St Clare Living Community Of Mora
ST CLARE LIVING COMMUNITY OF MORA in MORA, MN — inspection on May 1, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
through support of resident choice.
observation, interview, and document review the facility failed to ensure resident preferences for nail
assessment dated [DATE], indicated R8 was moderately cognitively impaired with the diagnoses of non-Alzheimer's dementia, renal insufficiency, hypertension, and depression.R8's care plan last reviewed 3/26/26 indicated R8 had limited range of motion in their upper extremities and required an assist of 1 for daily bathing, weekly showers, daily grooming, oral care, and dressing.R8's progress notes indicated R8 had last had a shower on 4/3/26.
Nail care was not addressed in progress notes.During an observation on 4/28/26 at 12:48 p.m., R8 was seated in wheelchair in room with their tv remote partially on their bedside table between their hands.
Noted tremor in both hands, fingernails were long beyond tips of fingers. R8 stated they were trying to get their remote onto the bedside table, but their hands were so bad they couldn't do it.
There was a nail clipper on the left side of R8's bedside table. R8 stated they had the nail clipper there because they wanted to have their nails trimmed, they were too long. R8 stated they couldn't trim their nails, so they had asked staff, but nobody had done it so far.
During an interview on 4/29/2026 at 8:57 a.m., R8 stated staff had trimmed their nails before, but nobody had trimmed them yet. It bothered them to have their nails so long.On 4/30/26 at 11:22 a.m., R8 was seated in wheelchair in room the nail clipper was still on the bedside table. R8 stated they know I want my nails trimmed but nobody has done it yet.
During an interview on 4/29/26 at 2:14 p.m., licensed practical nurse (LPN-C) stated all residents should have nail care offered on shower day.
Nursing assistants (NA) do nail care unless the resident is a diabetic or has some other considerations, then the nurse would do the nail care on bath day.
During an interview on 4/29/26 at 1:29 p.m., NA-J stated typically we do nail care on bath days but if a resident wanted their nails trimmed either the NA or the nurse should do it.04/29/2026 1:39 p.m., NA-G 3 stated NAs could do nail care for R8.
Activities did a spa day group so R8 could get their nails done in group, otherwise fingernails got done on bath days.04/29/2026 1:46 p.m., NA-B stated NAs could cut fingernails on most residents including R8.
Every room also had an activities calendar.
Residents can see when they can go to group and get their nails done by activities.
During an interview on 4/30/26 at 11:41 a.m., registered nurse (RN-B) stated both nursing assistant and wellness staff (they are NAs) can trim nails. R8 can have either trim their nails.
Regardless of what day it is, if a resident requests to have their nails trimmed, their nails should be trimmed. If the NAs can't do it, then they should get the nurse to do it.
During an interview on 4/30/26 at 12:52 p.m., the director of nursing (DON) stated nail trimming was typically done on shower days, but if a resident was requesting to have their nails trimmed on a different day, she would expect staff to trim those nails. A resident should not have to wait until their next bath day to get their nails trimmed.The facility policy Resident Choice Policy & Procedure dated 5/2/26, identified autonomy and self-determination were fundamental to quality of life and dignity.
The facility would provide a supportive environment that encouraged and facilitated resident choice, respected individual preferences and needs to the greatest extent possible consistent with safety and regulations.The undated facility policy Fingernails-Cleaning and Trimming provided instruction on how to complete nail care and instructed nursing staff will provide nail care as necessary to residents.
wandering interventions.
The MDS should be coded to reflect code alert placement because MDS
received.
245291 05/01/2026
St Clare Living Community of Mora 110 North 7th Street Mora, MN 55051
measurable objectives and timetables to meet the resident's physical, psychosocial and functional
quarterly with the care conference and they should include information about smoking, wanderguard use, enhanced barrier precautions, and medication use (including use of an antidepressant).
The DON stated this was important for direct care staff to have the information for safety, quality of life, and to address their needs and preferences for care.
