CLAREMONT, CA - A federal inspection at Claremont Heights Post Acute revealed significant failures in medical documentation and infection control protocols that put 93 residents at risk during a COVID-19 outbreak, according to a February 19, 2025 survey report.
Major Medical Documentation Breakdowns
The inspection uncovered systematic failures in documenting and following through on physician orders, with three residents experiencing compromised care due to inadequate record-keeping. The most concerning case involved a resident with metabolic encephalopathy who sustained a leg wound that went untreated for over a week.
Resident 2, who has severe cognitive impairment and cannot communicate or make decisions independently, scratched their right leg while seated in a wheelchair on January 23. While a Licensed Vocational Nurse documented the incident and notified the physician, critical breakdowns occurred in the treatment process. The physician ordered wound cleaning and dressing changes starting January 24, but this order was never properly transcribed into the resident's medication or treatment records.
Most significantly, staff admitted they monitored the wound but provided no actual treatment. LVN 3 told investigators they "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." This decision contradicted the physician's specific orders for daily wound care.
The documentation also failed to explain how a resident with limited mobility in both arms managed to scratch their leg while seated in a wheelchair, leaving questions about whether proper supervision or positioning was provided.
Dental Procedure Documentation Gaps
Two residents underwent tooth extractions without proper documentation of post-procedure monitoring. Resident 4, who has paralysis and weakness on one side of their body following a stroke, had two teeth extracted on January 23. However, investigators found no evidence that required 72-hour monitoring was conducted or documented.
The resident confirmed the dental work occurred, stating "the dentist came last month and extracted two of Resident 4's teeth at the bedside." Despite this major procedure, the facility failed to document where the extraction was performed, whether family members were notified, or that proper post-operative monitoring occurred.
Similarly, Resident 3 had a wisdom tooth extracted in December, but documentation was incomplete regarding the procedure's location and follow-up care.
Medical Consequences of Documentation Failures
These documentation lapses create serious medical risks for vulnerable residents. When physician orders aren't properly transcribed or followed, residents may not receive prescribed treatments, leading to wound complications, infections, or delayed healing. For elderly residents with compromised immune systems, untreated wounds can quickly escalate to serious infections requiring hospitalization.
Inadequate post-surgical monitoring is particularly dangerous for residents who underwent dental extractions. Complications can include excessive bleeding, infection, or adverse reactions to anesthesia. The 72-hour monitoring requirement exists because most post-extraction complications occur within this timeframe, and residents with cognitive impairments may be unable to communicate symptoms effectively.
The Director of Nursing acknowledged these risks, explaining that proper documentation "provided the reader information regarding how incidents happened and how to prevent them" and could "assist to develop the resident's care plan, to come up with the proper interventions, and to assess if staff training/education was needed."
COVID-19 Infection Control Violations
During an active COVID-19 outbreak affecting the facility's 93 residents, inspectors observed multiple staff members failing to follow basic infection control protocols that could spread the virus to vulnerable residents.
An Activity Assistant was observed removing their N95 mask in a hallway filled with residents and staff, just one room away from the facility's designated COVID-19 isolation zone. When questioned, the staff member acknowledged they knew they "were not supposed to remove N95 mask in resident care areas" and should go to the break room for eating or drinking.
A Certified Nursing Assistant was found wearing their N95 mask incorrectly, with the bottom strap hanging loosely under their chin rather than properly positioned above their ears. The employee admitted the straps were uncomfortable but demonstrated they knew the correct procedure when prompted.
More concerning was a CNA who failed to perform hand hygiene after removing gloves and before entering multiple resident rooms. This staff member removed gloves, discarded them, then entered two different resident rooms without washing hands or using sanitizer, potentially spreading pathogens between residents.
Industry Standards and Best Practices
Federal regulations require nursing homes to maintain complete, accurate medical records documenting all resident care, treatments, and physician orders. These records serve as the primary communication tool between care team members and ensure continuity of care across different shifts and staff members.
For infection control during disease outbreaks, facilities must implement comprehensive protocols including proper use of personal protective equipment and consistent hand hygiene. The CDC recommends N95 masks be worn correctly throughout shifts in healthcare settings, with removal only in designated break areas away from patient care zones.
Post-surgical monitoring protocols exist because dental procedures in elderly residents carry increased risks due to age-related factors such as slower healing, medication interactions, and difficulty reporting complications. The 72-hour monitoring requirement allows early detection and intervention for potential complications.
Additional Issues Identified
The inspection also revealed a confusing physician order that was never clarified with the prescribing doctor. One resident had an order stating "Apply excoriation site until bleeding stops," which staff found unclear but failed to seek clarification from the physician or supervising nurse.
Staff interviews revealed systemic confusion about documentation responsibilities, with one nurse stating they didn't transcribe treatment orders because they "thought all treatment orders had to go through the treatment nurse first." This indicates inadequate training on proper procedures and chain of responsibility.
The facility's own policies clearly outlined requirements that were not being followed, including documentation standards stating that "treatments, observations during treatments and effectiveness of treatments and the date and time noting physician orders must be documented in the resident's medical record."
Facility Response and Oversight
The violations were classified as causing minimal harm or potential for actual harm, affecting few to some residents. However, the cumulative effect of documentation failures and infection control lapses created an environment where resident safety was compromised.
The Director of Nursing acknowledged the importance of proper documentation and infection control but indicated that additional staff education was needed on N95 mask procedures and hand hygiene protocols. The facility must submit a plan of correction to address these deficiencies and prevent future occurrences.
These findings highlight the critical importance of consistent documentation practices and rigorous infection control measures in protecting nursing home residents, who are among the most vulnerable populations for healthcare complications and infectious disease outbreaks.
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.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.