The resident, who suffered left-side paralysis from a stroke and depends on staff for daily care, was referred in May for Physical Medicine and Rehabilitation treatment. The specialist recommended Botox injections to ease painful muscle contractions in his left shoulder, likely caused by arthritis and stiffness.
His first appointment was scheduled for July 3. The facility cancelled.
They rescheduled for July 23. The facility cancelled again.
They rescheduled for July 24. The facility cancelled a third time.
A follow-up appointment on August 13 was cancelled and moved to September 3. On October 31, transportation finally arrived at 8:30 a.m. — but the driver said the van couldn't accommodate the resident's wheelchair. The appointment had to be rescheduled again.
"Since that referral, Resident #31 had missed three appointments due to transportation not showing up or not having the right van for transportation," the resident's family member told inspectors on December 1.
PMR Staff #700 confirmed the pattern during an interview the same day. The specialist's office had scheduled an initial appointment for July 3, which the facility cancelled and rescheduled for July 23. When that was cancelled, they moved it to July 24. The August 13 follow-up was cancelled and rescheduled for September 3. The October 31 appointment was cancelled and rescheduled by the facility.
The Director of Nursing acknowledged that the resident had appointments scheduled for July 3 and August 13 on the facility calendar, but said there was no documentation explaining why the resident missed them. She confirmed that the July 23 appointment was cancelled because arranged transportation didn't show up, and the October 31 appointment had to be rescheduled because transportation didn't bring a wheelchair-accessible vehicle.
The resident has intact mental capacity but requires staff assistance for all daily activities due to his stroke-related paralysis. His medical record shows diagnoses including paralysis following stroke, urinary retention, anxiety, and diabetes with neuropathy that causes pain, tingling and numbness in his hands and feet.
The facility's own policy, dated October 24, states that when consultations cannot be performed on-site, "the facility would work with the resident and their family to secure appropriate transportation arrangements for appointments."
Federal inspectors found the facility failed to ensure transportation to medical appointments, affecting one of three residents they reviewed for outside medical care. The violation was classified as causing minimal harm or potential for actual harm.
The inspection was conducted in response to a complaint. St Clare Commons, located on Five Point Road in Perrysburg, had 54 residents at the time of the December 1 inspection.
The missed appointments left the resident without treatment for painful muscle contractions that a nurse practitioner determined required specialized intervention. The resident was initially seen in May for follow-up of his diabetes and neuropathy, along with left-side paralysis from his stroke. The practitioner noted left shoulder pain likely due to osteoarthritis and stiffness, leading to the referral for evaluation and possible Botox injections.
Each cancelled appointment meant continued pain for a resident whose stroke had already left him dependent on staff for basic daily needs. The facility's transportation failures stretched across five months, from the initial July appointment through the October wheelchair van incident.
The pattern suggests systemic problems with the facility's ability to coordinate outside medical care for residents who need specialized treatment unavailable on-site.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Clare Commons from 2025-12-01 including all violations, facility responses, and corrective action plans.