Health inspection·April 17, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to report an allegation of abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (the Department) within two hours, in accordance with the facility's policy and procedure (P&P), titled Adult Abuse, revised April 2018. This failure resulted in the delay of notification to the Department and had the potential for Resident 1 to be subjected to abuse while at the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/3/2025, with diagnoses including urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), metabolic encephalopathy (brain disease that alters brain function or structure), and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/10/2025, the MDS indicated Resident 1 was severely impaired in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from staff for lower body dressing and toileting hygiene. The MDS indicated Resident 1 required supervision (oversight, encouragement or cuing) from staff for eating, oral and personal hygiene, and upper body dressing. During an interview on 4/17/2025 at 8:43 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 made an allegation of sexual abuse to CNA 1 on 4/16/2025 at around 7 a.m. CNA 1 stated that Resident 1 had claimed that during the night (no time specified), Resident 1 had been raped. CNA 1 stated CNA 1 informed Licensed Vocational Nurse (LVN) 1 right away of Resident 1's allegation of sexual abuse. During an interview on 4/17/2025 at 8:56 a.m. with LVN 1, LVN 1 stated CNA 1 informed LVN 1 of Resident 1's allegation of sexual abuse on 4/16/2025 at around 7:25 a.m. LVN 1 stated LVN 1 informed the Director of Nursing (DON) of Resident 1's allegation of sexual abuse when the DON arrived at the facility at around 7:45 a.m. LVN 1 stated all allegations of abuse needed to be reported within 2 hours to the police, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and the Department. LVN 1 stated LVN 1 did not report the allegation of abuse to the police, Ombudsman, or the Department. LVN 1 stated the Administrator (ADM) reported it. During a concurrent interview and record review on 4/17/2025 at 9:20 a.m. with the ADM, the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555085 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 04/17/2025 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)