St Clara's Rehab & Senior Care

In the surveyor’s words

From the most serious findings on record at St Clara's Rehab & Senior Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 28, 2022

  Based on observation, interview, and record review, the facility neglected to provide R1 with a thorough assessment, medical assistance, pain control and pain assessment, and timely treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R1 being left in excruciating pain from an acute left hip fracture, without Physician or power of attorney notification or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in an Immediate Jeopardy. […]

• Actual harm, isolatedF689Oct 15, 2025

  Based on interview and record review, the facility failed to follow its procedure for transportation and failed to adequately supervise and safely secure resident during transport to prevent a fall for one (R1) resident of three residents reviewed for accidents/incidents in a sample of three. These failures resulted in R1 sustaining a subdural hematoma and left scapula fracture. Findings include: The facility's (State) Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, dated 11/28/18 documents: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life; and, Your rights to safety: The facility must provide services to keep your physical and mental health, at their highest practical… […]

• Actual harm, isolatedF686Feb 5, 2025

  Based on observation, interview, and record review, the facility failed to develop and implement specific pressure relieving interventions to prevent pressure ulcer development and worsening, conduct a pressure ulcer risk assessment once a week for four weeks after admission as directed by the facility's Wound and Ulcer Policy for one of four residents (R9) reviewed for facility acquired pressure ulcers in the sample of 33. These failures resulted in R9 developing a painful pressure ulcer to the right heel that deteriorated from a blister to a stage four pressure ulcer to R9's right heel, that required surgical debridement. […]

• Actual harm, isolatedF693Apr 29, 2022

  Based on interview and record review, the facility failed to ensure staff appropriately monitored enteral feedings for one (R1) resident reviewed for Gastrostomy Tube/G-Tube feeding in a sample of four. This failure resulted in R1 experiencing an emesis subsequently leading to an aspiration pneumonia requiring antibiotics. Findings include: The facility's Enteral/Tube Feeding Policy, (Revised 2/26/15) documents: It is the policy of this facility that all residents receive basic nutrition while in the facility and that no resident will have nutrition withheld in the absence of formulated advanced care plan/advanced directive directing such care. […]

• Actual harm, isolatedF678Oct 7, 2021

  Based on record review and interview, the facility failed to provide life sustaining medical interventions for a resident who was choking and became unresponsive and failed to ensure staff were certified to perform CPR (Cardio-Pulmonary Resuscitation, if required. These failures resulted in staff not providing proper chest compressions, oxygen or suctioning to R1 while R1 was choking, resulting in R1's death from choking. Findings include: The American Red Cross CPR/AED (Automated External Defibrillator) for Professional Rescuers and Health Care Providers handbook documents, Unconscious choking: If a ventilation attempt does not make the chest clearly rise: 1. Re-tilt the head and give another ventilation. 2. If the chest still does not rise clearly, give 30 chest compressions. 3. […]