Health inspection·November 7, 2025

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had the following orders: 1. Carvedilol oral tablet, 12.5 milligrams (mg- unit of measurement), give 12.5 mg by mouth one time a day for HTN. Hold for SBP less than 100 or heart rate less than 60 (beats per minute [bpm]). The order date indicated 10/1/2024. 2. Nifedipine extended release (ER) oral tablet 24-hour, 90 mg, give one (1) tablet by mouth at bedtime for HTN. Hold for SBP less than 100; do not crush. The order date indicated 10/14/2024. During a review of Resident 4's medication administration record (MAR- a report that serves as a legal record of the medications administered to a resident) dated 10/2025, the MAR indicated Resident 4 received carvedilol at 2 pm and nifedipine at 9 pm from 10/1/2025 to 10/31/2025. During a review of Resident 4's MAR dated 11/2025, the MAR indicated Resident 4 received carvedilol at 2 pm and nifedipine at 9 pm from 11/1/2025 to 11/6/2025. During a review of Resident 4's Weights and Vitals Summary (WVS) dated 10/1/2025 to 11/7/2025, the WVS indicated Resident 4's BP was check on the following dates, at the following times, by the following nurses: 1. On 10/1/2025 at 10:54 pm, Resident 4's BP was 143/74, assessed by LVN 6. 2. On 10/4/2025 at 2:51 pm, Resident 4's BP was 150/70, assessed by LVN 7.3. On 10/5/2025 at 6:46 pm, Resident 4's BP was 116/78, assessed by LVN 10.4. On 10/10/2025 at 8:07 am, Resident 4's BP was 129/76, assessed by LVN 1, and was checked again at 6:09 pm as 122/65, assessed by LVN 2. 5. On 10/11/2025 at 9:43 am, Resident 4's BP was 144/78, assessed by LVN 4. 6. On 10/12/2025 at 8:52 am, Resident 4's BP was 133/78, assessed by LVN 6.7. On 10/13/2025 at 10:21 am, Resident 4's BP 152/80, assessed by LVN 3, and was checked again at 10:38 pm as 132/80, assessed by LVN 9.8. On 10/14/2025 at 10:34 am, Resident 4's BP was 150/70, assessed by LVN 7. 9. On 10/15/2025 at 10:56 am, Resident 4's BP was 142/78, assessed by LVN 8.10. On 10/16/2025 at 10:27 am, Resident 4's BP was 130/80, assessed by LVN 3, and was checked again at 10:28 pm as 136/82, assessed by LVN 9.11. On 10/17/2025 at 9:45 am, Resident 4's BP was 144/80, assessed by LVN 4, and was checked again at 11:41 pm as 130/78, assessed by LVN 9. 12. On 10/18/2025 at 11:36 and 11:51 am, Resident 4's BP was 132/72, assessed by LVN 4. 13. On 10/19/2025 at 8:18 am, Resident 4's BP was 138/74, assessed by LVN 8, and was checked again at 5:41pm as 113/76, assessed by LVN 2. 14. On 10/20/2025 at 10:05 am, Resident 4's BP was 126/70, assessed by LVN 8. 15. On 10/21/2025 at 8:16 am, Resident 4's BP was 130/64, assessed by LVN 4. 16. On 10/22/2025 at 10:36 am, Resident 4's BP was 112/62, assessed by LVN 7, and was checked again at 10:15 pm as 126/66, assessed by LVN 9. 17. On 10/23/2025 at 10:24 am, Resident 4's BP was 128/70, assessed by LVN 4, and was checked again at 5:05 pm as 132/73, assessed by LVN 2. 18. On 10/24/2025 at 9:17 am, Resident 4's BP was 122/66, assessed by LVN 5, and was checked again at 3:56 pm as 119/75, assessed by LVN 2. 19. On 10/25/2025 at 9:12 am, Resident 4's BP was 138/78, assessed by LVN 8, and was checked again at 4:49 pm as 118/76, assessed by LVN 2. 20. On 10/27/2025 at 10:26 am, Resident 4's BP was 134/80, assessed by LVN 4.21. On 10/28/2025 at 10:16 pm, Resident 4's BP was 128/78, assessed by the IPN. 22. On 10/29/2025 at 7:48 pm, Resident 4's BP was 126/72, assessed by LVN 9. 23. On 11/1/2025 at 4:30 pm, Resident 4's BP was 121/84, assessed by LVN 2. 24. On 11/5/2025 at 7:19 pm, Resident 4's BP was 132/80, assessed by LVN 10. 