CLAREMONT, CA - State health inspectors found significant gaps in care planning and pressure ulcer prevention protocols at Claremont Manor Care Center during a January 24, 2025 inspection, documenting failures that put vulnerable residents at risk for inadequate monitoring and worsening medical conditions.
Critical Care Plan Deficiencies Discovered
The inspection revealed that the facility failed to develop required care plans for residents with serious medical conditions requiring specialized monitoring. Registered Nurse 1 acknowledged during the inspection that there was no care plan for a resident receiving Eliquis, a blood-thinning medication used to treat atrial fibrillation.
The resident, identified as Resident 27, was documented as having chronic systolic heart failure and atrial fibrillation, conditions that make anticoagulant therapy both necessary and potentially dangerous. Care plans serve as roadmaps for nursing staff, outlining specific interventions, monitoring requirements, and safety protocols tailored to each resident's medical needs.
When questioned about this omission, the registered nurse stated there should be care plans for anticoagulants to monitor for drug effects, establish treatment goals, and provide specific staff interventions. The nurse explained that without proper care planning, "staff could miss the specific interventions for the specific target behavior and put the resident at risk for unnecessary medication use."
Similarly problematic was the facility's handling of antipsychotic medications. Resident 6, diagnosed with dementia and cognitive impairment, was receiving Quetiapine Fumarate for behavioral control without an accompanying care plan. Antipsychotic medications in elderly patients with dementia carry significant risks, including increased mortality, and require careful monitoring and documentation of their necessity and effectiveness.
Medical Implications of Inadequate Care Planning
The absence of care plans for high-risk medications creates a dangerous gap in patient safety protocols. Anticoagulant therapy requires constant vigilance for signs of bleeding, regular laboratory monitoring, and careful attention to drug interactions. Without documented protocols, nursing staff may miss critical warning signs such as unusual bruising, changes in mental status, or bleeding episodes that could indicate dangerous medication levels.
For antipsychotic medications in dementia patients, proper care planning should include regular assessment of whether the medication is still necessary, monitoring for side effects, and documentation of behavioral interventions attempted before medication use. Federal regulations require that antipsychotics be used only when clinically appropriate and that facilities demonstrate ongoing efforts to reduce or eliminate their use when possible.
The facility's own care planning policy, revised in February 2021, clearly states that comprehensive written plans should be developed within 14 days of admission and updated quarterly or upon any change in condition. These plans should identify problems or needs based on standardized assessments and guide staff in implementing appropriate interventions.
Pressure Ulcer Prevention Failures
The inspection also uncovered serious deficiencies in pressure ulcer prevention protocols. Most concerning was the discovery of an unstageable pressure injury on Resident 37's coccyx area on January 11, 2025, which staff failed to properly address. The registered nurse admitted that no care plan was created when this significant skin breakdown was identified, stating there "should've been a care plan indicating when the injury started to ensure it was not getting worse."
An unstageable pressure injury represents severe tissue damage where the full extent of the wound cannot be determined due to dead tissue covering the area. These injuries require immediate, intensive treatment protocols to prevent further deterioration and potential life-threatening complications such as infection.
The facility's failures extended beyond documentation to basic care protocols. Resident 37's care plan required repositioning every two hours during night shifts to prevent pressure buildup on vulnerable body areas, yet inspectors found no documented evidence this positioning occurred for nearly a month, from December 26, 2024, through January 24, 2025.
Additionally, the facility failed to conduct weekly skin assessments as outlined in the resident's care plan and delayed implementing pressure-relieving devices when the injury was discovered. These oversights represent fundamental breakdowns in accepted wound care protocols.
Industry Standards and Expected Protocols
Professional wound care standards require immediate assessment and intervention when pressure injuries are identified. This includes photographing the wound, measuring its dimensions, determining the stage or severity, and implementing appropriate treatment protocols within 24 hours of discovery.
Pressure ulcer prevention relies on regular repositioning schedules, typically every two hours for bedridden patients, along with pressure-relieving mattresses and cushions. The inspection found that Resident 32's specialized air mattress was incorrectly calibrated, set for a 550-pound person when the resident weighed only 138 pounds, rendering the pressure-relief ineffective.
Weekly skin assessments are considered minimum standards for residents at risk for pressure injuries. These systematic examinations allow early detection of skin changes before they progress to full injuries, enabling preventive interventions that can halt deterioration.
Additional Issues Identified
Beyond the major care planning and wound care deficiencies, inspectors documented additional concerning practices. The facility failed to update existing care plans when residents experienced changes in condition, including increased confusion in a resident with Alzheimer's disease who required enhanced monitoring and safety interventions.
Medication-related care plans were also found to be outdated, with one resident's depression care plan showing incorrect dosage information that didn't match current physician orders. This type of documentation failure can lead to medication errors and inadequate symptom monitoring.
The facility's own policies acknowledge the importance of regular care plan updates, requiring reassessment "at least quarterly and upon change of condition." The inspection findings suggest these requirements were not being consistently followed, creating gaps between residents' actual needs and documented care protocols.
These violations represent systemic failures in fundamental nursing home operations that are designed to ensure resident safety and appropriate medical care. The documented deficiencies demonstrate the critical importance of proper care planning, wound prevention protocols, and regular assessment procedures in maintaining quality care for vulnerable nursing home residents.
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.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.