Claremont Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of five sampled residents (Resident 21, 61, 116, 117, and 35), were treated with dignity when:a. Licensed Vocational Nurse (LVN) 2 failed to knock on Resident 21 and 61, 116 and 117's doors prior to entering the resident's rooms.b. LVN 3 failed to draw (close) Resident 35's privacy curtains completely around Resident 35's bed during insulin (a medication, hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration in Resident 35's abdomen (belly). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure quality of care for three of three sampled residents (Residents 2, 66 and 35) by failing:A. To follow physician's order when the license nurses administered insulin (a medication that removes excess sugar from the blood.) on one of three sample residents (Resident 2)'s left arm with a shunt. (a surgically created access point on the body for dialysis [a treatment to clean your blood when your kidney can't do it well.]) B. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical record was complete and accurate for three of three sampled residents (Resident 2, Resident 66, and Resident 113). This failure had the potential to result in inaccurate assessments, inconsistent and/or inaccurate treatments provided to the residents and negatively impact Resident 2 and 66, and Resident 113's physical well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 2)'s care plan (CP - provides direction on the type of nursing care an individual needs that includes goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan) was implemented when licensed nurses administered insulin (a medication that removes excess sugar from the blood.) on Resident 2's Left arm where Resident 2 had a shunt (a surgically created access point on the body for dialysis [a treatment to clean your blood when your kidney can't do it well.]) This failure had the potential to increase the risk of bleeding and cause trauma to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 43), who was unable to carry out activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) received the necessary services to maintain personal grooming as indicated in the facility's policy and procedure (P&P) titled, ADL, Services to carry out. This deficient practice had the potential to impact Resident 43's overall health and could socially and psychologically affect Resident 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate fall prevention interventions for one of two sampled residents (Resident 113), who was at high risk for falls and had a history of recent falls, when on [DATE], Resident 113 was observed leaning toward the left side of Resident 113's bed and Resident 113's mattress did not have equal sized side borders. This deficient practice had the potential to result in a recurrent fall and injury to Resident 113.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 25) oxygen humidifier (a medical device used to add moisture to the air or oxygen [a colorless gas essential to living organisms] that a resident breathes to prevent nasal irritation for residents on oxygen therapy) bottle was labeled with a date as indicated in the facility's policy and procedures (P&P), titled Infection Control Policy/Procedure, Resident Care - Oxygen, Use of This deficient practice had the potential to result in Resident 25's humidifier becoming contaminated with bacteria (microscopic organism that can cause disease) and result in an infection to Resident 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices for four of five sampled residents (Resident 66, Resident 120, Resident 21, and Resident 61) by failing to:a. Ensure a personal care toiletry item (shaving cream) located inside Resident 21 and Resident 61's shared restroom was labeled and stored properly.b. Implement a physician order for Enhanced Barrier Precautions (EBP- extra measures, like wearing gowns and gloves, used during high-contact care activities with residents who are at a higher risk of having or spreading germs that are hard to treat, like multidrug-resistant organisms [MDROs, bacteria that have become resistant to certain antibiotics [medication used to treat bacterial infections], and these antibiotics can no longer be used to control or kill the bacteria]) for Resident 66. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the plastic strip air curtain leading to the walk-in refrigerator in one of one kitchen (Kitchen 1) did not have a missing strip. This deficient practice had the potential to result in foodborne illness (disease caused by consuming contaminated food or drinks), to the residents consuming the food from the walk-in refrigerator, due to not maintaining consistent temperatures or the entry of insects, dust, and pollutants.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal the need for assistance) system was within reach for two of two sampled residents (Resident 3 and Resident 115), as indicated on Resident 115's care plans (CP) and in accordance with the facility's policy and procedure (P&P) titled Call Light. This failure resulted in Resident 115 feeling discouraged and had the potential to result in unmet needs and inability to alert staff during an emergency for Residents 3 and115.

