Health inspection·May 16, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 2 and Resident 3. [NAME] 3 indicated PCP 1 ordered labs and a psych consult (physician and resident conference aimed at gaining a deeper understanding of the resident's mental condition and treatment plan to meet mental health goals). During a review of the facility's document of Resident 2's interview (IR 1), titled Interview/Debriefing Narrative Record, dated 5/7/2024, IR 1 indicated Resident 2 stated that Resident 3 kept interrupting the Activities Director (AD) while providing activities to the residents. IR 1 indicated Resident 2 stated Resident 3 got upset and started cussing at Resident 2 and threatened to hit Resident 2. 1b. During a review of Resident 3's FS 2, FS 2 indicated the facility admitted Resident 3 on 10/19/2023 with multiple diagnoses including HHD, type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and unsteadiness on feet. During a review of Resident 3's History and Physical Examination (H&P), dated 10/21/2023, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS (MDS 2), dated 4/25/2024, MDS 2 indicated Resident 3 had moderate impairment in cognition. MDS 2 indicated Resident 3 required substantial/maximal assistance with toileting hygiene, bathing, lower body dressing, and putting on/taking off footwear, and transfers. MDS 2 indicated Resident 3 had no physical, verbal, and other behavioral symptoms directed/not directed towards others. During a review of Resident 3's Plan of Care - Behavioral Disturbances (CP 2), revised on 5/5/2024, CP 2 indicated Resident 3 had a behavior of cursing and was abusive towards another resident. During a review of Resident 3's [NAME] 1 (R3CIN 1), dated 5/5/2024 and timed at 3 PM, R3CIN 1 indicated LVN 1 documented that Resident 3 had a verbal altercation with Resident 2 while in the dining room. R3CIN 1 indicated Resident 3 was cussing at resident and saying ' F*** your mom. You bi***. I am going to kick you a**.' During a review of the facility's document of Resident 3's interview (IR 2), titled Interview/Debriefing Narrative Record, dated 5/7/2024, IR 2 indicated Resident 3 stated Resident 2 started raising her voice and told Resident 3 she was not supposed to take a picture. IR 2 indicated Resident 2 used profanity on Resident 3, so Resident 3 responded, Fuck you or I will kick your ass. During an interview on 5/16/2024 at 10:40 AM, AD stated on 5/5/2024 at around 3:05 PM while the facility was celebrating Cinco de Mayo, Resident 3 requested AD to take a photo of Resident 3 with another resident. AD stated Resident 2 told Resident 3 not to disrupt the activities. AD stated Resident 3 responded, You don't tell me what to say, then the argument started. AD stated AD witnessed Resident 3 verbalizing profanities towards Resident 2. AD stated he separated the residents immediately and continued with the activities until 4 PM/4:15 PM on 5/5/2024. AD stated he did not report the incident to any Charge Nurse, Registered Nurse (RN) Supervisor, or the Abuse Coordinator. During an interview on 5/16/2024 at 2:29 PM, LVN 1 stated LVN 1 did not witness the altercation between Resident 2 and Resident 3. LVN 1 stated LVN 1 overheard from other staff members that Resident 3 was brought out of the activities room because Resident 3 needed to be separated from Resident 2 due to an argument they had while in the activities room with the other residents. LVN 1 stated SS 1 approached him on 5/6/2024 and asked him what happened on 5/5/2024. LVN 1 stated he spoke to AD on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555085 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 555085 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claremont Manor Care Center 621 W Bonita Ave Claremont, CA 91711 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5/6/2024 at the end of the shift (approximately 3 PM) to inquire about the incident details on 5/5/2024 between Resident 2 and Resident 3. During an interview on 5/16/2024 at 2:50 PM, RN 1 stated any alleged abuse, including verbal abuse, must be reported to the SSA, LTO, and LLE within 2 hours. RN 1 stated it was necessary to investigate the incident timely to prevent the recurrence of any abuse incident and to prevent any further abuse or injury of any resident/s. During an interview on 5/16/2024 at 3:32 PM, the Administrator stated the alleged abuse was reported to the agencies on 5/7/2024 (more than 24 hours after the incident occurred). During a review of the facility's policy and procedure (P&P), titled Adult Abuse, dated 4/2018, the P&P indicated the following: 1. The facility must enforce a non-tolerance of any form of behavior that might be construed as abuse by any individual, family member, staff member, visitor, volunteer, student, or other person, including resident-to-resident abuse of any type. 2. Abuse is the willful (deliberate action) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. 3. Verbal abuse refers to any use of oral, written, or gestured language that includes threats and/or disparaging and derogatory terms. 4. Any person having information, either by direct observation or by report, of any act or suspected act that may be considered to be a form of abuse, is responsible for reporting the information immediately to the individual's department head or Administrator, or their designee, regardless of the time of day. 5. Anyone who is an owner, operator, employee, manager, agent, or contractor of the facility who has observed, suspects, or has knowledge of an allegation of abuse must report to SSA, LTO, LLE, and the Administrator immediately but not later than 2 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555085 If continuation sheet Page 3 of 3