Resident 31 was referred to Physical Medicine and Rehabilitation in May for Botox injections to treat painful contractions caused by left-side paralysis from a stroke. The resident depends on staff for all daily activities and uses a wheelchair.
The first appointment was scheduled for July 3. The facility cancelled.
They rescheduled for July 23. The facility cancelled again because transportation didn't show up.
The facility rescheduled for July 24. Another cancellation.
An August 13 follow-up appointment was cancelled and pushed 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 federal inspectors on December 1.
PMR Staff 700 confirmed the pattern of cancellations and rescheduling during the inspection. The medical provider had been expecting the resident since July for treatment of pain caused by muscle contractions following the stroke.
Director of Nursing acknowledged that the facility had scheduled appointments for July 3 and August 13 but provided no documentation explaining why the resident missed them. She confirmed that the July 23 appointment was cancelled because arranged transportation failed to show up, and the October 31 appointment had to be rescheduled because the transportation company brought a vehicle that couldn't accommodate a wheelchair.
The resident had been admitted to St Clare Commons in January with diagnoses including paralysis following a stroke, urine retention, and anxiety. A November assessment showed intact mental capacity despite being completely dependent on staff for daily care.
The May nurse practitioner visit documented the resident's left shoulder pain, likely from osteoarthritis and stiffness, in addition to diabetes-related nerve damage causing pain, tingling and numbness. The practitioner specifically referred the resident for evaluation and possible Botox injections to address the painful muscle contractions.
Federal inspectors found that St Clare Commons has a policy requiring the facility to work with residents and families to secure appropriate transportation for off-site medical appointments when consultations cannot be performed at the nursing home.
The facility operates with 54 residents.
The transportation failures left the stroke survivor without access to specialized pain treatment for months despite having intact cognitive ability to understand the need for care. The resident remained dependent on staff for all activities while dealing with untreated painful muscle contractions that Botox injections were specifically designed to address.
Inspectors classified the violation as causing minimal harm or potential for actual harm, but noted it represented a pattern of failing to ensure residents could access ordered medical services outside the facility.
The inspection was conducted in response to a complaint filed with state regulators.
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.