Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Clare Home during CMS and state inspections, most recent first.
MDS Did Not Accurately Reflect Significant Weight Loss: A resident with bilateral knee OA and DM2 had significant weight loss over both 1 month and 6 months, but the Quarterly and Comprehensive MDS assessments did not code the documented weight loss. The MDS Coordinator acknowledged the assessments were inaccurate, and the DON stated the MDS should accurately reflect the resident's weight loss.
Care plans were not fully developed and implemented for two residents receiving psychotropic meds and one resident receiving pain management. The records lacked evidence of every-shift monitoring for med effectiveness, side effects, and mood/behavior/cognition changes for residents on Sertraline and Buspirone, and lacked evidence of every-shift pain med monitoring for a resident on Gabapentin, APAP, and Oxycodone/APAP. For another resident, bladder status was not addressed with a toileting program despite urinary incontinence documented in the record.
Failure to follow physician orders for wound care and weekly weights. A resident with DM and a skin picking disorder had a bordered gauze dressing over a skin tear, but staff acknowledged there was no treatment order for the wound. The same resident also had a physician order for weekly weights, yet several ordered weights were not obtained. The RD, RN, and DON all acknowledged the missed weights or could not provide evidence they were completed.
Failure to Assess, Treat, and Monitor Pressure Ulcers: A resident with DM, CKD, PVD, impaired mobility, incontinence, and a history of skin picking developed multiple Stage 2 pressure ulcers, a sacral wound that progressed to an unstageable necrotic ulcer, and additional deep tissue injuries. Staff did not complete comprehensive wound assessments, did not initiate treatment for a newly identified wound, and documented inaccurate air mattress settings despite an order for pressure checks every shift. The resident’s air mattress was observed at the wrong setting, and the DNS and provider acknowledged the correct setting should have been used and documented.
Failure to monitor and confirm significant weight loss: A resident with dysphagia and Parkinson's Disease had orders for appetite stimulant, protein supplement, and weekly weights, but the record showed severe and significant weight loss with missed weekly weights and no reweights after 5%+ losses as required by policy. Interviews with the RD, RN, provider, and DON confirmed the ordered weights were not obtained and the resident's weight loss was not being followed as ordered.
Failure to Post Oxygen-In-Use Signs: The facility did not post required oxygen-in-use cautionary signs for two residents receiving oxygen therapy. One resident had acute respiratory failure with hypoxia and an order to titrate O2 to keep sats above 92%, and another resident had COPD with a continuous O2 order to keep sats above 90%. Surveyors observed both rooms without the required signage, and the RN and DON acknowledged the omission.
During an overnight shift, only two nurses and two NAs were available to care for about 50 residents across three units, resulting in inadequate supervision and care. Due to this staffing shortage, a resident with a history of falls was left on the floor for about an hour after an unwitnessed fall, and another resident did not receive scheduled morning medications, including a cardiac drug. Staff and families reported concerns about residents being left alone and delays in care, confirming that the facility did not provide enough nursing staff to meet residents' needs.
Three residents with conditions such as hemiplegia, Alzheimer's disease, and cognitive impairment did not receive timely bowel interventions or GI assessments as required by facility protocol when experiencing multiple days without adequate bowel movements. Prescribed medications and interventions were not consistently administered, and providers were not notified of refusals or lack of results, as confirmed by staff interviews.
The facility failed to review and revise care plans for two residents at risk of falls. One resident, admitted with a femur fracture, experienced multiple falls without subsequent care plan updates. Another resident, with a history of surgical amputation, also had several falls without care plan revisions. The DON could not provide evidence of care plan reviews during a surveyor interview.
A resident with multiple sclerosis did not receive prescribed doses of Methylphenidate HCL (Ritalin) on three consecutive days due to the medication cart keys being locked inside. The MAR showed missed doses, and there was no evidence that the medical provider was notified. Both the RN and DON could not confirm the medication was administered on time or that the provider was informed.
The facility failed to properly store and label medications for two residents. A resident's expired medication was found in the medication cart, and another resident was given the wrong medication due to improper storage and labeling. The Director of Nursing Services acknowledged these failures.
