Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Clare Living Community Of Mora during CMS and state inspections, most recent first.
Code Alert System Failed to Prevent Resident Elopement: The facility failed to keep the code alert system functioning as intended and did not follow the manufacturer’s weekly testing and inspection guidance. Two residents with significant cognitive impairment were able to get through the main doors, and one resident exited the building before staff followed outside. The report also states that multiple residents with code alert devices did not have adequate elopement or wandering assessments and care plan interventions, and several attempts to leave were not documented in the record.
A facility failed to accurately code MDS assessments for code alert device use for multiple residents identified as at risk for elopement and wandering. Although a wander guard log showed several residents had code alert devices, the MDS often stated the devices were not in use and did not reflect wandering behavior. Several care plans also lacked elopement or wandering interventions, and staff interviews confirmed the MDS should reflect code alert placement because it drives the care plan.
A facility failed to include individualized care plan interventions for multiple residents with elopement and wandering risk, despite MDS findings of significant cognitive impairment and use of code alert devices. Staff stated these risks should be in the care plan and reassessed after changes, but several care plans lacked device location and resident-specific interventions. The facility also omitted care planning for a resident receiving trazodone for sleep, a resident who smoked and had COPD/Alzheimer’s disease, and a resident on dialysis who should have had EBP documented.
Failure to perform hand hygiene and use proper ice handling during the snack pass. An NA entered resident rooms without gloves, used a plastic water glass to scoop ice from over-sized pitchers, returned the glass to the ice, handled food and drinks, and repeatedly exited rooms without hand hygiene. The DON stated hand hygiene was expected before entering and after exiting resident rooms, and the facility policy required hand hygiene before and after handling food and soiled utensils or equipment.
Failure to honor a resident’s request for nail care. A resident with dementia, renal insufficiency, HTN, and depression had long fingernails beyond the fingertips and stated staff had not trimmed them despite repeated requests. Staff said nail care was usually done on shower days, but also stated that if a resident asked for nail trimming, an NA, wellness staff, or an LPN/RN could complete it and the resident should not have to wait until the next bath day.
The facility failed to monitor orthostatic blood pressures for residents on antipsychotic medications, did not obtain signed consent for an antidepressant, and did not implement non-pharmacological interventions before initiating antipsychotic medication. These deficiencies were observed in several residents, with staff confirming the lack of consistent monitoring and consent procedures. The facility also did not establish appropriate target behaviors for monitoring the effectiveness of psychotropic medications.
The facility failed to ensure proper use of PPE to prevent COVID-19 spread, with staff reusing N95 masks and goggles despite having adequate supplies. Additionally, the infection control program lacked comprehensive surveillance, only tracking infections treated with antibiotics and not including viral, fungal, or yeast infections. The facility's policies did not adequately address PPE use or infection tracking, contributing to potential infection spread.
Two residents with moderate cognitive impairment were found self-administering medications without proper assessment or physician orders. One resident was observed using a nebulizer independently, while the other self-administered muscle rub and eye drops. The facility's policy requires comprehensive assessments for self-administration, which were not adequately conducted or documented.
A resident with a history of smoking was not provided opportunities to smoke, despite having intact cognition and expressing a strong desire to continue the habit. The facility's non-smoking policy and lack of a tailored care plan led to repeated incidents of the resident expressing anger and frustration. Staff confirmed that the resident's behaviors were linked to nicotine withdrawal and the facility's failure to accommodate her smoking preference.
The facility failed to complete neurological assessments for two residents after unwitnessed falls, with assessments left incomplete or not initiated. Additionally, a resident did not receive bowel management medications as ordered, leading to prolonged constipation. The facility also failed to monitor vital signs as per physician's orders after a medication change. Staff interviews revealed non-compliance with protocols, and the facility's policy for processing orders was not provided.
A resident with moderate cognitive impairment and hearing difficulties did not receive proper audiology services as outlined in their care plan. Despite the resident's expressed difficulty in hearing and lack of hearing aids, the facility failed to offer an audiology appointment or document any discussion of such services. Interviews with staff confirmed the resident's hearing challenges and the absence of hearing aids, highlighting a lapse in following the facility's policy to assist hearing-impaired residents.
