Claremont Manor Care Center

In the surveyor’s words

From the most serious findings on record at Claremont Manor Care Center, in the surveyor’s own words.

• Actual harm, isolatedF744Jan 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 92), who had a diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life) and history of falling, received care and services to prevent a fall ( move downward, typically rapidly and freely without control, from a higher to a lower level) by failing to: a. Ensure Registered Nurse 1 (RN 1) notified Resident 92's physician/medical doctor (MD 1) regarding Resident 92's increased agitation (unable to relax and be still) and confusion (unable to think clearly) when Resident 92 attempted to stand up unassisted from Resident 92's wheelchair (WC) multiple times on 1/20/2025 as indicated in the facility's policy and procedure (P&P)… […]

• No harm, potential for more than minimal, patternF552Mar 13, 2026

  Based on observation, interview, and record review, the facility's licensed staff failed to obtain informed consents (IC, the process, a form indicating a resident or responsible party voluntarily agrees to a medical treatment or procedure after understanding the risks, benefits, and alternatives) from two of two sampled resident's (Resident 35 and Resident 46) responsible parties by failing to:A. Obtain an IC from Resident 35 and/or the resident's responsible party prior to the administration of Mirtazapine 15 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount). Additionally, the facility failed to obtain an IC in a timely manner for the administration of Mirtazapine 30 mg when the dose was increased from 15 mg to 30 mg on 10/2/2025.B. […]

• No harm, potential for more than minimal, patternF755Mar 13, 2026

  Based on observation, interview, and record review, the facility failed to have an effective medication reconciliation (systematic collection and verification of a resident's complete and accurate medications during transitions of care, aims to identify and resolve discrepancies and can result in preventable adverse drug events [SE, undesired harmful effect resulting from a medication] and helps to identify the loss or potential diversion [illegal distribution of prescription drugs or their use for unintended purposes] of controlled medications [medications with high potential for abuse]) system in place for controlled medications for 3 of 8 sampled residents (Resident 8, Resident 48, and Resident 49).This deficient practice resulted in unaccounted controlled medications for Resident 8,… […]

• No harm, potential for more than minimal, patternF925Feb 11, 2025

  Based on observation, interview, and record review, the facility failed to have an effective pest control program, to prevent cockroaches in one of one kitchen for a facility licensed for a 59-bed count. This deficient practice had the potential to expose 38 residents currently residing in the facility to foodborne illness. Findings During a concurrent observation and interview on 2/11/25 at 1:15 p.m. while in the kitchen with the head chef (HC), HC stated he has only been employed at the facility for a few weeks. HC stated he doesn't know the last time the kitchen had a deep cleaning for the floors and all areas of the kitchen. HC stated the kitchen crew does daily sweeping and mopping two times (once during the day and once in the evening after dinner). […]

• No harm, potential for more than minimal, patternF656Jan 24, 2025

  Based on observation, interview, and record review, the facility failed to develop and implement an individualized person-centered care plan (CP), for four of four sampled residents (Resident 37, Resident 27, Resident 6, and Resident 5), as indicated in the the facility's policy and procedure (P&P), tilted, Care Plan, by failing to, a. Develop a care plan (CP) for Resident 37 when there was a change in skin condition on 1/11/2025. b. Develop a CP for Resident 27 for anticoagulant (class of medication that help prevent blood clots from forming in the heart and blood vessels) use when Resident 27 received Eliquis (medication used to prevent blood clots) tablet 2.5 milligrams (mg, unit of measurement) by mouth twice a day. c. […]