Resident #31, who suffered from hemiplegia and nerve damage causing pain and numbness in his hands and feet, was referred to Physical Medicine and Rehabilitation in May for evaluation and possible Botox injections to treat painful muscle contractions. The resident depended on staff for all daily activities and used a wheelchair.
His 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.
Another reschedule to July 24. Cancelled.
The pattern continued through August and September. On October 31, transportation finally arrived at 8:30 a.m., but the driver said the van couldn't accommodate the resident's wheelchair. Another cancellation.
PMR Staff #700 confirmed the facility had cancelled and rescheduled the resident's appointments five times between July and October. The resident's family member told inspectors during a December 1 interview that their loved one had missed three appointments specifically due to transportation either not showing up or bringing the wrong vehicle.
The Director of Nursing acknowledged the facility had scheduled appointments for July 3 and August 13 but kept no documentation explaining why the resident missed them. She confirmed transportation failed to show for the July 23 appointment and brought an inaccessible vehicle on October 31.
Resident #31 had been admitted to St Clare Commons in January with diagnoses including retention of urine and anxiety alongside his stroke-related paralysis. A November assessment showed he maintained intact cognition despite requiring complete assistance with daily activities.
The May nurse practitioner evaluation documented his left shoulder pain, likely from osteoarthritis and stiffness, in addition to his diabetic neuropathy. The referral for specialized pain management came after months of documented discomfort from muscle contractions.
Between the initial May referral and the December inspection, the resident endured repeated cycles of hope and disappointment. Each cancelled appointment meant continued pain from untreated muscle spasms that Botox injections were designed to relieve.
The facility's own policy, updated in October, stated that when consultations couldn't be performed on-site, staff would "work with the resident and their family to secure appropriate transportation arrangements for appointments."
Yet the nursing home's calendar showed appointments scheduled without ensuring accessible vehicles would arrive. Transportation companies were contacted without specifying wheelchair requirements. Appointments were made and broken with mechanical regularity.
The October 31 incident crystallized the facility's failures. After months of missed appointments, transportation finally arrived on time. The resident was presumably prepared for his long-awaited pain treatment. Then the driver delivered the familiar refrain: wrong vehicle, wheelchair won't fit, appointment cancelled.
The inspection occurred following a complaint filed with state regulators. The deficiency affected one of three residents reviewed for outside medical appointments, though the facility housed 54 residents total.
St Clare Commons' transportation failures left Resident #31 in a medical limbo. His intact mind could fully comprehend each disappointment, each delay in treatment for pain that Botox injections might significantly reduce. Five cancelled appointments over four months meant five months of preventable suffering.
The resident's family watched their loved one endure continued pain while the facility repeatedly promised appointments it couldn't deliver. Each reschedule reset expectations that the nursing home would again fail to meet.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. For Resident #31, living with untreated muscle contractions while watching appointment after appointment disappear, the harm was neither minimal nor potential.
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.