The facility failed to document whether residents received or declined influenza and pneumococcal vaccinations, affecting several residents. The Infection Preventionist acknowledged the absence of necessary documentation and consent forms.
The facility failed to follow physician's orders for a resident using an insulin pump and a Freestyle Libre glucose monitoring system. Documentation was missing for the type of insulin, basal rate, and bolus amounts, and there was no order to monitor the pump's functionality. Additionally, the facility did not document when to change the Freestyle Libre sensor or the last time it was changed, and the order for glucose oral gel lacked parameters for administration.
A facility failed to update the care plan for a resident with a suprapubic catheter according to new urologist recommendations, leading to recurrent blockages and drainage issues. Staff continued outdated irrigation practices, and the deficiency was only addressed after surveyor intervention.
MDS Did Not Accurately Reflect Significant Weight Loss
Penalty
Summary
Ensure each resident receives an accurate assessment. Based on clinical record review and staff interview, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 3 residents reviewed related to nutrition. The resident was admitted with diagnoses including bilateral knee osteoarthritis and type 2 diabetes mellitus. Record review showed significant weight loss, including 24.4 lbs. (12.5%) within one month, from 195 lbs. on 12/11/2025 to 170.6 lbs. on 1/10/2026, and 40.6 lbs. (20.5%) within 6 months, from 197.6 lbs. on 10/2/2025 to 157 lbs. on 4/1/2026. However, the Quarterly MDS assessment did not code the resident as having a weight loss of 5% or more within the last month, and the Comprehensive MDS assessment did not code the resident as having a weight loss of 10% or more in the last 6 months. During interview, the MDS Coordinator acknowledged the assessments were inaccurate and did not reflect the resident's weight loss, and the DON stated she would expect the MDS assessments to accurately reflect the resident's weight loss.
Care Plans Not Implemented for Psychotropic Meds, Pain, and Bladder Status
Penalty
Summary
The facility failed to ensure that a person-centered comprehensive care plan was developed and implemented for residents who were receiving psychotropic medications and pain management. Resident ID #4, admitted with diagnoses including major depressive disorder and generalized anxiety disorder, had physician orders for Sertraline 100 mg in the evening and Buspirone 10 mg daily. Although the care plan directed staff to monitor and document the effectiveness and possible side effects of these medications every shift and to monitor, document, and report changes in behavior, mood, and/or cognition, the record did not show that this monitoring was being done every shift or that nurses were documenting changes in mood, behavior, or cognition. Resident ID #7, admitted with diagnoses including major depressive disorder and post-traumatic stress disorder, had an order for Sertraline 75 mg in the morning, and the care plan similarly directed every-shift monitoring for effectiveness, side effects, and changes in behavior, mood, and/or cognition, but the record also lacked evidence that this monitoring and documentation occurred. Resident ID #9, admitted with chronic pain, had orders for Gabapentin 600 mg twice daily, Acetaminophen 650 mg every 6 hours as needed, and Oxycodone/Acetaminophen 10-325 mg three times daily. The care plan stated that analgesic medications were to be administered as ordered and their effectiveness and side effects monitored and documented every shift, but the record did not show that this was being done. In addition, the resident’s bowel and bladder screening indicated that he/she always voided appropriately without incontinence, yet point-of-care documentation later showed urinary incontinence on multiple occasions. The admission MDS also indicated occasional urinary incontinence and there was no documentation that a trial toileting program had been attempted. During interview, the DNS acknowledged that Resident ID #9 was not on a toileting program and that the care plan failed to be developed and implemented to address the resident’s bladder status.