The facility failed to implement care plan interventions for a resident at high risk for pressure ulcers by not using pressure-relieving boots as required. Another resident with a stage four pressure ulcer was not repositioned every two hours as per their care plan, remaining in a wheelchair for over four hours without repositioning. Staff interviews confirmed the expectations for both residents' care plans were not met.
A facility failed to assess and supervise a resident with a history of smoking, despite being a non-smoking facility. The resident, with a diagnosis of dementia and other health conditions, was observed smoking outside multiple times without a smoking assessment being conducted. Staff interviews confirmed the resident's smoking habit, and the facility's policy requiring residents to leave the property to smoke was not enforced.
Two residents in the facility were administered digoxin without appropriate pulse monitoring. One resident with intact cognition and multiple diagnoses, including atrial flutter, and another with severe cognitive impairment and paroxysmal atrial fibrillation, received digoxin without parameters for heart rate monitoring. Staff interviews revealed no orders for pulse checks prior to administration, despite facility policy requiring it. The deficiency was identified through observations and staff interviews.
A resident was not offered the PCV20 vaccine as recommended by the CDC, despite having received previous pneumococcal vaccines. The infection preventionist confirmed the oversight, and the facility's policy did not address the administration of PCV20 with shared decision-making.
The facility failed to manage the bowel and constipation needs of a resident with Alzheimer's Disease and severely impaired cognition. Despite a care plan goal of having a bowel movement (BM) every three days, multiple periods showed no BM documentation and no evidence of the facility's Bowel Movement Protocol being implemented. Staff interviews revealed a lack of awareness and documentation regarding the resident's constipation issues.
A resident with Alzheimer's Disease and severely impaired cognition experienced two unwitnessed falls without new interventions being implemented to prevent reoccurrence. Despite being identified as at risk for falls and having a care plan in place, the facility failed to follow its policy requiring additional interventions after repeated falls.
Code Alert System Failed to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure the code alert system used for residents at risk for elopement was functioning properly and failed to follow the manufacturer’s recommendations for weekly testing and inspection. The report states that the immediate jeopardy began when R12 was able to exit the building after the main entrance code alert system malfunctioned, and that R19 was also able to get through the main doors because the doors did not lock as required by the system. The manufacturer’s binder in the facility called for weekly testing of the code alert units, regular testing of each detection zone, and quarterly service inspections, but the facility’s logs showed the doors were being tested monthly instead of weekly. R19 was severely cognitively impaired with Alzheimer’s disease. The resident’s assessment identified low elopement risk, and the care plan lacked interventions for elopement and wandering. During observation, R19 wheeled to the main entrance, went through the first door into the vestibule, and the alarm sounded, but the door did not lock. A nursing assistant responded and redirected R19 back to the central TV area. The resident’s progress note did not include the attempt to leave the building. R12 was severely cognitively impaired with non-Alzheimer’s dementia and anxiety. The resident had repeated attempts to leave the facility, but the care plan lacked elopement and wandering interventions, and the most recent assessment also identified low elopement risk with the door alarm band not selected. During observations, R12 repeatedly approached the main entrance, triggered the alarm, and was able to get through the first door into the vestibule; on one occasion R12 exited the building before being followed outside by staff. The report also states that R12’s record lacked documentation of the successful exit and other attempts to leave. In addition, the facility failed to adequately assess and develop care plans for multiple other residents assigned code alert devices, including residents with severe or moderate cognitive impairment and diagnoses such as dementia and Alzheimer’s disease, whose care plans did not include elopement or wandering interventions or, in some cases, the location of the device.
