting when they actually administer the insulin and the MAR currently appeared to indicate insulin was administered much past the dose schedule. The DON stated if a nurse was to give insulin at the indicated times past the dose schedule without a meal or snack, the resident could become hypoglycemic (have abnormally low level of sugar in the blood). During a review of the facility's policy and procedure (P&P) titled, Medication Administration, revised 11/2021 and reviewed 1/2024, the P&P indicated under Essential Points: 1. No medication is to be administered without a physician's order. Accurate and timely administration according to MD order is essential. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 7 of 14 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 12/12/2024 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure residents who were at risk for skin breakdown and pressure injuries (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) received treatment and services to prevent skin breakdown for one of three sampled residents (Resident 2) by failing to ensure the low air loss mattress (LAL mattress - air filled mattress used to relieve pressure) was set according to the resident's weight. Residents Affected - Few Resident 2's LAL mattress was set at 180 pounds (lbs) and Resident 2's body weight was 117 (lbs). This deficient practice put Resident 2 at risk for developing pressure injury and/or worsening of the pressure injury. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 11/13/2024, with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), metabolic encephalopathy (a change in how your brain works due to an underlying condition) and reduced mobility. During a review of Resident 2's History and Physical (H&P), dated 11/13/2024, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2' Care Plan, dated 11/13/2024, the Care Plan indicated Resident 2 had pressure ulcers and had potential for further pressure ulcer development related to decreased mobilization, admitted with pressure ulcers, incontinence, and poor nutrition. The Care Plan interventions indicated LAL mattress with bolsters for tissue load management. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 11/17/2024, the MDS indicated Resident 2 was dependent (helper does all the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities). During a review of Resident 2's Order Summary Report, dated 11/18/2024 indicated Resident 2 had a physician order for a LAL mattress with bolsters for tissue load management every shift, setting based by patient/resident's weight. During an observation of Resident 2's LAL mattress on 12/9/2024 at 09:58 AM, Resident 2's LAL mattress was set at 180 lbs. During a concurrent interview and record review on 12/12/2024 at 8:08 AM, with Treatment Nurse (TN) 1, Resident 2' s Weight Summary, dated 12/10 /2024, was reviewed. The Weight Summary indicated Resident 2's weight was 117 lbs. TN 1 stated the LAL mattress setting for Resident 2 was not set correctly so the air in the LAL mattress could be distributed correctly. TN 1 stated if the setting for the LAL mattress was not set correctly, it can give more pressure on the wound and it would be harmful instead of beneficial to the resident. TN 1 stated the LAL mattress setting for Resident 2 should be no more than 130 lbs, since Resident 2's weight was 117 lbs. TN 1 stated incorrect settings of LAL mattress was no longer therapeutic and placed Resident 2 at higher risk for further skin breakdown. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 8 of 14 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 12/12/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcers, revised 10/2024, the P&P indicated for A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. During a review of the Low Air Loss Mattress Operation Manual, ProtektTM Aire 6000, the operation manual indicated that the pump and mattress system is intended to reduce the incidence of pressure ulcers while optimizing patient comfort. The operation manual indicated for the pressure set up: It is recommended to press auto firm on the panel when the mattress is first inflated. Users can then easily adjust the air mattress to a desired firmness according to the patient's weight and comfort. Event ID: Facility ID: 055394 If continuation sheet Page 9 of 14 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 12/12/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure foods are handled, prepared, and stored in a manner that prevents foodborne illness (food poisoning) in the facility for one of one kitchen when: 1. Eleven milk cartons were observed in the reach-in refrigerator with an expiration date of 12/7/24. 2. Seven milk cartons with an expiration date of 12/7/24 were observed on a tray of drinks to be serve to residents. 3. One half empty milk carton with an expiration date of 12/7/24 on a resident's tray was observed being brought back to the kitchen by Certified Nursing Assistant (CNA) 4. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed the residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, and can lead to other serious medical complications and hospitalization. Findings: 1. On 12/9/24 at 7:45 a.m., during an initial Kitchen tour, eleven cartons of 2% fat milk were observed in the reach-in refrigerator with a manufacturer expiration date of 12/7/24. During a concurrent interview and observation with the Dietetic Service Supervisor (DSS) on 12/9/24 at 8 a.m., the DSS acknowledged the eleven cartons of milk were expired and should be tossed in the trash. The DSS was observed throwing the milk cartons in the trash can. 2. On 12/9/24 at 11:56 a.m., during a tray line observation in the kitchen, seven cartons of 2% fat milk with a manufacturer expiration date of 12/7/24 were observed on a tray of drinks to be serve to residents. During a concurrent interview and observation with the DSS on 12/9/24 at 12 p.m., the DSS acknowledged the seven cartons of milk were expired. The DSS stated he did not know where the cartons came from because he had checked the tray in the reach-in refrigerator. The DSS was observed throwing the milk cartons in the trash can. 3. On 12/9/24 at 2:40 p.m., CNA 4 was observed walking to the kitchen with a food tray that had one half empty carton of 2% fat milk with a manufacturer expiration date of 12/7/24. The lunch food slip indicated the milk was for Resident 40. During an interview with the DSS on 12/9/24 at 2:43 p.m., the DSS stated he did not know how the milk carton got to Resident 40. The DSS stated he checked all food trays before they went out to the residents for lunch. During a review of the facility's Policy and Procedure (P&P) titled, Labeling and Dating of Foods, dated 2023, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 10 of 14 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 12/12/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete labeled and dated based on established procedures for either food safety or product rotation (FIFO - First In - First Out). Some cultured dairy products such as milk, cream, yogurt, sour cream & buttermilk .shall be discarded following the manufacturer expiration date or seven days after opening whichever comes first. The P&P further indicated, Once daily, the PM [NAME] and/or PM Diet Aide will be responsible to inspect the refrigerators and discard perishable foods that are time/temperature control for food safety (TCS) in order to ensure food safety. Event ID: Facility ID: 055394 If continuation sheet Page 11 of 14 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 12/12/2024 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)