Failure to Follow Wound Treatment Orders and Obtain Ordered Weekly Weights
Penalty
Summary
The facility failed to ensure that treatment and care were provided in accordance with professional standards of practice for a resident admitted with diagnoses including type 2 DM with hyperglycemia and a skin picking disorder. During surveyor observation, the resident had a bordered gauze dressing dated 5/13 on the right lower extremity, and when the dressing was removed, a xeroform dressing was found covering a skin tear. Staff A acknowledged that there was no treatment order in place for the observed wound, and the DON was unable to provide evidence of a treatment order for the wound and stated that staff would be expected to obtain a physician's order for wound treatment. The facility also failed to obtain weekly weights as ordered for the same resident. A physician's order dated 2/15/2026 directed weekly weights starting 2/22/2026, and the care plan included obtaining and monitoring weights as ordered. The documented weights showed multiple entries, but the record did not show weekly weights were obtained on 2/22/2026, 4/9/2026, 4/23/2026, and 5/7/2026. The RD acknowledged that weekly weights were not obtained as ordered and stated she does not verify whether ordered weights are obtained, the RN acknowledged the weights should have been obtained, and the DON was unable to provide evidence that the ordered weekly weights were completed.
Failure to Assess, Treat, and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to promote wound healing and prevent new pressure ulcers for a resident admitted with diagnoses including type 2 diabetes mellitus, excoriation disorder, peripheral vascular disease, chronic kidney disease, impaired mobility, incontinence, and pruritus with a history of self-inflicted scratches. The resident was cognitively intact with a BIMS score of 14 out of 15. The care plan addressed impaired skin integrity and included an air mattress, lotions and medications as ordered, and weekly full skin inspections, but the record did not show a care plan developed and implemented for the resident’s actual pressure ulcers. Weekly skin and wound documentation showed multiple pressure injuries, including Stage 2 ulcers to the right hip, right buttock, and additional right buttock areas, along with a sacral wound that was not staged. The wound assessments did not include required descriptions such as wound bed characteristics, wound edges, surrounding tissue, drainage, odor, undermining or tunneling, or pain. Physician orders were entered for cleansing and topical treatment of the wounds, but the record did not show evidence that treatment orders were initiated for the left inner thigh Stage 2 pressure ulcer after it was identified, and the wound physician later identified additional deep tissue injuries while the sacral ulcer had progressed to an unstageable necrotic ulcer. The resident also had an order for an air mattress with pressure checks every shift, but staff documented inconsistent and inaccurate mattress settings. The resident’s weight indicated the mattress should have been set at 150, yet staff documented a setting of 190 on the TAR while the mattress was observed set at 180. Staff acknowledged there was no setting for 190 and that the correct setting should have been 150. The DNS and the resident’s provider both stated that the correct setting should have been implemented and documented, and the DNS acknowledged the resident now had deep tissue injuries and a necrotic sacral pressure ulcer.
Failure to Monitor and Confirm Significant Weight Loss
Penalty
Summary
The facility failed to maintain the nutritional status of Resident ID #4, who was re-admitted with diagnoses including right hip fracture, hypothyroidism, dysphagia, and Parkinson's Disease. The resident had a care plan for weight loss and physician orders for Remeron daily, Prostat daily, and weekly weights. Documented weights showed a decline from 112.5 lbs. to 99.0 lbs., then to 93.6 lbs. and 88.4 lbs., including a severe 12% weight loss over one interval and two additional significant weight losses of more than 5% in short time periods. The record did not show weekly weights were obtained as ordered on 4/30/2026 and 5/11/2026. The record also did not show reweights within one day of the 4/3/2026, 4/23/2026, and 5/4/2026 weights, despite the facility policy requiring confirmation of any 5% or greater weight change and immediate notification of the dietitian. During interviews, the RD acknowledged the resident's significant weight loss and that weekly weights were not obtained, the RN acknowledged the missed weekly weights and said the resident should have been weighed, the provider stated she was unaware staff had not followed the weekly weight order, and the DON acknowledged the weights were not obtained weekly as ordered.