Inaccurate MDS Coding for Code Alert Devices
Penalty
Summary
The facility failed to ensure accurate MDS coding for the use of code alert devices for 14 of 14 residents identified as at risk for elopement and wandering. The code alert system log titled Wander Guard Monitor for 4/2026 identified residents R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, and R46 as having a code alert device in use, but their MDS assessments did not consistently reflect that information in Section P. Instead, the assessments frequently indicated that a wander guard alarm was not in use and that the residents had not exhibited wandering behavior. Several resident records also lacked corresponding care plan interventions for elopement and wandering. R3, R4, R18, R22, R28, R32, R34, R37, and R46 had care plans that did not include elopement or wandering interventions, and R22's care plan did not identify the placement location of the code alert device. R37's problem area for elopement was not initiated until 5/1/26. R46 was discharged on 4/20/26, and the care plan was requested but not received. R19's most recent elopement assessment identified low risk and included clothing labeled with identification and an identification band, but did not select the door alarm band applied as an intervention. R12's assessments similarly identified low risk and listed clothing labeling and an identification band, but did not select the door alarm band applied. The record also showed inconsistencies between assessments, documentation, and staff statements. R13 and R17 had elopement assessments completed on 5/1/26 and their code alert devices were removed, while R19's EMR lacked evidence that elopement assessments were completed quarterly. R12's EMR lacked evidence of quarterly elopement assessments, and progress notes stated the assessments were reviewed with no change despite later documentation of a successful exit of the building and attempts to exit. During interviews, staff stated that residents with wandering or elopement risks should be identified on the care plan, that code alert devices were kept in a book at the main entrance desk, and that the MDS should be coded to reflect code alert placement because it drives care and the care plan.
Incomplete Care Plans for Elopement, Smoking, EBP, and Medication Needs
Penalty
Summary
The facility failed to develop comprehensive care plans with individualized elopement and wandering interventions for 14 residents who were identified as at risk for elopement and wandering. For multiple residents, quarterly, annual, or significant change MDS assessments documented severe or significant cognitive impairment, dementia, Alzheimer’s disease, vascular dementia, anxiety, or other neurocognitive disorders, yet the care plans did not include elopement or wandering interventions. Several of these residents also had code alert devices or wander guard alarms referenced in the record, but the care plans did not identify the device placement or include resident-specific interventions. In some cases, elopement assessments were completed and identified residents as low risk, but the care plans still lacked corresponding interventions or were not updated after later status changes. Specific examples included residents whose MDS assessments indicated cognitive impairment and no wandering behavior, while the care plans remained without elopement-related interventions. One resident’s elopement assessment was completed after a change in status and the code alert device was removed, but the care plan had not been revised to reflect the change. Another resident had a low-risk elopement assessment with interventions such as labeled clothing and an identification band, but the door alarm band was not selected. A resident with a code alert device on an assistive device had no care plan documentation identifying the device location. The facility’s own staff stated that wandering and elopement risks should be added to the care plan, that residents with code alert devices should be watched closely, and that assessments should be redone after events or changes, but this was not consistently done. The facility also failed to care plan other resident-specific needs for three residents. One resident’s care plan did not address sleep disturbance or antidepressant use despite receiving trazodone nightly for sleep. Another resident who smoked and had COPD, heart failure, Alzheimer’s disease, chronic cough, and emphysema was observed smoking outside the front door, but the care plan and nursing assistant group sheet did not identify smoking. A third resident receiving dialysis had no enhanced barrier precautions documented in the care plan or safety sheet, despite staff and the infection preventionist stating that such precautions were expected for residents with certain indwelling medical devices. The DON stated that care plans should include information about smoking, wanderguard use, enhanced barrier precautions, and medication use, but these items were not included for the residents reviewed.
Failure to Perform Hand Hygiene and Use Proper Ice Handling During Snack Pass
Penalty
Summary
The facility failed to ensure proper hand hygiene and proper use of an ice scoop during the snack pass. During an observation on 4/29/26 at 1:56 p.m., NA-A had a snack cart with two over-sized plastic pitchers filled with ice and stopped outside of R29's room. NA-A was not wearing gloves, entered the room, brought out the water cup, filled it with ice using a plastic water glass, returned the plastic glass to the over-sized pitcher with ice, exited the room, and did not perform hand hygiene. NA-A then went to R7's room without performing hand hygiene, entered the room, filled the water cup with ice using the plastic water glass resting on top of the ice, poured juice into a cup, and brought the items into the room. NA-A again exited without hand hygiene. NA-A then went to R30's room, exited with a plate of food, discarded it in the garbage bag attached to the snack cart, did not perform hand hygiene, picked up a banana, and brought it into the room before exiting again without hand hygiene. During interview, NA-A stated the snack cart was taken around to rooms twice daily and verified that the plastic water glass was put back into the over-sized pitcher with ice because it "doesn't touch anything." NA-A also verified that hand hygiene was not performed before or after exiting resident rooms or after disposing of uneaten food from R30's room. The residents involved had documented diagnoses including heart disease, hypertension, hyperlipidemia, GERD, heart failure, diabetes mellitus, and depression, and were described in their MDS assessments as moderately cognitively intact. The DON stated she would expect staff to perform hand hygiene before entering and after exiting a resident room and identified the use of a plastic water glass to fill resident water cups and then returning it to the ice pitcher as an infection control concern. The facility hand hygiene policy dated 6/2019 stated all employees would be trained on hand hygiene practices and that hand hygiene would be performed before and after handling food and after handling soiled utensils or equipment.
