CLAREMONT, CA - A newly admitted resident with Alzheimer's disease and severe cognitive impairment sustained a significant head laceration requiring emergency hospitalization after staff left the resident unsupervised in a room, despite repeated warnings that constant monitoring was needed, according to a state inspection conducted on January 24, 2025 at Claremont Manor Care Center.
Failure to Provide Constant Supervision Leads to Serious Injury
The incident involved Resident 92, who was admitted to the facility on January 16, 2025 with diagnoses including Alzheimer's disease and psychosis. Within days of admission, staff documented that the resident had an unsteady gait, poor balance, and was at risk for falls. Progress notes from the day of admission indicated the resident was confused and needed full assistance with all activities of daily living.
By January 20, 2025—just four days after admission—the resident's condition had notably changed. Staff observed that the resident was attempting to stand up from a wheelchair multiple times without assistance and had become increasingly confused. Certified Nursing Assistant (CNA) 3 told investigators that "the moment you turn your back, she will get up," recognizing the serious fall risk this behavior presented.
In response to these safety concerns, nursing staff placed the resident at the nurses' station for constant monitoring throughout the morning shift. Both the charge nurse and licensed vocational nurse on duty understood the resident required continuous visual supervision due to the persistent attempts to stand unassisted.
However, when the shift changed at 3:00 PM, a critical breakdown in care occurred. CNA 5 informed the evening nurse that the aide would take the resident back to her room to rest before dinner. Despite knowing the resident required constant monitoring, staff placed the resident in bed in a room located five to six rooms down the hallway—out of visual range from the nursing station—and left her completely unsupervised.
At approximately 4:30 PM, Licensed Vocational Nurse (LVN) 6 entered the resident's room to find the bed empty. The resident was discovered face-down on the floor with blood visible. The resident had sustained a 5.2-centimeter laceration on the right eyebrow that was actively bleeding, along with abrasions on both knees. Emergency services were called at 4:35 PM due to the severity of the head injury.
Hospital records documented the resident presented with a laceration on the right eye with contusions, abrasions on both knees, and a contusion on the right knee. When observed two days later during the inspection, the resident still showed visible signs of injury, with gray discoloration around the right eye, swelling under the eye, and a laceration requiring three adhesive strips to close the wound.
Multiple System Failures Contributed to Preventable Injury
The inspection revealed several interconnected failures in the facility's care systems that contributed to this preventable incident. Alzheimer's disease progressively destroys memory and cognitive function, making individuals unable to recognize danger or remember safety instructions. When residents exhibit sudden behavioral changes—such as attempting to stand repeatedly after being previously non-ambulatory—this represents a significant change in condition requiring immediate medical evaluation and updated care interventions.
Falls in residents with dementia carry particularly serious risks. Cognitive impairment means residents cannot communicate pain effectively, may not understand instructions to remain still, and cannot participate in their own fall prevention. Head injuries in elderly individuals can lead to subdural hematomas (bleeding between the brain and skull), increased confusion, and functional decline that may be permanent.
The facility's own care plan, initiated on January 17, 2025, identified the resident as being at risk for falls related to impaired cognition, lack of safety awareness, and poor communication. The plan's stated goal was to decrease the risk of falls and minimize injuries from falls, with interventions including reminding the resident not to get up without assistance. However, these interventions proved inadequate once the resident's behavior changed to show active attempts to stand.
According to facility policy on dementia care, residents who exhibit new or worsening behavioral symptoms should have an evaluation by the physician to identify and address treatable conditions that may be contributing to the behaviors. The facility's change in condition policy explicitly states that any sudden or serious change manifested by marked change in physical or mental behavior must be communicated to the physician prior to the end of the assigned shift.
Despite multiple staff members recognizing the dramatic change in the resident's behavior—from being non-verbal and not attempting to get up, to actively and repeatedly trying to stand—no one contacted the attending physician. Registered Nurse (RN) 1 acknowledged to investigators that she did not notify the physician about the changes in the resident's condition, even though she had endorsed to the evening shift that the resident attempted to stand multiple times and needed constant monitoring.