Failure to Post Oxygen-In-Use Signs
Penalty
Summary
The facility failed to post cautionary and safety signs indicating oxygen was in use for 2 of 3 residents reviewed who were receiving oxygen therapy. Facility policy titled Oxygen Administration stated that an "Oxygen in Use" sign should be placed on the outside of the room entrance door. Resident ID #33 was admitted with a diagnosis including acute respiratory failure with hypoxia and had a physician order dated 4/20/2026 to titrate oxygen to maintain oxygen saturation greater than 92%. Surveyor observation of the resident's room did not reveal an oxygen-in-use sign on 5/13/2026 at 9:00 AM or on 5/14/2026 at 11:11 AM. Resident ID #47 was admitted with a diagnosis including COPD and had a physician order dated 12/20/2025 to administer oxygen continuously via nasal cannula to maintain oxygen saturation greater than 90%. Surveyor observation of the resident's room also did not reveal an oxygen-in-use sign on 5/13/2026 at approximately 9:00 AM or on 5/14/2026 at 11:11 AM. During interview, the RN acknowledged that both resident rooms lacked the required cautionary safety sign, and the DON acknowledged that the facility failed to post the signs for both residents.
Insufficient Nursing Staff Leads to Unwitnessed Fall and Missed Medications
Penalty
Summary
The facility failed to provide sufficient nursing staff during the overnight shift, resulting in inadequate care and supervision for residents. On the night in question, only two nurses and two nursing assistants were present to care for approximately 50 residents across three units on different floors. Staff interviews confirmed that this staffing level was insufficient, with one nurse responsible for two units and nursing assistants having to cover multiple units, leaving some areas temporarily unstaffed. The facility's own policy requires adequate staffing to ensure resident safety and to meet care needs, but this was not met during the shift reviewed. As a result of the staffing shortage, a resident with Parkinson's disease and a history of falls experienced an unwitnessed fall in their room and remained on the floor for about an hour before being found. The resident required assistance for transfers and reported pain after the fall. Staff noted that the unsafe staffing ratios contributed to the incident and that residents requiring two-person assistance for care and transfers were not adequately supported. Another resident, dependent on staff for activities of daily living and requiring two-person assistance for transfers, did not receive scheduled morning medications, including a cardiac medication, due to the lack of available staff. Multiple complaints were made to the Ombudsman and the Department of Health regarding insufficient staffing, with reports that residents were left alone and felt fearful. Staff interviews corroborated that the facility was frequently short-staffed, requiring assistance from staff in the assisted living section to help cover care needs. The documented events demonstrate that the facility did not meet the required standard for staffing to ensure resident safety and the completion of necessary care and medication administration.
Failure to Follow Bowel Protocol and Provide Timely Interventions for Constipation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for three residents experiencing constipation. For one resident with right-sided hemiplegia and bowel incontinence, documentation showed gaps of four days without a bowel movement on two occasions, with no evidence that bowel interventions, GI assessments, or physician notifications were completed as required by the facility's bowel protocol. Another resident with Alzheimer's disease and bowel incontinence went five days without a documented bowel movement, and records did not show that interventions were administered per protocol, nor that a GI assessment or provider notification occurred after failed or refused interventions. A third resident, with mild cognitive impairment and a urinary system malignancy, had only one small bowel movement over four days and did not receive prescribed Polyethylene Glycol or required interventions per the bowel protocol. There was no documentation of GI assessments or provider notifications for this resident either. Staff interviews confirmed that the bowel protocol was not followed and that adequate bowel movements were not documented for these residents during the identified periods.
Failure to Revise Care Plans for Residents at Risk of Falls
Penalty
Summary
The facility failed to adequately review and revise the care plans for two residents who were at risk for falls. Resident ID #1, who was admitted with a displaced fracture of the left femur, experienced falls on multiple occasions, including 6/9/2024, 9/27/2024, and 10/16/2024. However, the care plan interventions were not reviewed and revised following the falls on 6/9/2024 and 9/27/2024, despite the care plan being revised on 11/13/2024 after the issue was brought to the attention of the Director of Nursing Services. Similarly, Resident ID #2, admitted with a diagnosis related to orthopedic aftercare following a surgical amputation, had a care plan indicating a risk for falls. This resident sustained falls on 5/23/2024, 7/27/2024, 9/29/2024, 10/22/2024, and 10/25/2024. The care plan interventions were not reviewed and revised for these falls. During an interview with the Director of Nursing Services, she was unable to provide evidence that the care plans for both residents were reviewed and revised as required.