Failure to Honor Resident Request for Nail Care
Penalty
Summary
The facility failed to honor a resident’s preference for nail care and did not ensure the resident’s nails were trimmed when requested. The resident had an annual MDS assessment showing moderate cognitive impairment and diagnoses including non-Alzheimer’s dementia, renal insufficiency, hypertension, and depression. The care plan noted limited range of motion in the upper extremities and assistance needs for bathing, showers, grooming, oral care, and dressing. Progress notes showed the resident’s last shower on 4/3/26, but nail care was not addressed in the notes. During observation, the resident was seated in a wheelchair with long fingernails extending beyond the fingertips and stated the nails were too long and that staff had not trimmed them despite requests. A nail clipper was kept on the bedside table because the resident wanted the nails trimmed. On later interviews, the resident again stated the nails had not yet been trimmed and that it bothered them. Staff interviews showed nail care was typically done on shower days, but multiple staff members stated that if a resident requested nail trimming, either nursing assistants, wellness staff, or the nurse could do it, and the DON stated residents should not have to wait until the next bath day for nail trimming.
Deficiencies in Monitoring and Consent for Psychotropic Medications
Penalty
Summary
The facility failed to monitor orthostatic blood pressures for residents on antipsychotic medications, which is crucial due to the risk of orthostatic hypotension. This deficiency was observed in four residents, who were receiving medications such as quetiapine and Zyprexa. Despite physician orders to monitor orthostatic blood pressures monthly, the facility's records lacked evidence of these measurements being taken. Interviews with staff, including the Director of Nursing (DON), confirmed that orthostatic blood pressures were not consistently monitored, which could increase the risk of falls due to medication side effects. Additionally, the facility did not obtain signed consent for the use of an antidepressant medication for one resident. The resident was prescribed Lexapro for major depressive disorder, but the medical record did not contain any evidence of signed consent. The DON acknowledged that consents should be obtained for all mood-altering medications to ensure residents are informed about their treatment and potential side effects. The facility also failed to implement non-pharmacological interventions before initiating antipsychotic medication for one resident. The resident's medical record did not indicate any attempts to address behavioral symptoms through other means before prescribing quetiapine. Furthermore, the facility did not establish appropriate target behaviors for monitoring the effectiveness of psychotropic medications. For instance, one resident's target behavior was listed as sleeping six to eight hours, which the DON identified as a goal rather than a behavior. These deficiencies highlight a lack of adherence to policies regarding the use of psychotropic medications and monitoring of their side effects.
