A list of the most recent deficiencies for St Clare Commons. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-10-11 | 2023-11-04 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-11 | 2023-11-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-11 | 2023-11-04 | N |
| Provide activities to meet all resident's needs. | Health | 2023-10-11 | 2023-11-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-11 | 2023-11-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-10-11 | 2023-11-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-11 | 2023-11-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-11 | 2023-11-04 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-10-11 | 2023-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-11 | 2023-11-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-11 | 2023-11-04 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-10-11 | 2023-11-04 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-11 | 2023-11-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-11 | 2023-11-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-11 | 2023-11-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-11 | 2023-11-04 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-10-11 | 2023-11-04 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-05 | 2023-11-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-05 | 2023-11-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-05 | 2023-07-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-31 | 2023-03-02 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-31 | 2023-03-02 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-01-31 | 2023-03-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-31 | 2023-03-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-31 | 2023-03-02 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-01-31 | 2023-03-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-15 | 2022-09-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-13 | 2022-09-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-13 | 2022-09-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-13 | 2022-09-07 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-07-13 | 2022-09-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-17 | 2022-09-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-17 | 2022-09-07 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-08-11 | 2021-08-30 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-07-29 | 2021-08-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-29 | 2021-08-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-29 | 2021-08-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-29 | 2021-08-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-13 | 2021-08-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-05-04 | 2021-06-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-04 | 2021-06-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-04 | 2021-06-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-04 | 2021-06-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-04 | 2021-06-11 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-05-04 | 2021-06-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-04 | 2021-06-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-23 | 2019-06-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-23 | 2019-06-21 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-05-23 | 2019-06-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-23 | 2019-06-21 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-05-23 | 2019-06-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-23 | 2019-06-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-23 | 2019-06-21 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-05-23 | 2019-06-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-05-20 | 2019-06-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-20 | 2019-06-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-20 | 2019-06-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-20 | 2019-06-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-20 | 2019-06-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-05-20 | 2019-06-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-20 | 2019-06-21 | N |
