Dwelling Place at St Clares

In the surveyor’s words

From the most serious findings on record at Dwelling Place at St Clares, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF695Jul 15, 2026

  Based on observation, interview, and record review, it was determined that the facility failed to maintain and document respiratory care and equipment for a resident who was receiving humidified, oxygen-enriched air via a medical ventilator (a machine that mechanically supports or entirely replaces a patient's breathing) for 12 of 12 residents reviewed (Residents #1, #2, #3, #4, #5, #6, #7, #8, #11, #17, #23, #25). This deficient practice was evidenced by the following: 1.) On [DATE] at 10:40 AM, the surveyor observed resident #1 in bed with a ventilator in place. […]

• No harm, potential for more than minimal, widespreadF812Apr 10, 2025

  Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 4/6/25 at 9:36 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. In the Nourishment supply standing two door refrigerator, the surveyor observed a 46 ounce (oz) Thickened Orange Juice bottle and a 16 oz bottle water, both bottles had been opened and were missing open and use by labels. The FSD stated all items should have a open and use by label once opened, both items were discarded. 2. […]

• No harm, potential for more than minimal, patternF880Apr 10, 2025

  c). On 4/6/25 at 10:38 am, the surveyor observed Resident #17 in bed watching television. A review of the Resident Face Sheet, Resident #17 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, tracheostomy, pressure induced deep tissue damage of the sacral region and pressure ulcer of the right buttock. A review of Resident #17's Quarterly Minimum Data Set (MDS), an assessment tool dated 3/30/25, revealed that the resident's Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated that the resident was cognitively intact. […]

• No harm, potential for more than minimal, patternF693Nov 27, 2023

  Based on observation, interview, and record review, it was determined that the facility failed to monitor enteral tube feeding administration to assure the total volume administered was in accordance with physician's orders. This deficient practice was identified for 12 of 12 residents reviewed for enteral tube feeding, Resident #24, #2, #19, #5, #7, #13, #16, #1, #9, #12, #20 and #21. This deficient practice was evidenced by the following: 1. On 11/15/23 at 10:07 AM, the surveyor observed Resident #24 in bed watching television. […]

• No harm, potential for more than minimal, patternF880Sep 22, 2021

  Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) maintain medication carts in a clean and sanitary manner to prevent the spread of infection, and b.) don (put on) the appropriate personal protective equipment (PPE) prior to entering a resident room that required transmission based precautions (TBP) due to a contagious infectious disease. This deficient practice was identified for 2 of 3 medication carts inspected, and 1 of 1 resident, (Resident #16) reviewed for TBP. This deficient practice was evidenced by the following: 1. […]