Claremont Nursing & Rehabilitation Center

Inspectors wroteFindings include: Review of Resident 1's clinical record revealed diagnoses that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident 1's current physician orders revealed the following orders dated April 3, 2026:Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML (medication to treat diabetes) inject 28 units subcutaneously two times a day. If blood sugar is less than 150 or NPO/not eating hold and notify provider. If blood sugar is greater than 400 notify provider; check blood sugar for signs and symptoms of high/low blood sugars and notify physician if the blood sugar is less than 60 or greater than 400. Give appropriate snack or administer as needed glucagon per physician orders; [...]

Inspectors wroteBased on review of facility contract, clinical record review, and resident family and staff interviews, it was determined that the facility failed to provide care and services to ensure the residents' highest level of functioning and well-being for one of three residents reviewed (Resident 1).

Inspectors wroteBased on facility policy review, observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for one of four residents reviewed for pressure ulcers (Resident 8).

Inspectors wroteBased on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to label medications properly in three of six medication carts observed (Third Floor [NAME] Hall, C-Wing C Hall, and Transitions East Hall) and two of four medication rooms observed (First Floor and Heritage Harbor); and the facility failed to discard expired medications in three of six medication carts observed (First Floor West, C-Wing C Hall, and Transitions East Hall) and in one of four medication rooms observed (Third Floor).

Inspectors wroteBased on observation, policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 35 residents reviewed (Residents 14 and 173). Findings Include: Review of facility policy, titled Comprehensive Care Plans; Dated 2022, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of Resident 14's clinical record revealed diagnoses that included Vitamin D deficiency and osteoporosis (a condition in which the bones become brittle and fragile). [...]

Inspectors wroteBased on observations, facility policy review, state regulation, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 35 residents reviewed (Resident 4). Findings Include: Review of the Pennsylvania Nursing Practice Act, Chapter 21.145. Functions of the LPN (Licensed Practical Nurse), revealed The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: The LPN may accept a written order for medication and therapeutic treatment from a practitioner authorized by law and by facility to issue orders for medical and therapeutic measures. [...]

Inspectors wroteBased on clinical record review, observation, facility documentation review, and resident and staff interviews, it was determined that the facility failed to provide care and services to ensure the residents' highest level of functioning and well-being for two of 35 residents reviewed (Residents 145 and 232).

Inspectors wroteBased on observations, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent accidents for one of 35 residents reviewed (Resident 8).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services to ensure acceptable parameters of nutrition and hydration for one of 35 residents reviewed (Resident 1).

Inspectors wroteBased on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon for two of five residents reviewed for unnecessary medications (Residents 5 and 8).

Inspectors wroteBased on review of facility policy, facility admission agreement, closed clinical records, resident account statements, and staff interview, it was determined that the facility failed to convey resident fund account balance and overpayment balance upon discharge in accordance with State law for three of three closed resident records reviewed (Residents 1, 2, and 3).

Inspectors wroteBased on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for three of 35 residents observed (Residents 156, 167, and 252); and failed to maintain a safe, clean, and home-like environment on one of six nursing units observed (Heritage Harbor).

Inspectors wroteBased on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to ensure that residents were protected from potential for abuse by failing to perform criminal history background checks prior to hire for three of five personnel files reviewed (Employees 3, 4, and 5). Findings Include: Review of facility policy, titled Abuse, Neglect and Exploitation, dated 2022, revealed, Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. [...]

Inspectors wroteBased on facility policy review, clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for one of four residents reviewed for respiratory care (Resident 369).

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for two of 35 residents reviewed (Residents 25 and 136).

Inspectors wroteBased on observations, clinical record review, and resident and staff interviews, it was determined the facility failed to ensure each resident receives proper treatment and assistive devices to maintain vision abilities for one of one resident reviewed for vision (Resident 240).

Inspectors wroteBased on observations, facility policy review, and staff interview, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of five residents with tube feedings reviewed (Resident 2).

Inspectors wroteBased on policy review, observation, record review, and staff interview, the facility failed to complete a risk-benefit analysis and obtain consent for enabler bar use for one of six residents reviewed for enabler use (Resident 33).

