St Clare Living Community of Mora

In the surveyor’s words

From the most serious findings on record at St Clare Living Community of Mora, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 1, 2026

  Based on observation, interview, and record review the facility failed to ensure the code alert system (a wander management system to protect residents from elopement) was functioning properly, failed to follow manufacture recommendation for weekly testing, and failed to follow manufacture recommendations for inspection. This resulted in an immediate Jeopardy situation for two residents (R19, R12) who were at risk for elopement and were able to get through the main doors, due to failure of the doors to lock as required per the code alert system. […]

• Actual harm, isolatedF689Jul 27, 2023

  Based on observation, interview and document review, the facility failed to appropriately assess and implement appropriate interventions to prevent repeated falls for 2 of 2 residents (R1 and R3), who were at high risk for falls. This failure resulted in actual harm for R1 who sustained a mildly displaced right femoral neck fracture, right hip fracture, which required surgical repair and sustained a right periprosthetic femur fracture. Findings include: R1's face sheet undated, identified R1 had the following diagnoses: Alzheimer's disease, dementia, adult failure to thrive, ataxic gait, muscle weakness, syncope with collapse, repeated falls and unsteadiness on feet. […]

• No harm, potential for more than minimal, widespreadF880Apr 21, 2022

  Based on observation, interview and document review, the facility failed to make sure staff were using personal protective equipment (PPE) according to the Center for Disease Control (CDC) guidelines during the COVID-19 pandemic. This had the potential to effect 47 of 47 residents, staff and visitors. Findings include: On 4/18/22, the Center for Disease Control (CDC) COVID Data Tracker website indicated that Kanabec county community transmission rate was red or high. For health care workers, this means they were required to wear eye protection and face mask whenever in resident care area. On 4/18/22, at 3:15 p.m. nursing assistant (NA)-B and NA-C were observed performing cares on R2. Cares included brief change, pericare's and repositioning. […]

• No harm, potential for more than minimal, widespreadF880Apr 26, 2021

  Based on interview and document review, the facility failed to ensure staff were restricted from entering the facility for 14 days following a high-risk COVID-19 exposure for the prevention and potential transmission of COVID-19. This had the potential to affect all 41 residents residing in the facility, as well as all facility staff. Findings include: On 4/22/21, an anonymous complaint was filed with the Minnesota Department of Health that indicated the facility had allowed unvaccinated COVID-19 exposed employees to return to work without following required quarantining recommendation by the Centers for Disease Control and Prevention. A photo copy of a BinaxNOW COVID-19 Ag CARD (rapid test for COVID-19) dated 3/24/21, at 10:00 a.m. […]

• No harm, potential for more than minimal, patternF641May 1, 2026

  Based on interview and document review, the facility failed to ensure accurate MDS coding of the use of a code alert device occurred for 14 of 14 residents (R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, R46) who were identified as at risk for elopement and wandering. Findings include:The code alert system log titled Wander Guard Monitor dated 4/2026, identified the following 14 residents as having a code alert device: R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, and R46.R3 was admitted on [DATE]. R3's quarterly MDS assessment dated [DATE], indicated R4 was severely cognitively impaired with a diagnosis of dementia neurocognitive Lewy body disease. MDS. Section P. indicated a wander guard alarm was not in use. […]