Claremont Heights Post Acute

In the surveyor’s words

From the most serious findings on record at Claremont Heights Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF744Jun 26, 2025

  Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1), who had diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life), had a history of fall (unintentionally coming to rest on a lower-level surface) on 6/1/25, and was assessed at a high fall risk on 6/1/25, received care needs and services to prevent a fall on 6/19/25 by failing to ensure:Licensed Vocational Nurse (LVN) 2 monitored (observed and checked) and promptly (quickly/rapidly/immediately) redirected Resident 1 (direct Resident 1 to a new or different place or purpose) when Resident 1 got up from Resident 1's wheelchair unassisted while Resident 1 was at Nurses' Station 1 on 6/19/25 [at around 10 am].As a result, on… […]

• Actual harm, isolatedF689Jan 25, 2023

  Based on observation, interview, and record review, the facility failed to provide care and services to prevent a fall for one of three sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) and CNA 2 provided two-person physical assistance (help from two person) to transfer Resident 1 from the bed to a shower chair using a Hoyer Lift (mechanical lift, a device used by staff to transfer residents from a bed to a chair or other similar places). 2. Ensure CNA 1 and CNA 2 followed the facility ' s Policy and Procedure (P&P) on Fall Management Program, How to Safely Lift A Patient Into A Patient Lift/Hoyer Lift, and Total Mechanical Lift. As a result, on 12/21/2022, at 9:10 a.m., Resident 1 fell from the Hoyer Lift. […]

• No harm, potential for more than minimal, patternF550Feb 27, 2026

  Based on observation, interview and record review, the facility failed to ensure three of three sampled residents (Resident 1, 6, and 54) were treated with dignity when:a. Certified Nursing Assistant (CNA) 6 left Resident 54's lower body exposed. b. CNA 12 stood over in front of Resident 1 while assisting Resident 1 to drink during lunch.C. Speech Therapist (ST) was standing while feeding Resident 6.These deficient practices resulted in Resident 54 feeling uncomfortable, cold and naked and had the potential to cause Resident 1, 6 and 54 feeling humiliated, negatively impacting the residents' psychosocial well-being. Findings: a. […]

• No harm, potential for more than minimal, patternF578Feb 27, 2026

  Based on interview and record review, the facility failed to implement the facility's policy and procedure (P&P) titled, Advance Directives, for two of two sampled residents (Resident 4 and Resident 35) when:1. Copies of Resident 4's and Resident 35's advance directives (AD-a legal document that provides instructions for medical care when a person can no longer decide on their own) were obtained and filed in Resident 4's and Resident 35's medical records.2. The Social Services Director (SSD) did not ensure the Durable Power of Attorney (DPOA, a legal document allowing another person to manage one's financial, legal, or medical affairs when one can no longer decide on their own) filed in Resident 35's medical records also covered medical or healthcare decisions.These failures had the… […]

• No harm, potential for more than minimal, patternF656Feb 27, 2026

  Based on interview and record review, the facility failed to develop a Care Plan (CP, a form where one can summarize a person's health conditions, specific care need, and current treatments) for three of three residents (Resident 103, 13, and 67) as evidenced by:Failure to develop a CP for Resident 13's behavior of pulling and removing Resident 13's gastrostomy tube (GT - medical feeding tube inserted through the abdomen directly into the stomach to deliver nutrients, fluids, and medications.)Failure to develop a CP for Resident 67's personal preference to apply tape to the eyelids. […]