Claremont Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Claremont Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF725Dec 7, 2022

  Based on clinical record reviews, review of facility deployment sheets, and resident and staff interviews, it was determined that the facility failed to provide adequate and sufficient nursing staff to provide medication administration in accordance with professional standards of practice and physician orders for 14 out of 14 residents reviewed (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) on the Transitions Unit. These staffing failures resulted in 269 missed medication doses including insulins, antipsychotics, antibiotics, antihypertensives, seizure medications, heart medications, and pain medications. […]

• Immediate jeopardy, patternF760Dec 7, 2022

  Based on clinical record review, as well as resident and staff interviews, it was determined that the facility failed to follow accepted professional standards and principles for administering medications and ensure the prevention of significant medication errors for 13 out of 14 residents sampled (Residents 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, and 14) on the Transitions Unit. This resulted in an Immediate Jeopardy situation because the missed medications had the potential to cause the residents discomfort or pain, to exacerbate medical conditions including blood pressure, cardiac and diabetic issues, increase the potential for seizures, and jeopardized the health and safety of 13 out of 14 residents reviewed. […]

• Immediate jeopardy, patternF678Nov 17, 2022

  Based on facility policy review, clinical record review, review of the American Heart Association (AHA) information, and staff interviews, it was determined that the facility failed to immediately provide Cardiopulmonary Resuscitation (CPR - emergency life-saving procedure performed when the heart stops beating) as required for one of one residents reviewed who had requested that CPR be administered in the event that they became unresponsive with no pulse. Resident 1 became unresponsive and pulseless, and the facility staff did not immediately administer CPR to Resident 1 as required. Resident 1 was pronounced dead at the facility. […]

• Immediate jeopardy, isolatedF689Jun 14, 2022

  Based on observation, clinical record review, review of facility policies, and staff interviews, it was determined that the facility failed to secure the stairway and elevators and failed to provide adequate supervision and interventions to prevent accident hazards for wandering residents on two of four nursing units (Floors 1 and 2). This failure placed the facility in an Immediate Jeopardy situation. Findings include: Review of the facility policy titled, Elopement Policy/Procedure last revised October 2020, outlines the following: defines wandering as aimless moving about without a desire to leave the facility; defines exit seeking behavior as the process of a resident endeavoring to leave the facility without authorization; and defines elopement as a resident who has left the facility… […]

• Actual harm, isolatedF689Jun 8, 2023

  Based on clinical record review, staff interview, and facility policy review, it was determined that the facility failed to provide interventions to ensure resident safety after an identified change in condition resulting in harm as evidenced by a repeated fall and fracture for one of 13 residents reviewed (Resident 71). Findings include: Review of facility policy titled, Fall Prevention Program, last reviewed March 28, 2023, revealed it stated the facility's policy was, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. […]