Health inspection·August 26, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop an individualized person-centered plan of care that included measurable objectives, timeframes, and interventions to meet the needs of one of three sampled residents (Resident 1). Specifically, the facility did not develop an individualized care plan (CP) for Resident 1 in a timely manner to address Resident 1's past trauma after Resident 1 reported the trauma to the administrator (ADM).This deficient practice had the potential to result in unmet individualized needs and adversely affect the delivery of necessary care and services to Resident 1.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/29/2024, with diagnoses including, heart failure (HF-a heart disorder which causes the heart to not pump blood efficiently, sometimes resulting in leg swelling), chronic (persistent or long-lasting) obstructive pulmonary disorder (COPD, , long standing group of diseases that cause airflow blockage and breathing-related problems, make it difficult to breathe), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/2/2025, the MDS indicated Resident 1's cognition (the ability to think and process information) was intact. The MDS indicated Resident 1 required 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) and mobility.During a review of Resident 1's CPs, a CP, dated 8/21/2025, indicated Resident 1's potential for emotional distress related to [an] abuse allegation. There was no individualized CP in place that addressed Resident 1's reported history of trauma related to a prior sexual assault.During an interview on 8/22/2025 at 12:41 PM, with the ADM, the ADM stated Resident 1 disclosed Resident 1 was a victim of rape several years ago. Resident 1 stated Resident 1 had never shared this information with the facility before, and it was not documented in Resident 1's medical history. Resident 1 stated Resident 1 made the facility aware on 8/21/2025 when the resident reported the abuse allegations regarding Certified Nursing Assistant (CNA) 1.During an interview on 8/22/2025 at 12:57 PM, with Resident 1, Resident 1 stated Resident 1 disclosed to the ADM Resident 1 was a victim of rape several years ago. Resident 1 stated Resident 1 had never felt comfortable sharing this information with the facility before because it was a very sensitive topic. Resident 1 stated, with the most recent abuse allegations regarding CNA 1, Resident 1 was able to disclose this information to the ADM.During an interview and a concurrent review of Resident 1's CPs on 8/26/2025 at 11:14 AM, with the Social Services Director (SSD), the SSD stated a CP was created for emotional distress related to the abuse allegations, but a trauma-related CP was not initiated the same day. The SSD explained that both CPs are equally important, as timely trauma-informed planning helped prevent re-traumatization and ensured Resident 1's emotional and psychological needs were fully addressed in Resident 1's care. The SSD emphasized this process is the responsibility of the entire Interdisciplinary Team (IDT, a team of health care professionals who work Page 1 of 2 055394 055394 08/26/2025 Claremont Care Center 219 E. Foothill Blvd Pomona, CA 91767

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few together to establish plans of care for residents), not just one individual, and must be approached as a collaborative effort to ensure comprehensive care.During an interview on 8/26/2025 at 11:48 AM, with the Director of Nursing (DON), the DON stated a CP addressing the abuse allegations was created; however, a trauma-informed CP specific to the resident's history of rape was not initiated on the same day. The DON stated timely care planning was critical, particularly with trauma-related concerns, because delays could leave gaps in addressing the residents' emotional safety and well-being. The DON stated immediate initiation and implementation of trauma-informed care helped guide staff in providing sensitive, appropriate interventions and ensured the resident's needs were fully supported without risk of further emotional harm.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Resident Centered Care Plan, reviewed 12/2023, the P&P indicated it is the policy of this facility that the IDT shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 055394 Page 2 of 2