St Clare Commons

In the surveyor’s words

From the most serious findings on record at St Clare Commons, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 11, 2023

  Based on record review, staff interview, and review of facility policy, the facility failed to conduct a thorough investigation to determine potential hazards and resident-specific interventions to reduce and/or eliminate falls with injury. Additionally, the facility failed to update a resident's care plan with person centered fall interventions to potentially prevent future falls. This resulted in Actual Harm for one resident when Resident #34 experienced a fall on 07/12/23 which was not investigated to implement effective interventions to potentially prevent future falls. As a result of the fall, Resident #34 sustained a fracture of the nasal bones and a spleen laceration Grade 3 from this fall. […]

• Actual harm, isolatedF686Jun 17, 2022

  Based on observation, resident and staff interview, medical record review, hospital record review, review of the National Pressure Injury Advisory Panel 2019 Reference Guide, and review of the facility policies, the facility failed to timely assess and provide treatments for a resident's pressure ulcers and failed to ensure interventions were implemented to heal a resident's pressure ulcer and prevent skin breakdown. This resulted in Actual Harm when Resident #54 had a pressure ulcer worsen from a stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) to an unstageable pressure ulcer (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) after no treatment interventions were… […]

• Actual harm, isolatedF686Jan 13, 2021

  Based on observation, resident and staff interviews, medical record review, and review of the facility's policy, the facility failed to provide wounds treatments as ordered by a physician, failed to assist residents with turning and repositioning as ordered, and failed to timely assess residents with wounds. This resulted in Actual Harm to one resident (#34) when facility staff did not provide wound treatments and turning and repositioning as physician ordered and did not complete timely monitoring of Resident #34's left hip pressure ulcer including measuring/staging the wound and Resident #34's left hip wound subsequently deteriorated into a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. […]

• Actual harm, isolatedF725Jan 13, 2021

  Based on observations, resident and staff interviews, medical record reviews, and review of facility policies, the facility failed to provide adequate nursing staff to provide wound treatments, turning and repositioning, timely and adequate bathing assistance, transfer assistance, assistance with response to resident call lights, incontinence care, and complete necessary COVID-19 respiratory assessments. This resulted in Actual Harm to one resident (#34) when facility staff did not provide wound treatments and turning and repositioning as physician ordered and did not complete timely monitoring of Resident #34's left hip pressure ulcer and Resident #34's left hip wound subsequently deteriorated into a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. […]

• No harm, potential for more than minimal, widespreadF806Mar 26, 2026

  Based on observation, review of meal order ticket, staff interview, and facility policy review, the facility failed to provide meals per resident preferences. This affected one (#11) of one resident reviewed for food preferences and had the ability to affect all residents that receive food from the kitchen. The facility identified all 51 residents receive meals from the kitchen. The facility census was 51.Findings include:Review of Resident #11's medical record revealed an admission date of 09/17/24. Diagnoses included Alzheimer's, congestive heart failure, anxiety, and seizures.Review of Resident #11's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had a cognitive deficit. […]