Health inspection·March 11, 2025

F 0609 residents. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/11/25 at 3:30 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated, Resident 1 was in the wheelchair by the nursing station and Resident 1 was trying to get up. CNA 2 stated, CNA 2 heard LVN 1 saying with a loud, strong voice sit down, sit down, you gonna fall to Resident 1. CNA 2 stated, CNA 2 could not remember the exact date of the incident, but CNA 2 stated, the incident happened on the same day Resident 1 fell. CNA 2 stated, abuse allegations should be reported within 2 hours so the facility could investigate. Residents Affected - Few During a review of Resident 1's Change in Condition (COC), dated 1/20/25, timed at 4:30 p.m. documented in the Progress Notes, the COC indicated, Resident 1 was found on the floor next to Resident 1's bed in a prone position (face down) on Resident 1's right side. During an interview on 3/11/25 at 3:48 p.m. with the Director of Staff Development (DSD), the DSD stated, during the DSD's follow-up meeting on 1/21/25 with CNA 1 about Resident 1's fall incident that happened on 1/20/25, CNA 1stated, one of the LVNs was raising her voice at Resident 1. The DSD stated, raising the voice was inappropriate and unprofessional and could be a form of verbal abuse. The DSD stated, the DSD notified the ADM about the LVN's voice raising on the same day (1/21/25) of the follow-up meeting with CNA 1. During an interview on 3/11/25 at 3:55 p.m. with the ADM, the ADM stated, it was possible the DSD reported to the ADM on 1/21/25 but the ADM, just can't remember. The ADM stated, facility was mandated to report allegations of abuse immediately, within 2 hours for the safety of the residents. During a review of the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC 341), date completed 2/25/25, the SOC 341 indicated, the ADM was notified on 2/25/25 at 11:45 a.m., of an incident that occurred on 1/20/25 at approximately 4:00 p.m. about a CNA (unnamed), who overheard, LVN 1 repeatedly and loudly instructing Resident 1 to sit down in Resident 1's wheelchair. The SOC indicated, LVN 1 was suspended immediately upon notification, pending investigation. The SOC 341 was the facility's report submitted to the State Agency. During a review of the facility's Statement (ST - interview report), of CNA 1, dated 2/26/25, the ST indicated, CNA 1 stated, CNA 2 told CNA 1 that the charge nurse was yelling at the resident [Resident 1] on 1/20/25. The ST indicated, CNA 1 stated, CNA 1 felt that yelling at a resident (in general) was a form of abuse. During a review of the facility's ST, of CNA 2, dated 2/26/25, the ST indicated, CNA 2 stated, on 1/20/25, CNA 2 observed a resident (Resident 1) tried to stand up from the wheelchair and CNA 2 heard LVN 1 kept yelling at Resident 1 to sit down. During a review of the facility's latest in-service lesson plan (LP), titled, Types of Abuse, Reporting protocol & SOC 341, dated 2/26/25, the LP indicated, to immediately report to the Abuse Coordinator (the ADM) who would complete the SOC 341, report to the Ombudsman, and report to CDPH (the State Agency) within two hours. During a review of the facility's P&P, titled, Adult Abuse, date revised 4/2018, the P&P indicated, 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 was responsible for reporting the information immediately to the individual's department head or Executive Director/ADM, or their designee, regardless (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 03/11/2025 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 of the time of day. The P&P indicated, anyone who was an owner, operator, employee, manager, agent of the facility who had observed, suspected, or had knowledge of an allegation of abuse should report to the Department of Public Health (CDPH) Licensing Division, the Ombudsman, law enforcement, and the ADM immediately, but not later than 2 hours. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555085 If continuation sheet Page 3 of 3