CLAREMONT, CA - A state inspection at Claremont Manor Care Center identified multiple violations involving improper medical equipment settings, inadequate wound care, and failures to prevent a serious fall that resulted in a resident's hospitalization.
Critical Equipment Failures Put Vulnerable Residents at Risk
The January 24, 2025 inspection revealed two instances where life-sustaining medical equipment was not properly configured, potentially compromising resident safety. In one case, a low air loss mattress designed to prevent pressure sores was set at 550 pounds for a resident who weighed only 138 pounds.
Low air loss mattresses are specialized therapeutic devices that redistribute pressure across a patient's body through controlled airflow. When properly calibrated to a patient's weight, these mattresses help prevent pressure ulcers by maintaining optimal pressure distribution, airflow, and moisture management. However, when the weight setting exceeds the patient's actual weight, the mattress cannot provide effective pressure relief.
The resident in question had severe cognitive impairment, was dependent for all activities of daily living, and had been identified as high-risk for pressure sores. According to facility staff interviewed during the inspection, the mattress was "set too high" and this "reduced its ability to maintain proper pressure redistribution, airflow, and moisture management, which were critical to preventing skin damage."
A second equipment failure involved oxygen therapy for a resident with chronic respiratory failure and asthma. Inspectors discovered that the resident's nasal cannula tubing had been disconnected from the oxygen concentrator and was lying on the floor. The resident required 3 liters of oxygen as needed for shortness of breath, but was unaware the oxygen was not being delivered.
Medical professionals recognize that proper oxygen delivery is essential for residents with respiratory conditions. When oxygen equipment becomes disconnected, residents can experience dangerous drops in blood oxygen levels, potentially leading to respiratory distress, organ dysfunction, or other serious complications.
Wound Care Deficiencies Lead to Preventable Complications
The inspection documented a concerning pattern of wound care failures for a resident who developed a pressure ulcer on the tailbone area. Despite being identified as high-risk for pressure sores and having specific care plan interventions in place, multiple breakdowns in care contributed to wound development and progression.
The resident's care plan specifically required turning and repositioning every two hours, weekly skin evaluations, and immediate intervention if skin changes were observed. However, documentation revealed that these critical interventions were not consistently implemented. When a skin change was first noted on January 11, 2025, nursing staff failed to complete required change of condition documentation, which serves to notify the care team and initiate proper assessment protocols.
A treatment dose was missed on January 12, and the wound "opened" the following day, demonstrating the direct consequences of care gaps. The resident required protective foam dressings to the tailbone and both heels, but treatment administration records showed the missed application.
Weekly skin evaluations, designed to catch early changes before wounds develop, were not performed according to the care plan schedule. Staff completed evaluations on December 26, 2024, January 15, 2025, and January 22, 2025 - missing the required weekly intervals. During the inspection, nursing staff acknowledged that "no documentation indicated the task was not done and possibly could lead to skin breakdown."
The pressure-relieving low air loss mattress that should have been implemented immediately when the skin change was discovered on January 11 was not ordered until January 14 - a three-day delay that may have contributed to wound progression.
Serious Fall Results from Inadequate Dementia Care
The most serious incident documented involved a resident with dementia who fell from bed and required emergency hospital treatment. On January 20, 2025, the resident exhibited increased agitation and confusion, repeatedly attempting to stand from a wheelchair without assistance.
Standard protocols for dementia care require immediate physician notification when residents experience significant changes in mental status or behavior, as these changes can indicate underlying medical issues, medication reactions, or environmental stressors that require prompt evaluation and intervention.
However, nursing staff failed to contact the resident's physician about the behavioral changes. Instead, a certified nursing assistant took the agitated resident to their room, placed them in bed, and left them unsupervised despite their altered mental state.
At 4:30 PM that same day, the resident fell out of bed, sustaining a laceration and bruising on the right eyebrow and abrasions on both knees. Emergency services transported the resident to the hospital emergency department, representing a serious safety event that the facility's own policies were designed to prevent.
Residents with dementia who experience sudden behavioral changes require increased monitoring and often benefit from environmental modifications, activity redirection, or medical evaluation. Leaving such residents unsupervised, particularly when they have demonstrated fall risk behaviors, contradicts established dementia care practices.
Medical Standards and Best Practices
Healthcare facilities are required to maintain specialized medical equipment according to manufacturer specifications and clinical protocols. Low air loss mattresses must be calibrated to each patient's weight to provide therapeutic benefit. Similarly, oxygen delivery systems require proper connection and monitoring to ensure patients receive prescribed treatments.
Pressure ulcer prevention relies on consistent implementation of evidence-based interventions including regular repositioning, specialized surfaces, skin assessment, and prompt intervention when changes occur. The standard of care requires documentation of all interventions to ensure continuity and accountability.
For residents with cognitive impairment, facilities must provide appropriate supervision and environmental safety measures. Changes in mental status warrant immediate medical evaluation, as they may signal treatable conditions such as infections, medication interactions, or other acute medical issues.
Additional Issues Identified
The inspection also documented failures in humidifier bottle dating for oxygen equipment, which creates infection control risks when equipment sterility cannot be verified. Proper labeling and dating of medical equipment helps prevent contamination and ensures devices are changed according to manufacturer and facility protocols.
Staff interviewed during the inspection acknowledged understanding of proper procedures but indicated systemic issues with implementation, including the absence of a designated treatment nurse and inconsistent documentation practices that made it difficult to verify whether required care was actually provided.
The facility's own policies outlined appropriate procedures for wound assessment, oxygen therapy, and change of condition protocols, but implementation failures resulted in compromised resident care and safety outcomes.
These violations highlight the critical importance of consistent adherence to established medical protocols, proper equipment maintenance, and appropriate supervision of vulnerable residents to prevent serious adverse outcomes in long-term care settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Claremont Manor Care Center from 2025-01-24 including all violations, facility responses, and corrective action plans.
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