Inspection Reports for
St. Clair Nursing Center

The facility failed to ensure residents were safely propelled in wheelchairs with foot pedals in place and failed to securely store hazardous materials, exposing residents to potential injury. Protective oversight for residents on voluntary leave was also found deficient.

The facility failed to ensure safe wheelchair propulsion for three residents, with staff pushing wheelchairs without foot pedals causing residents' feet to slide on the floor. Additionally, hazardous materials were not securely stored, with unlocked cabinets containing chemicals accessible to residents.

The facility failed to maintain resident dignity and proper hygiene for several residents, including failure to clean and maintain fingernails. The facility also failed to obtain proper orders and conduct adequate respiratory assessments for a resident using CPAP therapy.

The facility failed to ensure hazardous area doors were self-closing, positively latched, and resistant to smoke passage. Additionally, the fire alarm system and sprinkler system were out of service for extended periods without proper fire watch policies in place.

The facility failed to maintain resident dignity by not properly cleaning and maintaining the fingernails of three dependent residents, which posed a risk of infection and dignity issues. Additionally, the facility failed to obtain physician orders for a resident's CPAP use and did not conduct daily respiratory assessments or document respiratory status and response to therapy.

The facility failed to provide required notices to the Ombudsman for resident transfers and discharges, did not ensure safe mechanical lift transfers for residents, failed to maintain proper food safety and hand hygiene practices, and did not fully implement infection prevention and control protocols.

The facility failed to meet several Life Safety Code requirements including delayed egress door signage, fire alarm system testing and maintenance, sprinkler system maintenance, smoke barrier door closures, fire drills, smoking regulations, electrical system maintenance, and night-light provisions. The census was 49 with a capacity of 79 during the inspection.

The facility failed to notify the ombudsman of resident transfers and discharges, did not follow safe mechanical lift procedures for resident transfers, had inadequate food handling and storage practices including failure to change gloves and perform hand hygiene, and failed to ensure proper hand hygiene during medication administration.

The complaint investigation found the violation to be at an imminent danger class I level due to failure to separate COVID-19 positive residents from negative roommates. Corrective actions were taken including moving residents to private rooms and staff re-education. The immediate jeopardy was removed during the survey.

The facility failed to use appropriate infection control procedures to prevent or reduce the risk of spreading bacteria including COVID-19, as staff failed to separate residents who tested positive from those who tested negative but shared rooms. The violation was determined to be at an immediate jeopardy level but was later lowered to a Class II deficiency after corrective actions were implemented.

The visit was complaint-related, focusing on deficiencies in required postings and notice requirements for transfer/discharge. The complaint was substantiated as evidenced by the cited deficiencies.

The facility failed to post required hotline and ombudsman information in an accessible and understandable manner. The facility also failed to ensure proper notice of discharge/transfer containing all required information for nine out of fifteen sampled residents.

The facility failed to meet the requirements for gas equipment qualifications and training of personnel. Specifically, staff did not receive adequate education on safety guidelines and usage requirements for medical gases and their cylinders.

The facility failed to properly inspect, test, and maintain battery-powered emergency lighting fixtures and failed to ensure corridor doors were solid, resisted smoke passage, and had positive latching. These deficiencies have the potential to affect all facility occupants.

The facility was found to have multiple deficiencies related to resident rights, abuse/neglect policies, professional standards of care, accident hazards, psychotropic medication use, food safety, infection control, and call system functionality. Corrective actions and monitoring plans were submitted in the plan of correction.