Inspectors wroteBased on interview and record review, the facility failed to accurately administer medication for two of six sampled residents (Resident 2 and Resident 4) according to the facility's policy and procedure (P&P) titled, Medication Administration, by failing to: 1. Ensure Licensed Vocational Nurses (LVN) 1, 3, 4, 5, 6, 7, and 8 assessed and documented Resident 4's blood pressure (BP- the pressure circulating blood against the walls of blood vessels where low BP was less than 120/80 millimeters of mercury [mmHg- unit of measurement] and BP above 140/90 mmHg considered high blood pressure) just prior to administering carvedilol (medication used to treat hypertension [HTN- condition where the force of blood against artery walls is consistently too high and BP is consistently high]) on 10/10/2025 to 10/25/2025, 10/27/2025 to 11/6/2025 at 2 pm. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized person-centered plan of care that included measurable objectives, timeframes, and interventions to meet the needs of one of three sampled residents (Resident 1). Specifically, the facility did not develop an individualized care plan (CP) for Resident 1 in a timely manner to address Resident 1's past trauma after Resident 1 reported the trauma to the administrator (ADM). This deficient practice had the potential to result in unmet individualized needs and adversely affect the delivery of necessary care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care and treatment in accordance with the facility's policy and procedure (P&P) titled, Transportation to Doctors/Diagnostic Appointments, by failing to ensure staff was available to accompany Resident 1 to Resident 1's scheduled GI (gastrointestinal, refers collectively to the organs of the body that play a part in food digestion) consult (a process where a healthcare professional requests advice or expertise from another healthcare professional specialist or expert in a particular area regarding a patient's care) appointment on 6/25/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess and manage reported pain for one of three residents (Resident 1) as indicated in Resident 1's care plan and the facility's policies and procedures titled, Pain Recognition and Management, and Pain Management, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 assessed and documented Resident 1's pain location. 2. Ensure Resident 1 received pain medication when Resident 1 complained of persistent pain to Resident 1's right lower extremity (RLE- right leg, including hip, thigh, knee, calf, and foot) on 4/7/2025. These deficient practices had the potential for Resident 1 to experience unrelieved/uncontrolled pain that could result in physical, mental, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1) by failing to: 1. Ensure Physical Therapist (PT- a healthcare provider who helps improve how the body performs physical movements) 1 and PT 2 accurately documented Resident 1's pain location in Resident 1's Physical Therapy Encounter Notes (PT TEN) dated 4/7/2025 and 4/14/2025. 2. Ensure Licensed Vocational Nurse (LVN) 1 assessed and documented Resident 1's pain location in Resident 1's medical record. 3. Ensure staff documented the rationale for initiating a room transfer for Resident 1 on 4/7/2025 in Resident 1's medical record. These failures resulted in Resident 1's medical record to contain inaccurate and incomplete information and had the potential to affect Resident 1's care.

Inspectors wroteBased on interview and record review, the facility failed to revise the plan of care for one of three sampled residents (Resident 1), who was at high risk for falls, following episodes of getting up unassisted on 4/8/2025. This deficient practice had the potential to increase Resident 1's risk for falls and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and homelike environment for ten of ten sampled residents (Residents 13, 23, 30, 32, 44, 56, 61, 75, 298, and 299's) rooms. These deficient practices had the potential for Resident 13, 23, 30, 32, 44, 56, 61, 75, 298, and 299 to be exposed to dirt, mold, and drywall dust, which can lead to adverse health effects such as irritating eyes, skin, nose, throat, and lungs. Prolonged exposure can cause more serious problems such as acute respiratory illness, persistent coughing, and asthma.

Inspectors wroteBased on interview and record review, the facility failed to administer insulin as ordered for one of one sampled resident (Resident 19) in a timely manner. This deficient practice had the potential to make Resident 19 become lethargic, experience an altered level of consciousness or unresponsive to external stimuli.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods are handled, prepared, and stored in a manner that prevents foodborne illness (food poisoning) in the facility for one of one kitchen when: 1. Eleven milk cartons were observed in the reach-in refrigerator with an expiration date of 12/7/24. 2. Seven milk cartons with an expiration date of 12/7/24 were observed on a tray of drinks to be serve to residents. 3. One half empty milk carton with an expiration date of 12/7/24 on a resident's tray was observed being brought back to the kitchen by Certified Nursing Assistant (CNA) 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its infection prevention and control program for two of six sampled residents (Residents 20 and 78) by failing to: a. [NAME] (put on) a gown before entering Resident 78's room which it was under contact precautions. b. Wear personal protective equipment (PPE, prefers to protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) when cleaning Resident 20's room which it was under enhanced barrier precautions. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for all the residents and staff in the facility. Findings a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS, a standardized assessment and care-screening tool) was accurate for one of one sampled resident (Residents 90). Resident 90's MDS did not accurately reflect the resident's discharge status. This deficient practice resulted in inaccurate assessment on Resident 90's discharge status with wrong medical information on Resident 90's MDS.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a communication board easily accessible for one of two sampled residents (Resident 79) as indicated in Resident 79's care plan. This deficient practice prevented Resident 79 from communicating with facility staff and had a potential to delay appropriate nursing care/treatment and services for Resident 79.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were at risk for skin breakdown and pressure injuries (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) received treatment and services to prevent skin breakdown for one of three sampled residents (Resident 2) by failing to ensure the low air loss mattress (LAL mattress - air filled mattress used to relieve pressure) was set according to the resident's weight. Resident 2's LAL mattress was set at 180 pounds (lbs) and Resident 2's body weight was 117 (lbs). This deficient practice put Resident 2 at risk for developing pressure injury and/or worsening of the pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of two sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Fall Management System, and Resident 1's care plan when facility staff failed to turn on Resident 1's pressure pad alarm (a device that alerts a caregiver when a patient or family member is getting out of bed) and return Resident 1's bed to the lowest position. These failures had the potential to increase Resident 1's risk of fall and result in Resident 1 to sustain injury and/or harm in an event of a fall.

Inspectors wroteBased on interview and record review, the facility failed to provide two of two sampled residents (Resident 28 and 32) or Resident 28's family member/representative with information regarding the right to formulate an advance directive (AD, a legal document that provides instructions for medical care and only goes into effect if the person cannot communicate their wishes) and failed to have ADs on file prior to, upon, or immediately after admission as stated in the facilities policy and procedure (P&P). This deficient practice had the potential to result with Resident 28 and Resident 32 to receive inaccurate or unnecessary care and/or treatment services regarding life-sustaining treatment and the resident's wishes not met.