245291 05/01/2026
St Clare Living Community of Mora 110 North 7th Street Mora, MN 55051
2:08 p.m., the administrator stated they had not been notified of R19 and R12's attempts to exit the
jeopardy to resident health or past the first door.
They expected staff to notify maintenance anytime a door didn't seem to be safety functioning correctly so maintenance could service the door immediately.
They had discussed the code alert system with DPS-A and decided they would start doing weekly door testing as
facility scheduled maintenance for the call alert system, placed staff at the door to monitor the system at all times when the door was not locked, updated resident assessment and care plans for residents who used a code alert device, revised their Code Alert System policy, and educated staff on reporting failures in the call alert system.The facility policy Code Alert System dated 9/2017, identified the code alert transponder devices were to be tested weekly and the door function was to be tested by maintenance monthly.
Malfunctions or repairs made were to be reported to the administrator and nursing along with the current status of the system and need for special monitoring due to delay in repairs.
The policy did not address malfunctions and actions to be taken for malfunctions outside of monthly testing.
Nor did it address down time procedures for malfunction of the system or doors.The facility policy Elopement dated 1/2023, identified residents known to wander and or who have cognitive deficits may wear the signaling device which activates an alarm should they leave the facility.
Staff instruction for resident elopement was outlined in the policy.
The policy did not include instruction to staff for reporting code alert system malfunctions or alternative actions to be implemented during code system malfunctions.
245291 05/01/2026
St Clare Living Community of Mora 110 North 7th Street Mora, MN 55051
of an ice scoop was followed during the snack pass.
This deficient practice affected 3 of 3 residents
include:R29's comprehensive Minimum Data Set (MDS) dated [DATE], identified she was moderately cognitively intact and had diagnoses which included heart disease, hypertension, hyperlipidemia, and gastroesophageal reflux disease.R30's quarterly MDS dated [DATE], identified she was moderately cognitively intact and had diagnoses which included heart failure (a chronic serious condition in which the heart muscle cannot pump enough blood to meet the body's needs for oxygen), diabetes mellitus and depression.R7's quarterly MDS dated [DATE], identified he was moderately cognitively intact and had diagnoses which included heart failure and diabetes mellitus.During an observation on 4/29/26 at 1:56 p.m., nursing assistant (NA)-A had a snack cart with two over-sized plastic pitchers filled with ice. NA-A stopped the cart outside of R29's room, NA-A was not wearing gloves entered the room, brought out the water cup, filled the water cup with ice using a plastic water glass, NA-A put the plastic glass back into the over-sized pitcher with ice, exited the room and did not perform hand hygiene. NA-A proceeded to R7's room and did not perform hand hygiene, entered the room brought out the water cup filled it with ice using the plastic water glass that was resting on top of the ice, poured juice into a cup, brought the water cup, the juice, a bag of chips and brought the items into R7's room.
NA-A exited the room; no hand hygiene was performed. NA-A went into R30's room after knocking asked if they wanted any snacks, exited the room with a plate with food on it and put the plate and food into the garbage bag attached to the snack cart. NA-A did not perform hand hygiene, picked up a banana and brought it into R30's room, exited the room. No hand hygiene was performed.During an interview on 4/29/26 at 2:01 p.m., NA-A stated they took the snack cart around to rooms twice daily.
NA-A verified she would put the plastic water glass back into the over-sized pitcher with ice and stated, it doesn't touch anything. NA-A verified they did not perform hand hygiene before or after exiting resident rooms or after disposing of uneaten food removed from R30's room.During an interview on 4/30/26 at 9:42 a.m., the director of nursing (DON) stated she would expect staff to perform hand hygiene before entering and after exiting a resident room.
The DON stated using a plastic water glass to fill water cups coming from resident rooms and then putting the plastic water cup back into the over-sized ice pitcher was an infection control concern.
Hand Hygiene dated 6/2019, identified all employees would be trained on hand hygiene practices.
The policy identified hand hygiene would be performed before and after handling food and after handling soiled utensils or equipment.
245291 05/01/2026
St Clare Living Community of Mora 110 North 7th Street Mora, MN 55051
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.