CLAREMONT, CA - Federal inspectors cited Claremont Heights Post Acute for failing to properly account for a palliative care resident's morphine supply, along with dialysis monitoring breakdowns affecting three residents and a psychiatric medication care plan gap, according to a complaint inspection completed April 28, 2025.
Morphine Doses Missing from Narcotic Records
Inspectors reviewing the records of a resident receiving hospice-level pain management found that nursing staff administered morphine sulfate oral solution on at least five occasions in April 2025 without documenting the doses on the facility's Individual Narcotic Record (INR).
The resident, who had severe cognitive impairment and was fully dependent on staff for daily care, had a physician's order for morphine sulfate oral solution — 0.5 ml administered by mouth every 12 hours for pain management. The facility's own records confirmed nurses gave the medication at the scheduled 6:00 p.m. time on April 14, 15, 20, 22, and 23, 2025. However, the narcotic log that tracks each use and remaining supply of the controlled substance contained no corresponding entries for those five evening doses.
The Assistant Director of Nursing (ADON) confirmed the discrepancy during a joint record review with inspectors.
Controlled substance tracking exists for a critical reason: morphine is a Schedule II narcotic subject to Drug Enforcement Administration oversight, and gaps between what is administered and what is logged raise the possibility of drug diversion — the unauthorized redirection of medications. Accurate, real-time narcotic reconciliation is a fundamental pharmacy safeguard in any long-term care setting. When a facility cannot account for where a controlled substance went, it cannot rule out that medication was taken by someone other than the intended patient.
The facility's own policy on medication storage states that "controlled substance inventory is regularly reconciled to the Medication Administration Record" and that "current controlled substance accountability records are kept in the MAR, or designated book."
Dialysis Assessment Failures Across Three Residents
Inspectors also found that Claremont Heights failed to complete required assessments before and after dialysis treatments for all three sampled dialysis residents.
Each of these residents — identified as Residents 10, 11, and 12 in the report — had end-stage renal disease or dialysis dependence and traveled off-site multiple times per week for hemodialysis treatments. Federal regulations and the facility's own Dialysis Management policy require licensed nurses to perform pre-dialysis and post-dialysis evaluations and to maintain treatment documentation from the dialysis center in each resident's medical record.
Inspectors found multiple failures:
- Resident 11's pre-dialysis forms from April 11 and April 14, 2025 were sent to the dialysis center but returned with the treatment sections left entirely blank. Post-dialysis evaluations for April 7, 11, and 14 were missing altogether. - Resident 12's medical record contained no documentation from the dialysis center for treatments on April 19 and April 22, 2025. - Resident 10's pre-dialysis form from April 11, 2025 was returned from the dialysis center with the treatment section incomplete.
The ADON confirmed each of these documentation gaps during interviews with surveyors.
Pre- and post-dialysis assessments are not administrative formalities. Dialysis carries risks including dangerous drops in blood pressure, electrolyte imbalances, and access site complications. Without documented pre-treatment baselines and post-treatment evaluations, nursing staff at the facility cannot identify warning signs such as fluid overload, abnormal vital signs, or treatment complications that may require immediate medical intervention.
As one Licensed Vocational Nurse told inspectors: the nurse at the dialysis center "would document the treatment the resident received and return the documentation with the resident when the resident returned to the facility."
Psychiatric Medication Monitoring Gap
A separate deficiency involved a resident with Alzheimer's disease, schizoaffective disorder, and metabolic encephalopathy who was prescribed Clozapine — a powerful antipsychotic that carries serious risks including a potentially fatal blood condition called agranulocytosis, in which the body stops producing white blood cells.
Because of this risk, Clozapine requires mandatory weekly blood monitoring. The resident had physician's orders for weekly complete blood counts every Monday and weekly valproic acid level checks every Wednesday. Yet inspectors found the resident's care plan did not include the intervention of drawing these weekly labs.
The Director of Nursing acknowledged the gap during the inspection, stating the care plan "should also include interventions for the behavior of refusing the weekly labs."
Clozapine is one of the most closely regulated psychiatric medications in the United States. Prescribers must be registered with the Clozapine REMS program, and patients must have verified blood test results before pharmacies can dispense the next supply. A failure to draw and track these labs does not just violate care planning standards — it can result in a resident continuing to receive a medication that may be actively harming their bone marrow without anyone detecting it.
Inspection Outcome
All three deficiencies — the morphine tracking failure (F755), the dialysis assessment breakdowns (F698), and the care plan gap (F656) — were classified at the level of minimal harm or potential for actual harm. The inspection was conducted in response to a complaint.
The full inspection report is available through the Centers for Medicare & Medicaid Services and contains additional details on each deficiency. Residents and families with concerns about care at any nursing facility can contact the California Department of Public Health or their local long-term care ombudsman program.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Claremont Heights Post Acute from 2025-04-28 including all violations, facility responses, and corrective action plans.
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