CLAREMONT, CA - Federal inspectors found significant deficiencies at Claremont Manor Care Center during a January 24, 2025 inspection, citing the facility for failing to properly communicate changes in resident conditions to physicians and for inadequate care planning for residents with complex medical needs.
Critical Communication Breakdown Endangers Resident Safety
The most serious violation documented involved a failure to notify physicians about significant changes in a resident's condition. According to the inspection report, a 92-year-old resident with Alzheimer's disease and psychosis experienced a dramatic change in mental status that went unreported to medical staff.
The resident, who was initially described as "non-verbal and did not attempt to get out of bed" upon admission on January 16, 2025, showed marked behavioral changes by January 20. Staff observed the resident "consistently attempted to stand up, mumbled, and spoke to herself," prompting nurses to place the resident at the nurse's station for constant monitoring due to fall risk.
Despite these concerning changes, Registered Nurse 1 admitted to inspectors that she "did not notify MD 1 about the change in Resident 92's condition/mentation." This communication failure violated the facility's own policy requiring notification of physicians before the end of the assigned shift when changes in resident conditions are noted.
The facility's Director of Nursing confirmed to inspectors that increased confusion and attempts to get up unassisted represented a significant change from the resident's baseline that required physician notification. A hospice nurse caring for the resident stated that if properly informed, "we would have sent out a nurse to reassess or to rule out the cause of the change in mentation and notified MD 1 to obtain new physician orders with new interventions that benefited Resident 92."
Medical Implications of Communication Delays
Changes in cognitive function and behavior in elderly residents, particularly those with dementia, can signal serious underlying medical conditions requiring immediate attention. Sudden increases in confusion may indicate infections, medication reactions, dehydration, or other treatable conditions that, if left unaddressed, can lead to serious complications.
When nursing staff fail to promptly communicate these changes to physicians, residents may experience prolonged discomfort, increased fall risk, and potentially preventable medical deterioration. The facility's RN Consultant acknowledged that "increased confusion was considered a change of condition" and emphasized the importance of informing physicians "to see if further investigation was needed, additional labs, increased monitoring, medication changes."
Inadequate Care Planning Compromises Individual Care
Inspectors identified widespread failures in developing comprehensive care plans for residents with complex medical needs. Four out of four sampled residents had significant gaps in their individualized care plans, representing a systemic problem with the facility's care planning process.
The deficiencies included:
Missing Skin Care Planning: Resident 37 developed a change in skin condition on January 11, 2025, but no care plan was created to address this new medical issue. Proper skin care planning is essential for preventing pressure ulcers and promoting healing.
Anticoagulant Monitoring Gaps: Resident 27 was receiving Eliquis, a blood-thinning medication that requires careful monitoring for bleeding risks and drug interactions, yet no care plan existed to guide staff in safe administration and monitoring protocols.
Antipsychotic Medication Management: Resident 6 was prescribed Quetiapine for behavioral symptoms including "yelling and screaming spells," but lacked a care plan to monitor for side effects or track medication effectiveness.
Dementia Care Deficiencies: Resident 5 had a diagnosis of dementia but no comprehensive care plan addressing the specific needs and interventions required for cognitive impairment management.
Industry Standards and Required Protocols
Federal regulations require nursing homes to develop individualized care plans that address each resident's specific medical conditions, medications, and care needs. These plans must include measurable goals, specific interventions, and timeframes for achieving outcomes.
For residents receiving antipsychotic medications, facilities must implement monitoring protocols to track effectiveness and watch for serious side effects including movement disorders, falls, and cardiovascular complications. Anticoagulant therapy requires regular monitoring of bleeding signs, drug interactions, and coordination with laboratory testing.
Dementia care planning should encompass behavioral interventions, safety measures, communication strategies, and approaches to maintain the resident's dignity and quality of life. When skin conditions develop, immediate care planning helps prevent deterioration and promotes healing through appropriate wound care protocols.
Medicare Coverage Communication Failures
The inspection also revealed failures in obtaining required signatures on Medicare coverage notices. Resident 26's Advance Beneficiary Notice form was never signed by the resident or their representative, despite the resident having severely impaired cognitive abilities documented in their assessment.
The facility's Social Services Designee acknowledged that "there were no signatures in Resident 26's SNFABN form" and recognized that "the risk of not having the SNFABN form signed was that the resident or resident's RP could dispute it because the form indicated they were not aware of the billing and costs."
This administrative failure potentially leaves families uninformed about Medicare coverage limitations and personal financial responsibility for services that may not be covered.
Additional Issues Identified
Beyond the major violations, inspectors documented other compliance concerns affecting resident care and safety. These additional findings demonstrate ongoing challenges with regulatory compliance across multiple areas of facility operations.
The violations identified at Claremont Manor Care Center reflect serious gaps in fundamental nursing home operations that could compromise resident safety, medical care quality, and family financial protection. The facility received citations requiring corrective action to address these deficiencies and prevent future occurrences.
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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