Improper PPE Use and Inadequate Infection Control Program
Penalty
Summary
The facility failed to ensure the correct use of personal protective equipment (PPE) to prevent the spread of COVID-19, affecting all residents, visitors, and staff in the short-term stay unit. Observations revealed that registered nurse (RN)-A reused N95 masks and goggles stored in paper bags, a practice that was common in the facility. Despite having an adequate supply of PPE, staff continued to reuse masks and goggles, which were stored in paper bags labeled with staff names. The infection preventionist (IP) and director of nursing (DON) acknowledged that new surgical masks should have been used to reduce the risk of spreading COVID-19. The facility also failed to develop and implement a comprehensive infection control program that included surveillance of infections not treated with antibiotics. The infection control logs from October to December 2024 only documented infections treated with antibiotics, such as urinary tract infections and cellulitis, but did not include viral, fungal, or yeast infections. The IP admitted that there was no tracking of infection symptoms or COVID-19 infections on spreadsheets, as they were not prescribed antibiotic therapy. The DON confirmed that tracking should include all residents with symptoms of illness, not just those prescribed antibiotics. The facility's policy on airborne precautions did not address the use of PPE, and the surveillance policy was not effectively implemented to identify conditions that increase the risk of infections. The lack of comprehensive infection tracking and the improper use of PPE contributed to the potential spread of infections within the facility. The IP and DON recognized the need for improved tracking and use of PPE to prevent the spread of COVID-19 and other infections among residents and staff.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were comprehensively assessed for self-administration of medications, as evidenced by the cases of two residents, R3 and R10. R3, who had moderate cognitive impairment and required assistance with all activities of daily living, was observed self-administering nebulizer treatments without staff supervision. Despite a previous assessment indicating R3 was not appropriate for self-administration, R3 was found using the nebulizer independently on multiple occasions. R10, also with moderate cognitive impairment and requiring assistance with most activities of daily living, was found with muscle rub cream and eye drops in his room, which he self-administered without a physician's order. Although R10 expressed a desire to self-administer medications, the assessment did not specify which medications he could self-administer, and it was determined he was not appropriate for self-administration. Despite this, R10 continued to self-administer the muscle rub and eye drops, and his nebulizer treatment was not completed as prescribed. The facility's policy requires a comprehensive assessment to determine if self-administration is clinically appropriate and safe, considering factors such as cognitive and physical abilities. However, the assessments for R3 and R10 were not adequately conducted or documented, leading to unsupervised self-administration of medications. The Director of Nursing confirmed that assessments should be completed at admission, quarterly, or with significant changes in status, and that a provider's order is necessary for self-administration, which was not obtained in these cases.
Failure to Support Resident Smoking Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination and choice by not providing opportunities for smoking, which was a significant aspect of the resident's quality of life. The resident, identified as R13, had a history of smoking and expressed a strong desire to continue this habit. Despite having intact cognition and being capable of making her own decisions, the facility did not assess or address her smoking preferences in her care plan. This oversight led to repeated incidents where R13 expressed anger and frustration due to the inability to smoke, as documented in multiple progress notes. R13's electronic health record lacked evidence of any assessment regarding her smoking habits, and her care plan did not address her wish to smoke. The facility's policy required residents who wished to smoke to leave the property, but R13 was not supported in doing so. This resulted in numerous documented instances of R13 attempting to smoke on the premises, asking staff for cigarettes, and expressing anger when her requests were denied. Staff interviews confirmed that R13's behaviors, including verbal aggression, were linked to nicotine withdrawal and the facility's failure to accommodate her smoking preference. The facility's non-smoking policy and lack of a tailored care plan for R13's smoking needs contributed to ongoing behavioral issues. Staff members reported that R13's aggressive behaviors were primarily verbal and stemmed from her inability to smoke. Despite the facility's recognition of resident rights to self-determination, the failure to facilitate R13's smoking preference led to repeated conflicts and dissatisfaction, impacting her quality of life and well-being.
Failure to Complete Neurological Assessments and Follow Physician Orders
Penalty
Summary
The facility failed to complete neurological assessments following unwitnessed falls for two residents, R7 and R25. R7 experienced multiple unwitnessed falls, with one incident on 6/5/24 where a bump was noted on her forehead, yet the neurological assessment was incomplete with several time slots left blank or marked as 'sleeping.' Similarly, on 12/13/24, R7 had two unwitnessed falls, but there was no evidence of neurological assessments being completed. R25 also had an unwitnessed fall on 1/7/25, resulting in a large bump above her right eye, but the neurological assessment was not thoroughly completed, with time slots left blank or marked as 'eating.' Interviews with staff revealed a lack of adherence to the facility's fall protocol, which required waking residents to complete assessments. The facility also failed to administer medications per physician's orders for resident R30, who was reviewed for bowel management. R30 had not had a bowel movement in six days, and the electronic health record lacked evidence that as-needed medications for constipation were provided. Despite R30's complaints of constipation due to dialysis, fluid restriction, and pain medication, the facility did not follow the bowel protocol, which included administering prune juice, senna, suppositories, and enemas on specific days without a bowel movement. Additionally, the facility failed to obtain vital signs per physician's orders for R30. After the discontinuation of carvedilol on 2/4/25, there was an order to monitor R30's heart rate closely, but the last recorded pulse was on 2/1/25. The Director of Nursing confirmed that the order for regular pulse checks was not followed, which was crucial for R30's health. The facility's policy for processing physician's orders was requested but not provided, indicating a potential gap in ensuring compliance with medical directives.
