Federal inspectors found Claremont Heights Post Acute failed to maintain complete medical records for three residents, including missing documentation of dental procedures and wound treatments that left vulnerable patients without proper follow-up care.
The most serious gap involved Resident 4, who had a bottom left wisdom tooth and adjacent tooth extracted on January 23. The resident confirmed to inspectors that "the dentist came last month and extracted two of Resident 4's teeth at the bedside."
Yet nurses never recorded the procedure in the resident's clinical record. They failed to monitor the patient each shift for 72 hours after the extraction, as required by facility policy. The resident's family was never informed about the dental work.
The only evidence of the procedure was a dental progress note that inspectors had to request separately. Even that document failed to specify where the extractions took place.
A second case involved Resident 2, who had metabolic encephalopathy and couldn't understand or make decisions. The resident sustained a wound on the right leg after scratching it on a wheelchair footrest on January 23.
Licensed Vocational Nurse 2 received a physician's order for wound treatment that evening at 7:45 pm. But the nurse never transcribed the order into the resident's medical record, believing "all treatment orders had to go through the treatment nurse first."
The treatment order didn't appear in the clinical record until the next day. It was never transcribed into the Treatment Administration Record, where staff document care provided to residents.
As a result, there was no evidence the wound treatment was ever given. Licensed Vocational Nurse 3, who worked as the treatment nurse, told inspectors she "only monitored Resident 2's right shin scratch and did not treat it because the dressing made the scratch humid and made the scab soft."
The resident remained dependent on others for all activities of daily living, including eating, bathing, dressing, and moving in bed.
A third resident had a tooth extraction on December 9, but nurses failed to document where the procedure occurred.
The documentation failures created confusion among staff about basic medical orders. One physician's order for Resident 4, transcribed by a registered nurse on January 23, read: "Apply excoriation site until bleeding stops."
Inspectors found no evidence that nurses sought clarification of this unclear order, which appeared to confuse a skin scrape treatment with the dental extraction that had actually occurred.
Director of Nursing officials acknowledged the problems during interviews. The director was "unable to find documentation of how Resident 2 scratched Resident 2's right leg while seated in the wheelchair" and couldn't locate the treatment order in the resident's records.
"It was important to document details of what happened to the resident and what was done for the resident in the resident's clinical record because it provided the reader information regarding how incidents happened and how to prevent them," the director told inspectors.
The director explained that documentation helps develop care plans, determine proper interventions, and assess whether staff need additional training.
Licensed Vocational Nurse 4 reinforced this point, telling inspectors that "licensed nurses must document everything the licensed nurses do for the resident in the resident's clinical record to communicate care provided to the resident to other care providers."
Facility policy requires entries to be "recorded promptly as the events or observations occur" and be "complete, legible, descriptive, and accurate." The policy specifically mandates documentation of "treatments, observations during treatments and effectiveness of treatments."
The Medical Records Director, reached by phone, confirmed the documentation gaps. After reviewing Resident 4's record, the director "was unable to find any documentation that Resident 4 had teeth extracted on 1/23/25."
These record-keeping failures put residents at risk of receiving inappropriate care and prevented proper evaluation of whether procedures followed clinical guidelines. The missing documentation also made it impossible to assess whether staff needed additional education or training.
Resident 2 had limited range of motion in both shoulders and elbows, requiring positioning with pillows or splints to prevent contractures. The resident needed assistance with turning, repositioning, and all daily activities.
The inspection found that critical medical information was either missing entirely or scattered across different record systems, creating dangerous gaps in continuity of care for some of the facility's most vulnerable patients.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Claremont Heights Post Acute from 2025-02-19 including all violations, facility responses, and corrective action plans.
