St. Clare Home

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 3 residents reviewed related to nutrition, Resident ID #32.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that a person-centered comprehensive care plan was developed and implemented for 2 of 4 residents reviewed who utilize psychotropic medications, Resident ID #s 4 and 7, for 1 of 2 residents reviewed for pain management and for 1 of 1 resident reviewed related to bladder continence, Resident ID #9.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to 1 of 1 resident observed with a with a wound dressing applied without a physician's order, and for 1 of 4 residents reviewed with a physician's order for weekly weights that were not obtained, Resident ID #32.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 1 resident reviewed with pressure ulcers (a localized injury to the skin and/or underlying skin usually over a boney prominence), Resident ID #32. Specifically, the facility failed to obtain and implement timely treatment orders, failed to complete comprehensive weekly wound assessments, failed to ensure accurate documentation, and failed to ensure pressure-relieving equipment was properly set and monitored for Resident ID #32. These failures resulted in the worsening of the resident's skin condition, including the development of additional pressure injuries, deep tissue injuries, and progression of a sacral wound to an unstageable necrotic ulcer.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to maintain nutritional status, such as usual body weight, for 1 of 3 residents reviewed who experienced actual weight loss, Resident ID # 4.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to post cautionary and safety signs related to oxygen use for 2 of 3 residents reviewed receiving oxygen therapy, Resident ID #s 33 and 47.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to have sufficient nursing staff to assure resident safety and attain the highest practicable, physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care relative to insufficient staffing for 2 of 3 residents reviewed, Resident ID #s 2 and 3.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 3 of 5 residents reviewed with constipation, Resident ID #s 2, 3 and 4.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents are treated with respect and dignity for 1 of 1 resident observed who was not being assisted with eating, Resident ID #39. Record review revealed the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, dementia and anxiety. Review of the Minimum Data Set assessment dated [DATE] revealed the resident required physical assistance with eating. During a surveyor observation in the unit's common dining area on 4/8/2025 at 12:04 PM, Resident ID #39 was served his/her lunch tray along with other resident's in the common area. The resident sat at the table with the food in front of him/her while two other residents were being fed. [...]

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 1 resident reviewed receiving hospice services, Resident ID #21.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a person-centered comprehensive care for 1 of 1 resident reviewed for Post Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful or a terrifying event), Resident ID #41.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to review and revise the resident's comprehensive care plan for 1 of 2 residents reviewed with a deep tissue injury (DTI; a type of pressure injury where damage occurs to the underlying soft tissue) and a Foley catheter (a device that drains urine from the bladder into a collection bag), Resident ID #35.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician's orders for 1 of 1 resident reviewed, with an order for a nutritional consult, Resident ID #41.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 2 of 2 residents reviewed with constipation, Resident ID #s 29 and 148.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to store food in accordance with professional standards of food service safety, relative to the main kitchen.

Inspectors wrote1. Record review revealed Resident ID #2 was transferred to the hospital on 2/6/2025, 2/14/2025 and 2/17/2025. Record review failed to reveal evidence that the Office of the State Long-Term Care Ombudsman was notified of the hospital transfers for Resident ID #2. 2. Record review revealed Resident ID #20 was transferred to the hospital on 3/5/2025. Record review failed to reveal evidence that the Office of the State Long-Term Care Ombudsman was notified of the hospital transfer for Resident ID #20. During a surveyor interview with the Director of Operations on 4/9/2025 at 9:33 AM, she acknowledged that the Ombudsman was not notified of the transfers for Resident ID #s 2 and 20.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to review and revise the resident's care plan relative to 2 of 3 residents reviewed for falls, Resident ID #s 1 and 2.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that residents are free of any significant medication error for 1 of 3 residents reviewed, Resident ID #6.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles, for 2 of 3 residents reviewed for medication storage, Resident ID #s 4 and 5.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident either received the influenza or pneumococcal vaccination or did not receive the vaccination due to medical contraindications or refusal, for 4 of 6 residents reviewed for pneumococcal vaccination, Residents ID #s 1, 6, 23, and 26 and for 3 of 6 residents reviewed for the influenza vaccination, Resident ID #s 23, 26, and 29.

Inspectors wroteBased on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed for glucose gel and the utilization a Freestyle Libre (a continuous glucose monitoring system that's designed to replace fingersticks and lessen the need for test strips in people with diabetes) for 1 of 1 resident reviewed for implementing orders related to the use of an insulin pump, Resident ID #146.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with a suprapubic catheter (SP tube, a flexible tube inserted into your bladder via a surgical opening in the abdomen), Resident ID #1.