When investigators interviewed the attending physician on January 24, 2025, the physician confirmed being unaware of either the resident's behavioral changes or the fall that occurred on January 20. The physician stated they should have been notified upon the resident's change in behavior so they could evaluate the resident and write new orders to implement safety measures to prevent falls. The physician indicated they would have ordered one-to-one supervision as an intervention for the resident's change in condition.
Understanding the Medical Significance of These Failures
The failures documented in this case reflect fundamental misunderstandings about dementia care and fall prevention in nursing facilities. Dementia is not a static condition—residents can experience fluctuations in symptoms, and sudden behavioral changes often signal underlying medical issues such as infections, medication reactions, pain, or disease progression.
When a resident with Alzheimer's disease suddenly begins attempting to ambulate after being previously sedentary, this represents a significant change requiring immediate assessment. The behavior could indicate increased agitation from an undiagnosed urinary tract infection, a reaction to medications, uncontrolled pain, or worsening dementia. Without physician evaluation, the underlying cause remains unidentified and untreated.
Constant visual supervision means exactly that—a staff member must be able to see the resident at all times. Placing a high-risk resident in a room out of visual range, even for "just a few minutes" to rest, defeats the entire purpose of constant supervision. Falls in elderly individuals with dementia typically occur within seconds—the time it takes to shift position in bed or attempt to stand.
The facility's fall prevention policy specifically identifies appropriate interventions including frequent observation, assigning rooms near the nurse's station, and specialized strategies for residents with dementia and recurrent fall attempts. None of these measures were implemented despite clear recognition of the elevated risk.
The Director of Nursing confirmed to investigators that the CNA should not have taken the resident back to her room and left her unsupervised given the increased confusion and multiple attempts to get up. The DON acknowledged the resident needed constant monitoring and that leaving her unsupervised could result in a fall—which is exactly what occurred.
Additional Issues Identified
Beyond the serious supervision failure, inspectors documented several other compliance concerns at Claremont Manor Care Center:
Medication Management Problems: The facility failed to ensure a routine pain medication was available for Resident 7, who required a lidocaine patch applied daily to the right shoulder. The medication was not administered on January 21, 2025 because it had not been delivered by the pharmacy, despite being a scheduled routine medication. The resident confirmed needing the patch for shoulder pain.
Drug Allergy Documentation Errors: The facility failed to maintain accurate medication allergy information for two residents. Resident 28, who had 12 documented drug allergies, received Ambien nine times in December 2024—a medication listed as one of their known allergies. Resident 27's electronic medical record failed to document allergies to clindamycin and Norco, while incorrectly indicating allergies to prednisone and prednisolone. These documentation failures create serious risks for anaphylactic reactions and other severe allergic responses.
Food Safety Violations: Kitchen inspections revealed multiple sanitary violations including a cook preparing food wearing only a ball cap without a hairnet underneath, four containers of cottage cheese stored past their expiration date, expired cake mix in dry storage, and dented cans of marinara sauce that should have been discarded. Dented cans pose particular risks for botulism contamination.
Infection Control Lapses: Staff failed to follow enhanced barrier precautions when providing perineal care to a resident requiring such precautions, entering the room without wearing a gown. For a resident who tested positive for COVID-19, the facility failed to place a portable HEPA filtration system in the room despite keeping the door open, and allowed a family member to visit without proper personal protective equipment. Additionally, laundry staff were found pre-filling disinfection logs before tasks were actually completed.
Call Light Accessibility: Inspectors observed Resident 4's call light tucked and hanging on the back of the bed headboard between the wall and bed, completely out of the resident's reach. This resident was fully dependent for all mobility and activities of daily living.
The inspection demonstrates patterns of inadequate supervision, incomplete safety protocols, and insufficient attention to clinical changes requiring medical evaluation—all of which place vulnerable residents at risk for preventable harm.
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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