Inspectors wroteBased on interview and record review, the facility failed to ensure seven of seven Resident Council members (Resident 7, 15, 17, 34, 39, 48, and 61) and one alert and oriented resident (Resident 47) knew how to file a grievance (official statement of a complaint) and the identity of the facility's designated Grievance Official. The facility also failed to include the contact information of the facility's Grievance Official in the facility's policy and procedure (P&P) for grievances. These failures violated the rights of Residents 7, 15, 17, 34, 39, 48, 61 and 47, and had the potential for the residents to feel the facility did not hear or address the residents' concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan for two of two sampled residents (Resident 21and 5). 1. For Resident 21, the facility failed to implement the care plan related to Resident 21's fluid restrictions to address the fluid imbalances related to the resident's kidney failure and hemodialysis (mechanical filtering of the blood when the kidneys are not working properly). 2. For Resident 5, the facility failed to implement the care plan related to Resident 5's oxygen therapy. These failure had the potential to result in the decline of Resident 5 and 21's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the care plans for bowel/bladder incontinence (inability to hold urine or stool) and skin problems for one of one sampled resident (Resident 21). This failure resulted in Resident 21's confusion and frustration of Resident 21's plan of care related to fluid intake (fluid consumed, daily) vs. fluid restriction (restriction of fluid intake consumed, daily), causing Resident 21 to become teary-eyed from the misinformation the facility was providing Resident 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory services were provided for two of two sampled residents (Residents 19 and 5). The facility did not follow the physician's orders to provide continuous oxygen therapy (administration of oxygen with the intent of treating or preventing the symptoms and manifestations of decreased level oxygen in tissues) for Residents 19 and 5. This failure resulted in incomplete respiratory care and had the potential to result in respiratory distress to Residents 19 and 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices and implement interventions to prevent and control the spread of infections in the facility in accordance with the facility policy and procedures (P&P) and national health guidelines for five of five sampled residents (Residents 22, 3, 32, 238, and 76) when, 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure any abnormal vital signs for one of one sampled resident (Resident 83) was reported to the physician timely. This failure had the potential to result in a decline in Resident 83's condition due to a delay in the delivery of treatment and services.

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse (LVN) 1 failed to monitor Resident 238's heart rate prior to administering blood pressure medication per the parameters indicated in the physician orders. This deficient practice had the potential to result in Resident 238 having an increased risk for complications related to the management of blood pressure, dizziness and falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 10), was provided the preferred choice of activities. This deficient practice resulted in Resident 10 being bored and had the potential to result in a decline in Resident 10's physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and correctly apply a splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to one of six sampled residents (Resident 26) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] by failing to: 1. Ensure Resident 26 received passive range of motion (PROM, movement of joint through the ROM with no effort from the person) to the left arm from 11/13/2023 to 11/27/2023. 2. Provide PROM to Resident 26's left elbow prior to application of a left elbow extension splint (material used to extend or straighten the elbow as much as possible) on 11/28/23, and correctly apply a left elbow extension splint to the left elbow. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services for one of one sampled resident (Resident 236) in accordance with Resident 236's physician's order to follow up with a urologist (a medical doctor that treat bladder issues) for Resident 236's urinary retention (unable to empty the bladder) This failure had the potential to result in Resident 236 to experience a delay in treatment and had the potential to result in a physical decline to Resident 236 and affect the resident's overall well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the signed binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by an arbitrator [third party decision-maker] instead of a judge or jury in court) for one of one sampled residents (Resident 136) provided a selection of a convenient venue (location to carry out arbitration proceedings agreed upon and suitable to both parties). This failure had a potential to result in a decline in Resident 136's physical and psychosocial wellbeing due to possible hardships related to arbitration proceedings.

Inspectors wroteBased on interview and record review, the facility failed to designate a staff representative to coordinate and ensure hospice services (a type of care and philosophy of care that focuses on the relief and comfort of a terminally ill patient's pain and symptoms and attends to their emotional and spiritual needs) and visits were given as ordered for one of one sampled resident (Resident 3). This failure had the potential to result in Resident 3 not receiving well-coordinated and comprehensive hospice services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician that one of three sampled residents (Resident 486) did not qualify for antibiotic use based on the facility's guide (McGreer's Criteria) used to review true infections. This deficient practice had the potential for the resident to develop adverse effects related to antibiotic use and antibiotic resistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain infection prevention and control practices (a set of practices that prevent or stop the spread the of infection and/or diseases in the healthcare setting) in accordance with the facility ' s policy and procedure and Centers for Disease Control and Prevention (CDC) guidelines by failing to: a. Ensure one of 13 sampled staff (Licensed Vocational Nurse 1 [LVN 1] performed hand hygiene (procedures that included the use of alcohol-based hand rub (ABHR- containing 60%-90% alcohol) and hand washing with soap and water before entering and after providing care to one of six sampled residents (Resident 5), who was positive for COVID-19 (infectious disease caused by SARS-CoV-2 virus). b. [...]