Inspection Reports for
Claremont Manor Care Center

The complaint investigation found that Resident 2 verbally abused Resident 1 on 7/1/2025 by yelling, cursing, and threatening Resident 1. Resident 1 was scared and upset after the incident. The facility's policy prohibits any form of abuse including verbal abuse. The Director of Nursing and other staff confirmed the incident.

The facility failed to prevent verbal abuse when Resident 2 threatened, cursed, and yelled at Resident 1, causing Resident 1 to feel scared and angry. The incident was confirmed through interviews with residents, staff, and review of records.

The complaint involved an allegation of sexual abuse made by Resident 1 on 4/16/2025. The facility delayed reporting the allegation to the Department beyond the required two-hour window, although reports to the police and Ombudsman were timely. The allegation was substantiated by interviews and documentation.

The facility failed to report an allegation of sexual abuse for Resident 1 to the Department within two hours as required by policy, resulting in delayed notification. Interviews and record reviews confirmed the delay in reporting, although the facility did report to the police and Ombudsman within the required timeframe.

The complaint investigation found that an alleged abuse incident on 1/20/25 involving Resident 1 was not reported to the administrator until 2/25/25, well beyond the required 2-hour reporting window. The allegation was substantiated based on interviews with staff and review of records.

The facility failed to report an alleged abuse incident involving Resident 1 immediately and within 2 hours as required by policy, resulting in delayed notification to the State Agency and Ombudsman. Interviews and record reviews confirmed the abuse allegation and the failure to report in a timely manner, with the implicated Licensed Vocational Nurse suspended pending investigation.

The facility failed to maintain an effective pest control program, resulting in cockroach presence in the kitchen. Observations included grease and dirt buildup, cockroaches seen near the dishwashing area, and unsanitary conditions. The kitchen was closed for 48 hours due to the infestation, and food was prepared offsite during this period. The facility lacked a pest control policy and housekeeping did not clean the kitchen area.

The facility was found deficient in multiple areas including failure to update resident code status, failure to notify physicians of changes in resident condition, incomplete care plans, inadequate pressure ulcer care, improper respiratory care, medication management issues including missing pain medication and incorrect allergy documentation, improper use of psychotropic drugs, food safety violations, infection control lapses, and call light accessibility.

Complaint involved allegation that CNA 1 squeezed Resident 2's brief around the genitalia area to check if it was wet. The facility's investigation was unable to substantiate the complaint. The complaint was received on 9/13/24, investigation commenced the same day, but the facility reported the incident to authorities on 9/16/24, exceeding the required two-hour reporting window.

The facility failed to report the alleged physical abuse to the state agency and law enforcement within the required two-hour timeframe, resulting in delayed notification. Additionally, the facility failed to immediately remove CNA 1 from resident care duties during the investigation, allowing the CNA to continue working, which posed a potential risk for further abuse. The complaint was ultimately unsubstantiated.

The complaint investigation found that the facility did not report the verbal abuse incident between Resident 2 and Resident 3 within the required 2-hour timeframe to the State Survey Agency, Long-Term Ombudsman, and local law enforcement. The Administrator confirmed the report was made more than 24 hours after the incident occurred.

The facility failed to report an alleged verbal abuse incident involving Resident 2 and Resident 3 within the required timeframe, potentially risking further abuse. The investigation revealed that Resident 3 verbally abused Resident 2 during a Cinco de Mayo activity, and the incident was not reported promptly as required by facility policy and regulations.

The facility failed to conduct annual N95 mask fit testing for one of four sampled staff members and did not notify all residents and family representatives about the COVID-19 outbreak in a timely manner. Staff were observed wearing PPE properly, but notification delays and incomplete fit testing posed risks for COVID-19 spread.

The facility was found deficient in multiple areas including failure to maintain resident dignity and timely response to call lights, inadequate fall risk assessment and care plan updates, failure to provide appropriate oxygen therapy and hearing aids, incomplete skin assessments leading to pressure injuries, improper infection control practices, inaccurate nurse staffing documentation, and unsafe food handling practices.

The facility failed to annually conduct N95 mask fit testing for 63 of 68 staff members, which posed a potential risk for the spread of COVID-19 among residents, staff, and visitors. Interviews and record reviews confirmed expired fit tests and lack of updated testing for most staff.

The complaint investigation found that Resident 1's physician ordered a neurology consult to rule out dementia, but the facility did not follow through with the order. The Interim Director of Nursing and Administrator confirmed no documentation of the consult, and Resident 1's Emergency Contact was unaware of the consult appointment.

The facility failed to ensure that Resident 1 received a neurology consult as ordered by the physician, resulting in Resident 1 not being seen or evaluated by a neurologist. Interviews and record reviews confirmed no documentation of the consult being completed, posing potential harm to the resident's well-being.

The complaint investigation was substantiated by findings that the facility did not adequately monitor a resident at risk for elopement, and door alarms were not functioning properly. The investigation also found failure in infection control practices by contracted staff in the COVID-19 red zone.

The facility failed to ensure adequate supervision for a resident at risk of elopement, resulting in the resident being found outside the facility due to a malfunctioning door alarm. Additionally, the facility failed to follow infection control protocols when contracted staff did not properly remove PPE before exiting a COVID-19 isolation room, risking spread of infection.

The complaint investigation found substantiated issues including disrespectful care by a CNA and medication administration errors involving glipizide given despite low blood sugar levels.

The facility failed to treat one resident with respect and dignity during care, as a CNA did not stop turning the resident when requested. Additionally, the facility failed to hold the medication glipizide when the resident's blood sugar was below the prescribed threshold, potentially placing the resident at risk for hypoglycemia. Both deficiencies were assessed as causing minimal harm or potential for actual harm.

The complaint investigation found that Resident 1 alleged $1,600 was taken from her. The allegation was reported to facility staff on 7/15/23 but was not reported to the Department, Ombudsman, or law enforcement until 7/20/23, five days later. Staff interviews revealed confusion and lack of knowledge about reporting requirements. The complaint was substantiated as the facility failed to report timely and train staff adequately.

The facility failed to timely report an allegation of financial abuse involving $1,600 missing from Resident 1 to the California Department of Public Health, Ombudsman, and local law enforcement within the required 2-hour timeframe. Additionally, three staff members (LVN 1, DON, and CNA 1) failed to identify the missing money claim as an allegation of financial abuse due to lack of proper training and confusion about reporting procedures.

The complaint investigation found that the facility did not notify the physician promptly after Resident 1 complained of foot pain on 5/15/23, which delayed diagnosis and treatment of a fracture. The complaint was substantiated with findings from interviews and record reviews.

The facility failed to ensure that Resident 1's physician was notified of the resident's complaint of right foot pain in a timely manner, resulting in a delay in diagnosis and treatment of a right fifth metatarsal neck fracture. The Physical Therapist Assistant did not report the complaint on 5/15/23, and the physician was only informed after the Licensed Vocational Nurse was notified on 5/17/23.

The facility failed to ensure accurate documentation of seizure monitoring for Resident 1, who has epilepsy. Despite medication administration and care plans indicating monitoring requirements, no documentation of seizure monitoring was found in the resident's medical record for the year 2023.

The facility was found deficient in multiple areas including call light accessibility, resident rights notification, protection of resident property, accuracy of resident assessments, care planning, treatment provision, restorative nursing services, medication management, dietary services, hospice coordination, infection control, and quality assurance processes.