F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review, the facility failed to ensure safe provision of pharmaceutical
services for two of two sampled residents (Resident 10 and 11) by failing to:
1. Ensure Resident 10's physician ordered medication Cilostazol and Memantine HCI were not on the desk
at Nurse Station (NS) 1 unsupervised.
2. Ensure Resident 11's physician ordered medication Metoprolol was not on the desk at NS 1
unsupervised.
These deficient practices had the potential for diversion of medication and/or ingestion by other residents of
the facility which could lead to harm.
Findings:
a. During a review of Resident 10 ' s admission Record (AR), the AR indicated, Resident 10 was admitted
to the facility on [DATE] with diagnoses including peripheral vascular disease (PAD- a circulatory condition
where blood vessels outside the heart and brain narrow, become blocked, or spasm), dementia
(progressive loss of cognitive function, including memory, thinking, and reasoning, that significantly impairs
a person's ability to perform daily activities), and Parkinsonism (a syndrome characterized by tremor,
rigidity, and postural instability).
During a review of Resident 10 ' s Minimum Data Set (MDS, a standardized assessment and care
screening tool), dated 02/28/2025, the MDS indicated, Resident 10 was severely impaired (never/rarely
made decisions) in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 10 was
dependent on staff for toileting, oral hygiene, personal hygiene, putting on/taking off footwear, and lower
body dressing. The MDS indicated, Resident 10 always needed substantial/maximal assistance (helper
does more than half the effort) for eating.
During a review Resident 10 ' s Order Summary Report (OSR, all active physician orders), indicated
Resident 10 was prescribed Cilostazol (treats intermittent problems with blood flow in legs) 50 milligrams
(mg- a unit of mass or weight equal to one thousandth of a gram) one tablet two times a day for PAD and
Memantine HCI (treats dementia associated with Alzheimer ' s disease) 10 mg one tablet twice daily for
dementia.
b. During a review of Resident 11 ' s AR, the AR indicated, Resident 11 was admitted to the
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
055344
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055344
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claremont Heights Post Acute
590 S. Indian Hill Blvd.
Claremont, CA 91711
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
facility on [DATE], with diagnoses including type 2 diabetes mellitus (a long term condition in which the
body has trouble controlling blood sugar and using it for energy), hypertension (high blood pressure), and
anemia (a condition in which the blood doesn ' t have enough healthy red blood cells and hemoglobin, a
protein found in red blood cells, to carry oxygen all through the body).
During a review of Resident 11 ' s MDS, dated 2/20/2025, the MDS indicated, Resident 11 was dependent
on staff for toileting, dressing, and bathing.
During a review of Resident 11 ' s OSR, dated 4/18/2025, indicated Resident 11 was prescribed Metoprolol
(treat high blood pressure, chest pain, and heart failure) 25 mg one tablet twice daily for hypertension.
During a concurrent observation and interview on 4/4/2025 at 6:05 a.m. with LVN 2 at NS 1, three
medication packets belonging to Resident 10 (Cilostazol and Memantine HCI) and Resident 11(Metoprolol)
were observed. LVN 2 stated, I put them there on the desk because I am changing them out when I take
them out the cart, I should have put them in the medication room and popped each pill out and put it in the
waste (incinerator jar). LVN 2 stated the medications were not disposed of properly. LVN 2 stated other
resident's of the facility could have come and taken the medication that was not prescribed to them nor
supervised.
During a concurrent observation and interview on 4/4/25 at 6:20 a.m. with RN 1 at NS 1, RN1 stated the
medication packets did not belong on the desk. RN 1 stated LVN 2 did not follow the facility's policy and
should have disposed of the medications properly. The facility policy was to remove the medication from the
medication cart, document with another nurse in the medication destruction binder (name, date, medication
name, prescription number, amount of medication destroyed, and the signatures of witnesses) and place
the medication in the incineration container. RN 1 stated residents not prescibed the medication could have
come, taken the medication, and become sick.
During a review of the facility ' s updated policy and procedure (P&P) titled, Medication Destruction, dated
08/2019 indicated, discontinued medication and medications left in the facility after a resident's discharge
are destroyed. The licensed nurse(s) and/or pharmacitst witnessing the destruction ensures that the
fillowing information is entered on the (medication disposition form): date of destruction, resident's name,
name and strength of medication, prescription number, amount of medication destroyed, and signatures of
witnesses.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055344
If continuation sheet
Page 2 of 2