25. On 11/6/2024 at 8:21 am, Resident 4's BP was 136/78, assessed by LVN 5. During a concurrent interview and record review on 11/6/2025 at 4:16 pm, with LVN 2, Resident 2's MAR dated 10/2025 and 11/2025 and Resident 2's WVS dated 10/1/2025 to 11/6/2025 were reviewed. LVN 2 stated (in general), when giving BP (lowering) medications, LVN 2 was supposed to check the resident's BP just prior to giving the medication to ensure the resident did not develop hypotension or other cardiac (heart) - related problems such as dizziness. LVN 2 stated, It's a safety. LVN 2 stated on 10/10/2025 at 6:09 pm, LVN 2 assessed Resident 4 for COVID-19 (infectious disease caused by SARS-CoV-2 virus) by checking Resident 4's BP. LVN 2 stated LVN 2 used the last recorded BP (122/65 at 6:09 pm) in order to give Resident 4 nifedipine. LVN 2 stated on 10/19/2025 at 5:41 pm, LVN 2 assessed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 2 of 4 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 11/07/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 4 for COVID-19 by checking Resident 4's BP. LVN 2 stated LVN 2 used the last recorded BP (113/76 at 5:41pm) in order to give Resident 4 nifedipine. LVN 2 stated on 10/23/2025 at 5:05 pm, LVN 2 assessed Resident 4 for COVID-19 by checking Resident 4's BP. LVN 2 stated LVN 2 used the last recorded BP (132/72 at 5:05 pm) in order to give Resident 4 nifedipine. LVN 2 stated on 10/24/2025 at 3:56 pm, LVN 2 assessed Resident 4 for COVID-19 by checking Resident 4's BP. LVN 2 stated LVN 2 used the last recorded BP (119/75 at 3:56 pm) in order to give Resident 4 nifedipine. LVN 2 stated on 10/25/2025 at 4:49 pm, LVN 2 assessed Resident 4 for COVID-19 by checking Resident 4's BP. LVN 2 stated LVN 2 used the last recorded BP (118/76 at 4:49 pm) in order to give Resident 4 nifedipine. LVN 2 stated on 10/30/2025 at 11 pm, LVN 2 assessed Resident 4 for COVID-19 by checking Resident 4's BP. LVN 2 stated LVN 2 used the last recorded BP (117/76pm at 11 pm) in order to give Resident 4 nifedipine. LVN 2 stated on 11/1/2025 at 4:30 pm, LVN 2 assessed Resident 4 for COVID-19 by checking Resident 4's BP. LVN 2 stated LVN 2 used the last recorded BP (121/84 at 4:30 pm) in order to give Resident 4 nifedipine. LVN 2 stated the risk of using a BP from a few hours prior to Resident 4's scheduled nifedipine dose of 9 pm, was that the BP could change and if given the medication, could cause adverse reactions like hypotension. LVN 2 stated, I'm not going to use the last recorded BP next time. During an interview on 11/6/2025 at 4:31 pm, with the IPN, the IPN stated the IPN passed (administered) medications from time to time if needed. The IPN stated (in general) prior to giving BP medications, the IPN was supposed to check a resident's BP right before giving a BP medication to make sure the resident's BP was within the parameters of the medication. The IPN stated BP were supposed to be checked at the time licensed nurses gave the medication. The IPN stated if BP were checked at the time of medication administration, they risked residents developing hypotension or even bradycardia (slow heart rate, defined as a resting heart rate of less than 60 BPM). During a concurrent interview and record review on 11/7/2025 at 9:58 am, with LVN 1, Resident 2's MAR dated 10/2025 and 11/2025 and Resident 2's WVS dated 10/1/2025 to 11/6/2025 were reviewed. LVN 1 stated (in general). LVN 1 was supposed to check a resident's BP and HR when giving carvedilol. LVN 1 stated, LVN 1 had to check the resident's MAR to ensure the BP and HR were within the parameters to give the medication. LVN 1 stated, I am supposed to check the HR and BP when I am ready to give the medication, just prior to giving. I check the BP and HR to make sure the resident doesn't get hypotension or have adverse effects to the medication. LVN 1 stated on 10/10/2025 LVN 1 gave Resident 4 carvedilol at 2 pm. LVN 1 stated that Resident 4 had Lasix (medication used to treat fluid retention and high blood pressure) due at 8 am that day, so LVN 1 checked Resident 4's BP at that time. LVN 1 stated, I remember taking [Resident 4's] BP but I guess I didn't document it. During a concurrent interview and record review on 11/7/2025 at 10:14 am, with LVN 3, Resident 2's MAR dated 10/2025 and Resident 2's WVS dated 10/1/2025 to 10/31/2025 were reviewed. LVN 3 stated (in general) LVN 3 checked residents' BP and HR just prior to giving the BP medication when ready to give the medication to ensure the medication was safe to be administered based on the BP and HR. LVN 3 stated on 10/13/2025, 10/16/2025, and 10/31/2025, LVN 3 gave Resident 4 carvedilol at 2 pm. LVN 3 stated if there was a parameter for giving BP medications, LVN 3 had to check Resident 4's BP prior to giving the medication. b. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 8/11/2025 and was readmitted on [DATE] with diagnoses that included hypotension, hypertensive heart disease with heart failure, and end stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life). During a review of Resident 2's untitled CP initiated 9/16/2025, the CP indicated Resident 2 had hypotension and was at risk for dizziness, fainting, and fatigue. The CP goals indicated Resident 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055394 If continuation sheet Page 3 of 4 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 11/07/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete would be free of signs and symptoms of hypotension through the review date. The CP interventions indicated to give Resident 2's medications as ordered, and to monitor side effects and effectiveness. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had moderately impaired cognition. The MDS indicated Resident 2 had hypertension and heart failure. During a review of Resident 2's OSR, dated 10/1/2025 to 10/31/2025, the OSR indicated Resident 2 had an order for Isosorbide Mononitrate Oral Extended Release 24-hour, 30 mg, give one (1) tablet by mouth one time a day for HTN. Hold for SBP less than 100 or HR less than 60 BPM. The OSR indicated the order date was 10/14/2025. The OSR indicated the order was discontinued. During a review of Resident 2's MAR dated 10/2025, the MAR indicated on 10/27/2025, Resident 2 received isosorbide mononitrate at 9 am. The MAR indicated Resident 2's BP was 92/54. The MAR indicated LVN 4 administered the medication. During a telephone interview on 11/7/2025 at 1:26 pm, with LVN 4, LVN 4 stated (in general) when giving BP medications, LVN 4 checked the BP and HR prior to administration to ensure that the parameters were met prior to giving. LVN 4 stated, If the medications need to be held, we can check that. LVN 4 stated in for BP medications, the general parameters were to hold the medication of the HR was less than 60 and/or the SBP was less than 100. LVN 4 stated, If a resident had a BP of 92/54 and the parameter was to hold for SBP less than 100, I would not give BP medication because we could slow down their (the resident's) HR and cause hypotension. LVN 4 stated this could lead to hospitalization. During an interview on 11/7/2025 at 11:37 am, with the Director of Nursing (DON), the DON stated the purpose of hold parameters was an order to hold BP medications if the SBP was less than 100 and sometimes if the HR was less than 60. The DON stated, if hold parameters were not followed then residents could develop and injury and need to be hospitalized . The DON stated, isosorbide mononitrate should not be given if a resident's BP was 92/54. The DON stated isosorbide mononitrate was used to treat HTN. The DON stated if there was a parameter in a BP medication order, then the BP needed to be checked prior to administration of the BP medication, within a couple minutes but not more than an hour before or after the medication was given to ensure the BP was within the parameters of the medication. The DON stated those orders were to ensure a resident's BP was not too low prior to medication administration and that the resident did not have hypotension. During a review of the facility's P&P titled, Medication Administration, revised 10/2025, the P&P indicated it was the policy of the facility to accurately prepare, administer, and document oral medications. The P&P indicated, when administering unit doses and previously prepared drugs to.take vital signs (VS- fundamental measurements of basic bodily functions, including temperature, pulse [heart rate], respiration [breathing rate], and blood pressure) and to hold drugs if indicated. Event ID: Facility ID: 055394 If continuation sheet Page 4 of 4