Health inspection·July 11, 2025

F 0774 Help the resident with transportation to and from laboratory services outside of the facility. 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 one of three sampled residents (Resident 1) received care and treatment in accordance with the facility's policy and procedure (P&P) titled, Transportation to Doctors/Diagnostic Appointments, by failing to ensure staff was available to accompany Resident 1 to Resident 1's scheduled GI (gastrointestinal, refers collectively to the organs of the body that play a part in food digestion) consult (a process where a healthcare professional requests advice or expertise from another healthcare professional specialist or expert in a particular area regarding a patient's care) appointment on 6/25/2025.This failure resulted in Resident 1 missing Resident 1's scheduled GI consult appointment and had the potential to result in the delay in treatment for Resident 1 that could potentially lead to disease progression and complications to Resident 1.Findings:During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including vascular disorder of intestine (long tubed-shaped organ in the abdomen that completes the process of digestion [food breakdown], condition where blood flow to the intestines is reduced or blocked), unspecified, anemia (a condition where the body does not have enough healthy red blood cells), unspecified, and difficulty in walking, not elsewhere classified.During a review of Resident 1's History and Physical Reports (H&P), dated 6/13/2025, from the General Acute Care Hospital (GACH), the H&P indicated, Resident 1 was recently discharged , [from the GACH] after being diagnosed ischemic colitis (a condition where reduced blood flow to the colon [longest part of the large intestine] causes inflammation and injury), a few days ago. The H&P indicated Resident 1 recently presented to the GACH with diarrhea, abdominal pain, and bloody stools. During a review of Resident 1's Progress Notes (PN), dated 6/17/2025, timed at 2:28 PM, the PN indicated, ST (Speech Therapist) recommended ENT (Ear, Nose, Throat) and GI consultations to r/o (rule out) possible reflux (the backward flow of stomach contents into the esophagus [tubular elongated organ that connects the throat to the stomach]). During a review of Resident 1's undated Order Summary Report (OSR), the OSR indicated, a physician's order, dated 6/20/2025, for a GI consult with the gastroenterologist (MD, medical doctor who specializes in the diagnosis and treatment of diseases and conditions affecting the GI tract and liver) on 6/25/2025 at 2 PM for dx (diagnoses) of ischemic colitis and GI bleed. The OSR indicated an order, dated 6/25/2025, for a GI consult with the MD on 7/15/2025 at 2 PM for dx of ischemic colitis and GI bleed.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/22/2025, the MDS indicated, Resident 1's cognition (ability to understand and process information) was moderately impaired. The MDS indicated, Resident 1 required substantial/maximal assistance (helper does more than half the effort) to partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities).During a review of Resident 1's social services PN, dated 6/24/2025, timed at 11:08 AM, the PN indicated, the Residents Affected - Few Page 1 of 3 055394 055394 07/11/2025 Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767

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 055394 Page 2 of 3 055394 07/11/2025 Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767

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 055394 Page 3 of 3