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** b. During a review of Resident 20's AR, the AR indicated Resident 20 was admitted on [DATE] and readmitted on [DATE]. The AR indicated Resident 20 was admitted with multiple diagnoses including type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (a disorder characterized by difficulty in blood sugar control and poor wound healing) and heart failure (condition when the heart muscle does not pump enough blood for the body's needs). Residents Affected - Some During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20 had intact cognition. The MDS indicated Resident 20 was dependent on staff for toileting, and bathing. During a review of Resident 20's Order Summary Report (OSR) dated with active orders as of 12/12/2024, the OSR indicated a physician order with a start date on 11/30/2024 for Enhanced Barrier Precautions: PPE required for high resident contact care activities. During a concurrent observation and interview on 12/12/2024 at 10:22 AM with the Housekeeping Staff (HSK) 1 in Resident 20's room, the HSK 1 was mopping the floor while wearing a surgical mask and gloves without a protective gown. A sign posted outside the room from the Los Angeles County Department of Public Health dated 9/8/2021 indicated staff must perform hand hygiene and wear gloves and gown for cleaning the environment due to enhanced standard precautions. The HSK 1 stated the HSK 1 should have been wearing a gown to clean but had forgotten. During an interview on 12/12/2024 at 1:00 PM with the Maintenance Director (MD), the MD stated staff need to wear a gown when cleaning the resident rooms and providing patient care under enhanced standard precaution. The MD further stated it's not always known if the residents have an infection and what they've touched in the room so housekeeping staff should have extra protection and wear a gown, mask and gloves when cleaning the rooms. The MD sated germs could get on the housekeeper themselves or their clothes while cleaning and spread to other residents or rooms. During an interview on 12/12/2024 at 1:12 PM with the Infection Preventionist Nurse (IPN), The IPN stated housekeeping would need to wear a gown for cleaning resident rooms to prevent the spread of infection from room to room. During a review of the facility's P&P titled, IPCP Standard and Transmission-Based Precautions, revised 10/2024, the P&P indicated the use and type of PPE is based on the predicted staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens (e.g., gloves are worn when contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment are anticipated). The P&P further indicated under Implementation, ii. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Based on observation, interview, and record review, the facility failed to follow its infection prevention and control program for two of six sampled residents (Residents 20 and 78) by failing to: a. [NAME] (put on) a gown before entering Resident 78's room which it was under contact precautions. b. Wear personal protective equipment (PPE, prefers to protective clothing, helmets, gloves, face (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 12 of 14 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 12/12/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) when cleaning Resident 20's room which it was under enhanced barrier precautions. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for all the residents and staff in the facility. Findings a. During a review of Resident 78's admission Record (AR), the AR indicated the facility admitted Resident 78 on 9/3/2024, and re-admitted on [DATE], with diagnoses including pneumonia (an infection/inflammation in the lungs), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Resident 78's Minimum Data Set (MDS, a resident assessment tool), dated 11/21/2024, the MDS indicated Resident 78's cognition (the ability to think and process information) was moderately intact. The MDS indicated Resident 78 was dependent (helper does all the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) such as toileting hygiene, shower/bathe self, lower body dressing and putting/on/taking off footwear. During a review of Resident 78's untitled Care Plan, date initiated 12/1/2024, the Care Plan indicated Resident 78 was on Bactrim (antibiotic medication) for urinary tract infection. The care plan intervention indicated Resident 78 was on contact isolation for Methicillin-Resistant Staphylococcus Aureus (MRSA, a staph germ (bacteria) that does not get better with the type of antibiotics that usually cure staph infections. When this occurs, the germ is said to be resistant to certain antibiotics) of the urine. During an observation on 12/9/2024 at 09:40 AM, Certified Nursing Assistant (CNA) 1 entered Resident 78's room which it was under contact isolation without donning a gown. During an interview on 12/9/2024 at 09:46 AM, with CNA 1, CNA 1 stated that staff should wear proper PPE, before entering a room under contact isolation, which includes donning gown and gloves. CNA 1 stated she should have donned a gown before entering resident 78's room. CNA 1 stated that wearing proper PPE could protect residents and staff from cross-contamination of infections and ensures everyone's safety. During an interview on 12/10/2024 at 1:56 PM, with the Infection Preventionist Nurse (IPN), the IPN stated the expectation of staff when entering a room under contact isolation was always don and doff (remove) appropriate PPE including gown and gloves. The IPN stated that PPE could protect residents and staff from the transmission of communicable diseases and prevents the spread of infections. During a review of Resident 78's Order Summary Report, dated 12/11/2024, the report indicated Resident 78 was on contact isolation for MRSA. During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Program and Transmission-Based Precautions, revision dated 10/2024, the P&P indicated that it was the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions. The P&P indicated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 13 of 14 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 12/12/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm A. Contact Precautions (Transmission-Based Precautions or TBP) are used with a known infection that is spread by direct or indirect contact with the resident or the resident's environment. (e.g. MDROs, A multidrug resistant organism is a germ that is resistant to many antibiotics. If a germ is resistant to an antibiotic, it means that certain treatments will not work or may be less effective. MDROs can be difficult to treat since many antibiotics won't work to treat them). Residents Affected - Some B. Personal protective equipment: i. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. ii. [NAME] PPE upon room entry, then doff and properly discard PPE and perform hand hygiene before exiting the patient room to contain pathogens. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 14 of 14