Health inspection·July 11, 2025

F 0774 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Social Services Assistant (SSA) scheduled a wheelchair transportation for GI appointment on 6/25/2025 at 2 PM. The PN indicated the transportation pick up time was at 1:10 PM and the return pick up time at 3:15 PM. The PN indicated, a staff member (unnamed) would accompany Resident 1 to the appointment.During a concurrent interview and record review on 7/11/2025 at 12:25 PM with Registered Nurse Supervisor (RNS) 1, Resident 1's medical records were reviewed. A PN dated 6/25/2025, timed at 2:21 PM documented by the Case Manager (CM), indicated, the GI appointment was rescheduled due to Resident 1's family unable to attend and no cg (care giver) was available. RNS 1 stated, the facility provided staff such as the SSA or a CNA (Certified Nursing Assistant) if a resident (in general) did not have a family member to accompany the resident during transport to a doctor's appointment. RNS 1 stated, it was important to accompany the resident for safety reasons and to assist the resident if the resident needed assistance. RNS 1 stated, Resident 1 missing Resident 1's GI consult appointment on 6/25/2025 could cause a delay in Resident 1's treatment. During a concurrent interview and record review on 7/11/2025 at 12:47 PM with the Director of Nursing (DON), the facility's P&P titled, Transportation to Doctors/Diagnostic Appointments, revised 10/2024 was reviewed. The P&P indicated, a member of the nursing staff, or social services, may accompany the resident as needed to the diagnostic center when the resident's family was not available. The DON stated, a responsible party or staff accompanied the resident during transport to doctor appointments, so the resident had a representative to assume responsibility of the resident's care and to make sure they're [the residents were] safe while out of the facility for their appointment. The DON stated the facility did not have a designated staff to accompany residents during transport. The DON stated, the staff could be an SSA, CNA, or RNA (Restorative Nursing Assistant), somebody must be there. The DON stated, Resident 1 missing Resident 1's scheduled GI consult appointment on 6/25/2025 could result in Resident 1 not receiving the necessary treatment as Resident 1, had a GI bleed before.During an interview on 7/11/2025 at 1:28 PM with the SSA, the SSA stated, Resident 1's GI consult appointment scheduled 6/25/2025 was rescheduled because the facility had no staff available to go with Resident 1 to the appointment.During an interview on 7/11/2025 at 3:34 PM with RNS 2, RNS 2 stated, the facility encouraged the responsible party to accompany the resident to the resident's appointment and if no responsible party was available, then the facility provides a staff companion for resident safety. During an interview on 7/11/2025 at 4:11 PM with the Case Manager (CM), the CM stated, Resident 1's scheduled GI consult appointment on 6/25/2025 was rescheduled due to the facility not having a staff available, we did not have an extra staff and the facility was not able to accommodate. The CM stated the facility did not have any issues with short staffing.During a review of the facility's staff Sign-In Sheet (SIS - a document used to record the presence of staff at work), dated 6/25/2025, the SIS indicated, there were eleven CNAs and two RNAs working during the day (7AM - 3PM) shift.During an interview on 7/11/2025 at 4:28 PM with the CNA, the CNA stated, Resident 1 needed two people to transfer, in general and was not ok for Resident 1 to leave the facility by himself for doctor appointments. The CNA stated, residents usually leave the facility with a staff member for their doctor appointments.During a review of the facility's Facility Assessment 2024 Guidelines (FA), the FA, indicated, Based on our resident population and their care needs, we have made a good faith effort and approach to ensure we have sufficient and qualified staff to meet the needs of the residents at any given time.During a review of the facility's P&P titled, Transportation to Doctors/Diagnostic Appointments, revised 10/2024. The P&P indicated it was the policy of the facility to assist residents in arranging transportation to/from diagnostic appointments when necessary. The P&P indicated, shall it become necessary for the facility to provide transportation, the social service designee will be responsible for arranging (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 2 of 3 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 07/11/2025 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 0774 Level of Harm - Minimal harm or potential for actual harm transportation through coordination with the business office. The P&P indicated a member of the nursing staff, or social services, may accompany the resident as needed to the diagnostic center when the resident's family is not available. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 3 of 3