Inspectors wroteBased on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure that the drug regimen of each resident was reviewed at least monthly by a licensed pharmacist, that irregularities were reported to the appropriate parties, and that these reports were acted upon in a timely manner for two of five residents reviewed for unnecessary medications (Residents 100 and 147).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice related to wound assessments for one of six residents reviewed (Resident 5).

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to maintain an effective pest control program for one of four months reviewed (May 2024). Findings Include: Review of Resident 5's clinical record revealed diagnoses that included atherosclerosis (buildup of plaque in the walls of arteries causing reduced blood flow) and type two diabetes mellitus (the body does not make enough insulin or cannot use it as well as it should). Further review of Resident 5's clinical records revealed a wound care note dated June 3, 2024, that stated maggots were present in Resident 5's left anterior shin wound. A staff interview on July 11, 2024, at 10:35 AM, with Employee 2 (Registered Nurse) revealed, Employee 2 was one of the registered nurse supervisors for the building the evening of June 2, 2024. [...]

Inspectors wroteBased on facility policy review, facility document review, clinical record review, and staff interviews, it was determined that the facility failed to report sexual abuse to the State Agency within the specified timeframes for two of two incident reports reviewed. Findings Include: Review of facility policy, titled Abuse, Neglect and Exploitation, dated 2022, revealed 'Sexual Abuse' is non-consensual sexual contact of any type with a resident. Further review of the policy revealed: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. [...]

Inspectors wroteBased on observations, facility policy review, and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of 35 residents reviewed (Residents 36) and in two of two dining rooms observed (Heritage Hall dining area and Second Floor dining area).

Inspectors wroteBased on policy review, review of facility documentation, clinical record review, and staff and resident interviews, it was determined that the facility failed to ensure that prompt efforts were made to resolve grievances/concerns for one of 35 residents reviewed (Resident 199).

Inspectors wroteBased on review of the clinical record and resident and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 35 residents reviewed (Residents 86 and 129).

Inspectors wroteBased on observations, facility policy review, manufacturer product label review, and staff interviews, it was determined that the facility failed to discard expired medication in one of three medication rooms observed (second floor medication room); failed to properly store and label drugs in two of four medication carts observed (third floor, west hall medication cart and second floor, west hall medication cart); failed to properly store medications inside a locked medication cart for one of two medication carts observed during a medication pass observation (first floor); and failed to lock a mediation cart when not in direct sight of a staff member. Findings Include: Review of facility policy, titled Administering Medications, revised December 2021, revealed, The expiration/beyond use date on the medication label must be checked prior to administering. [...]

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and equipment in accordance with professional standards for food service safety in the main kitchen and five of six nourishment areas.

Inspectors wroteBased on review of the clinical record, policy review, and resident and staff interviews, it was determined that the facility failed to ensure that the clinical record accurately reflected the resident preference for code status for one of 35 residents reviewed (Resident 81).

Inspectors wroteBased on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 35 residents reviewed (Resident 87).

Inspectors wroteBased on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to provide assistance with activities of daily living for dependent residents for one of 35 residents reviewed (Resident 34).

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to prevent accident and hazards for one of 35 residents reviewed (Resident 139).

Inspectors wroteBased on observations, clinical record review, staff interview, and facility policy review, it was determined that the facility failed to provide the physician prescribed therapeutic diet for one of five residents reviewed for nutrition (Resident 156).

Inspectors wroteBased on observations, clinical record review, and staff interview, it was determined that the facility failed to ensure that it was free from a medication error rate of five percent or greater based on two medication errors out of 38 opportunities. Findings Include: Observation of medication administration on December 12, 2023, at 8:30 AM, revealed Employee 1 (Licensed Practical Nurse) administering Trelegy Ellipta Inhaler 200-62.5-25 inhaler to Resident 42. Review of Resident 42's physician orders revealed an order for Trelegy Ellipta Inhaler 200-62.5-25 (an inhaled medication) inhale one puff orally one time a day for chronic obstructive pulmonary disease (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations) with specific directions to rinse mouth and spit after administration. [...]

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to storage of staff personal items in a medication cart in one of three carts observed and the preparation and administration of medications to one of four Residents observed (Resident 42).

Inspectors wroteBased on observations, facility document review, and staff interviews, it was determined that the facility failed to provide a therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) for the lunch meal on October 19, 2023, for seven of seven residents on the Renal Diet (Resident 1, 2, 3, 4, 5, 6, and 7).