St Clare Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jan 28, 2021

  Based on record review and staff interview it has been determined that the facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent accidents relative to transfers requiring two staff assistance and the use of an E-Z stand lift device for 2 of 2 residents reviewed, Resident ID#s 1 and 2. Findings are as follows: Review of the facility policy titled, St Clare Home Operational Policy and Procedure Manual .Safety Precautions-Lifting/Handling Heavy Objects, states in part: .As St. Clare is a no lift facility, there are mechanical devices available to assist you in moving residents more safely. […]

• Actual harm, patternF726Jan 28, 2021

  Based on record review and staff interview it has been determined that the facility has failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 3 of 3 new hires reviewed related to orientation competency evaluations, Staff A, H and I. Review of the facility policy titled, Facility Operational Manual Orientation On-the Job Training , states in part: .2. Department Supervisors will be responsible for on-the-job training to assure that our established training schedules are followed .3. […]

• Actual harm, isolatedF686Feb 20, 2023

  Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new pressure ulcers from developing for 3 of 6 residents reviewed, Resident ID #'s 20, 31 and 38. Findings are as follows: Review of the facility policy titled, Skin and Wound Management, dated February 2022, states in part, .The facility will ensure that .A resident .does not develop pressure ulcers .Interventions will be implemented in the resident's care plan to prevent pressure ulcer development .prevent deterioration and promote healing of the pressure ulcer .The facility may utilize an outside wound care specialist, to assist with wound… […]

• Actual harm, isolatedF760Jul 15, 2022

  Based on record review and staff interview, it has been determined that the facility failed to ensure residents are free of any significant medication error for 1 out of 5 residents reviewed for insulin, Resident ID #1. Findings are as follows: Record review of a facility policy titled Diabetes-Clinical Protocol, states in part, .Steps in the Procedure (insulin injections via Syringe) .Check the order for the amount of insulin .Double check the order for the amount of insulin .Re-check that the amount of Insulin drawn into the syringe matches the amount of insulin ordered . […]

• Actual harm, isolatedF600Jan 28, 2021

  Based on record review and staff interview, it has been determined that the facility failed to protect the resident's right to be free from abuse and neglect for 2 of 3 residents reviewed, Resident ID#s 3 and 5. Findings are as follows: Review of the facility policy, titled, Abuse Reporting, states in part, .4a. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical mental and psychosocial well-being . 1. […]