Resident #31, who suffered left-side paralysis and muscle contractions following a cerebral infarction, was referred in May for Botox injections to treat painful shoulder spasms. The appointments never happened.
The first scheduled appointment on July 3rd was cancelled by the facility. They rescheduled for July 23rd, then cancelled again. A third attempt on July 24th also fell through.
On October 31st, transportation finally arrived at 8:30 AM to take the resident to his appointment. The driver took one look and said the van couldn't accommodate the resident's wheelchair. Another cancellation.
"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 1st.
The medical need was clear. Resident #31 had been admitted to St Clare Commons in January with diagnoses including hemiplegia, hemiparesis, urine retention, and anxiety following his stroke. A nurse practitioner's May assessment documented left shoulder pain likely due to osteoarthritis and stiffness, leading to the Physical Medicine and Rehabilitation referral.
PMR Staff #700 confirmed the appointment pattern during the December inspection. An initial July 3rd appointment was cancelled and rescheduled for July 23rd. That was cancelled and moved to July 24th. An August 13th follow-up was cancelled and pushed to September 3rd. The October 31st appointment was cancelled after the transportation debacle.
The facility's Director of Nursing acknowledged the appointments were on the calendar for July 3rd and August 13th but had no documentation explaining why the resident missed them. She confirmed the July 23rd appointment was cancelled because arranged transportation never showed up.
Resident #31 required full assistance with daily activities and used a wheelchair due to his stroke-related paralysis. Federal inspectors noted his cognition remained intact, meaning he understood his medical needs and the repeated appointment failures.
The facility's own policy, dated October 24th, stated that when consultations couldn't be performed on-site, "the facility would work with the resident and their family to secure appropriate transportation arrangements for appointments."
The inspection found no evidence the facility worked with the family to secure reliable wheelchair-accessible transport. Instead, the same problems repeated month after month.
Medical records showed the resident's condition warranted prompt treatment. Diabetic neuropathy caused pain, tingling and numbness in his hands and feet. The stroke left him with left-side weakness and painful muscle contractions that Botox injections could relieve.
Each missed appointment meant continued pain and delayed recovery for a resident already dealing with multiple complications from his stroke. The facility census was 54 residents, with inspectors reviewing three residents' outside medical appointments and finding transportation failures affected one.
The violation occurred under a complaint investigation, suggesting family members or others reported the transportation problems to state regulators. Federal inspectors classified the harm level as minimal, though the resident experienced months of untreated pain.
St Clare Commons is located on Five Point Road in Perrysburg, serving residents who often require specialized medical care beyond what the facility can provide on-site. For wheelchair-bound residents like #31, reliable transportation becomes essential for accessing that care.
The inspection report provides no indication the facility has resolved its transportation coordination problems or established backup arrangements for wheelchair-accessible vehicles. The resident's family watched appointment after appointment disappear while their loved one remained in pain from treatable muscle contractions.
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.