The resident, identified as #31 in inspection records, suffers from left-sided paralysis following a stroke and needs Botox injections to relieve painful muscle contractions. His family member told state inspectors the resident had "missed three appointments due to transportation not showing up or not having the right van."
But medical records revealed the problem was worse than the family knew.
Staff at Physical Medicine and Rehabilitation told inspectors the facility cancelled appointments on July 3, July 23, August 13, and October 31. The July 23 appointment was rescheduled to July 24 — then that appointment was cancelled too. Each time, the facility cited transportation problems.
The October 31 incident captured the pattern of failures. Transportation arrived at 8:30 AM to take the resident to his appointment, but the driver said the van could not accommodate his wheelchair. The appointment had to be rescheduled again.
The resident has been at St Clare Commons since January 13. His diagnoses include paralysis following a stroke, urinary retention, and anxiety. A quarterly assessment from November showed he depends on staff for all daily activities but has intact thinking ability.
In May, a nurse practitioner treating his diabetes and nerve damage referred him to Physical Medicine and Rehabilitation for evaluation and possible Botox injections. The referral noted left shoulder pain likely caused by arthritis and stiffness — common complications for stroke patients with limited mobility.
PMR Staff #700 confirmed to inspectors that the resident was referred for Botox injections to treat pain from muscle contractions. The initial appointment was scheduled for July 3.
What followed was a cascade of cancellations. July 3: cancelled by the facility, rescheduled to July 23. July 23: cancelled because transportation didn't show, rescheduled to July 24. July 24: cancelled again. August 13: cancelled, rescheduled to September 3. October 31: cancelled because the van couldn't accommodate his wheelchair.
The Director of Nursing acknowledged during the December 1 inspection that appointments on July 3 and August 13 appeared on the facility calendar with no documentation explaining why the resident missed them. She confirmed transportation failures caused the July 23 and October 31 cancellations.
For a resident dealing with painful muscle contractions from stroke-related paralysis, each missed appointment meant continued suffering. Botox injections can provide months of relief by temporarily paralyzing overactive muscles that cause pain and limit movement.
The facility's own policy, updated in October, 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."
But working with the family appeared to mean leaving them to watch their loved one's condition go untreated. The family member's interview revealed they were aware of three missed appointments — unaware that facility records showed five cancellations over four months.
State inspectors found the transportation failures violated federal requirements that nursing homes help residents access laboratory services and medical appointments outside the facility. The violation affected one of three residents reviewed for outside medical appointments at the 54-bed facility.
The resident's medical record shows he was eventually scheduled for a follow-up appointment on September 3, but inspection documents don't indicate whether he actually received the Botox treatment he was referred for in May.
The inspection was conducted in response to a complaint filed as case number 2663701. St Clare Commons must submit a plan of correction explaining how it will prevent similar transportation failures from denying residents access to prescribed medical care.
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.