Failure to Provide Audiology Services for Hearing-Impaired Resident
Penalty
Summary
The facility failed to ensure proper treatment was provided to maintain hearing for a resident with moderate cognitive impairment who required assistance with most activities of daily living (ADLs). The resident's care plan indicated that qualified nursing staff would monitor for changes in communication abilities and offer to arrange a hearing evaluation as needed. However, the resident's electronic health record lacked evidence that an audiology appointment was offered. During multiple observations, the resident was noted to be without hearing aids and expressed difficulty hearing, stating that the facility had not discussed audiology services with him. Interviews with nursing assistants and the clinical manager confirmed that the resident was very hard of hearing and did not wear hearing aids. The clinical manager acknowledged the absence of documentation indicating that audiology services were discussed with the resident. The Director of Nursing stated that if staff noticed a progression in hearing loss, the facility should offer audiology services and check for wax buildup. The facility's policy indicated that staff would assist hearing-impaired residents in maintaining effective communication and arranging necessary services, which was not adhered to in this case.
Failure to Implement Pressure Ulcer Prevention and Repositioning Interventions
Penalty
Summary
The facility failed to implement care plan interventions to prevent pressure ulcers for a resident who was at high risk due to severe cognitive impairment and dependency on staff for care. The resident's care plan included the use of pressure-relieving boots while in bed, but observations on multiple occasions showed the boots were not on the resident's feet while in bed. Interviews with staff confirmed that the boots were supposed to be used during all bedtimes, including naps, but were not consistently applied as required by the care plan. Additionally, the facility did not provide timely assistance with repositioning for another resident with a stage four pressure ulcer and severe cognitive impairment. The care plan required repositioning every two hours, but observations indicated the resident remained in a wheelchair for over four hours without repositioning. Interviews with staff confirmed the expectation to reposition the resident every two hours, which was not adhered to, despite the resident's high risk for skin integrity issues due to existing conditions and severe malnutrition.
Failure to Assess and Supervise Resident Smoking in Non-Smoking Facility
Penalty
Summary
The facility failed to comprehensively assess and ensure the safety of a resident, R13, who was smoking outside the facility, despite being a non-smoking facility. R13's medical records indicated a history of tobacco use, dementia, and other health conditions, but there was no evidence of a smoking assessment in her electronic health record. The facility's staff, including the administrator and clinical manager, initially stated that there were no residents who smoked. However, multiple progress notes documented instances where R13 attempted to smoke outside, sometimes with the assistance of staff, and at other times by herself. These incidents included R13 attempting to light a match on the building, hiding cigarettes, and demanding them back from staff who confiscated them. Interviews with various staff members, including nursing assistants, a registered nurse, and the director of nursing, confirmed that R13 was known to smoke outside frequently, despite the facility's non-smoking policy. The facility's Tobacco/Smoke Free policy required residents who wished to continue smoking to sign out and leave the property, but this was not enforced for R13. The director of nursing acknowledged that a smoking assessment should have been completed when R13 was first observed smoking, but confirmed that no such assessment had been conducted. This oversight led to a failure in adequately supervising and ensuring the safety of R13 in relation to her smoking habit.
Failure to Monitor Pulse Before Administering Digoxin
Penalty
Summary
The facility failed to ensure the development and implementation of parameters for administering heart rate control medication, specifically digoxin, for two residents, R13 and R40. Both residents were receiving digoxin for heart rate control without appropriate monitoring of their pulse prior to administration. R13, who had intact cognition and multiple diagnoses including atrial flutter, was receiving digoxin without any parameters indicating when the medication should be held based on heart rate. The Medication Administration Record (MAR) for R13 did not include pulse measurements before digoxin administration, and only three pulse measurements were recorded over a period of more than a month. Similarly, R40, who had severe cognitive impairment and multiple diagnoses including paroxysmal atrial fibrillation, was also receiving digoxin without parameters for heart rate monitoring. The MAR for R40 did not include pulse measurements before digoxin administration, and only 12 pulse measurements were recorded over a similar period. During an observation, a trained medication aide administered medications to R40 without checking the pulse, and the aide confirmed that there were no vitals obtained prior to medication administration. Interviews with staff, including a registered nurse and the director of nursing, revealed that there were no orders in place for pulse checks prior to administering digoxin for either resident. The director of nursing and consultant pharmacist both stated that it was standard practice to obtain a pulse before administering digoxin, and the facility's policy indicated that an apical pulse should be obtained prior to administration. However, this practice was not being followed, leading to the deficiency in medication administration for R13 and R40.
Failure to Offer PCV20 Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, was offered and/or provided the pneumococcal vaccine series as recommended by the CDC. R30, who was over the age of 65, had received the PPSV23 vaccine on two occasions and the PCV13 vaccine once. However, there was no evidence in the records of shared clinical decision-making with a physician regarding the administration of the PCV20 vaccine, which should have been considered at least five years after the last pneumococcal dose. The absence of this documentation indicates that R30 was neither offered nor received the PCV20 vaccine. During an interview, the infection preventionist acknowledged that R30 was not listed for the PCV20 vaccine on the tracking worksheet, despite the last pneumococcal vaccine being administered over six years prior. The facility's policy on pneumococcal vaccines, last reviewed in October 2022, did not address the administration or offering of the PCV20 vaccine with shared decision-making with a provider. This oversight in policy and practice contributed to the deficiency identified in the report.
Failure to Manage Bowel and Constipation Needs
Penalty
Summary
The facility failed to manage the bowel and constipation needs of a resident (R2) who had diagnoses including Alzheimer's Disease, constipation, and severely impaired cognition. R2's care plan indicated a goal of having a bowel movement (BM) at least every three days, with interventions such as monitoring BM status daily and administering medications as ordered. However, the medical record showed multiple periods where no BM was documented, specifically from 12/29/23 through 1/4/24, 2/4/24 through 2/9/24, 2/14/24 through 2/17/24, and 2/23/24 through 2/28/24. During these periods, there was no evidence that the facility's Bowel Movement Protocol was implemented, which included steps like administering Milk of Magnesia, Bisacodyl suppository, or a fleet enema, and contacting the provider for further orders if no BM occurred by day three. Interviews with staff, including LPN-A, RN-A, RN-B, and the Director of Nursing (DON), revealed a lack of awareness and documentation regarding R2's constipation issues. LPN-A mentioned that Milk of Magnesia or MiraLAX was effective for R2's constipation, but there was no documentation of these interventions during the specified periods. RN-A and RN-B were not aware of any constipation concerns for R2, and the DON confirmed the lack of evidence in the medical record for both BM documentation and the implementation of the Bowel Movement Protocol. The facility's Bowel Protocol directed staff to review bowel reports daily and take specific actions if no BM occurred, but these steps were not followed for R2 during the documented periods.
Failure to Implement New Interventions After Resident Falls
Penalty
Summary
The facility failed to assess and implement new interventions to prevent future falls for a resident with Alzheimer's Disease and severely impaired cognition. The resident had a history of falls, with two unwitnessed falls occurring within a short period. Despite the resident's care plan identifying them as at risk for falls and listing several interventions, no new interventions were implemented following the falls to prevent reoccurrence. The resident's medical record lacked evidence of new interventions after each fall, even though the interdisciplinary team reviewed the incidents and ruled out abuse and neglect. Interviews with staff confirmed that the resident was at risk for falls due to impulsive behavior and poor safety awareness. Staff were directed to visually check on the resident frequently, keep the bed in the lowest position, and ensure the resident wore gripper socks or shoes. However, the registered nurse and director of nursing acknowledged that no new interventions were implemented following the falls, despite the facility's policy requiring additional or different interventions if falls reoccur. The failure to implement new interventions was noted, even though the falls occurred around the time the resident typically went to bed, indicating a potential pattern that was not addressed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 29 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Milaca Elim Meadows Health Care Center | 18.8 mi | ★★★★★ | 7 | 0 |
| The Estates At Rush City Llc | 21.4 mi | ★★★★★ | 7 | 0 |
| Gracepointe Crossing Gables | 21.6 mi | ★★★★★ | 9 | 0 |
| Cura Of Onamia | 21.6 mi | ★★★★★ | 6 | 0 |
| Elim Wellspring Health Care Center | 25.7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for St Clare Living Community Of Mora.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.