Failure to Administer Prescribed Medication Timely
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A resident, admitted in April 2022 with multiple sclerosis, was prescribed Methylphenidate HCL (Ritalin) 30 mg to be taken three times daily. However, the Medication Administration Record (MAR) showed missed doses on three consecutive days in November. A Registered Nurse confirmed that the resident received a delayed dose on one of these days due to the medication cart keys being locked inside the cart. There was no evidence in the progress notes that the medical provider was notified of the missed doses, and both the nurse and the Director of Nursing Services could not provide evidence that the medication was administered at the scheduled times or that the provider was informed of the missed doses.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for two residents. For Resident ID #4, who was admitted with pneumonia and had expired, a surveyor observed a blister medication card containing 10 tablets of Methylphenidate HCL with the resident's name on it in the nursing medication cart. This indicates that the medication was not removed or destroyed following the resident's expiration, as per the facility's policy. For Resident ID #5, who was admitted with Alzheimer's disease, a medication error was documented where the resident was administered Alprazolam instead of Lorazepam, despite there being no physician's order for Alprazolam. During a surveyor observation, a blister medication card with 26 tablets of Alprazolam with the resident's name was found in the medication cart. This demonstrates a failure to adhere to the facility's policy on medication storage and removal, as acknowledged by the Director of Nursing Services.
Failure to Document Vaccination Status
Penalty
Summary
The facility failed to ensure that residents' medical records included documentation of either receiving the influenza or pneumococcal vaccinations or not receiving them due to medical contraindications or refusal. This deficiency was identified for four out of six residents reviewed for pneumococcal vaccination and three out of six residents reviewed for influenza vaccination. Specifically, the records for Residents ID #1, #6, #23, and #26 lacked evidence of the pneumococcal vaccine being offered, received, or declined. Similarly, the records for Residents ID #23, #26, and #29 lacked evidence of the influenza vaccine being offered, received, or declined. During an interview, the Infection Preventionist acknowledged the absence of consent or declination forms for the mentioned residents concerning both the pneumococcal and influenza vaccines. Additionally, the Infection Preventionist was unable to provide evidence that the residents' medical records included documentation indicating whether the residents received or declined the vaccinations due to medical contraindications or refusal. This issue was only brought to the facility's attention by the surveyor.
Failure to Follow Physician's Orders for Insulin Pump and Glucose Monitoring
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for a resident using an insulin pump and a Freestyle Libre continuous glucose monitoring system. The resident, who manages their own insulin pump, did not have documentation in their record regarding the type of insulin, basal rate of insulin administration, or the amount of insulin delivered via bolus. Additionally, there was no evidence of a physician's order to monitor the functionality of the pump every shift as per facility policy. The Director of Nursing Services (DNS) was unable to provide documentation or explain how this information would be communicated to other healthcare providers. Furthermore, the facility did not document when to change the resident's Freestyle Libre sensor or the last time it had been changed, despite the resident stating it needs to be changed every 14 days. Additionally, there was a physician's order for glucose oral gel to be administered as needed for hypoglycemic events, but the order lacked parameters for when to administer the gel. The DNS acknowledged the absence of these parameters in the physician's order.
Failure to Update Suprapubic Catheter Care as per Urologist's Recommendations
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a suprapubic catheter (SP tube). The resident, who has multiple sclerosis and neuromuscular dysfunction of the bladder, was admitted to the facility in May 2019. The care plan included following up with urology as indicated. Physician orders required the SP tube to be irrigated with Renacidin solution and normal saline on specific days to prevent occlusion. However, after a urology appointment, it was recommended to increase the irrigation volume to 60 mL of normal saline and to aspirate on certain days. The facility did not address these new recommendations with the provider, and staff continued to follow the outdated orders, leading to recurrent blockages and drainage problems for the resident. During interviews, both a Licensed Practical Nurse (LPN) and the Director of Nursing Services (DON) acknowledged that the updated urology recommendations were not addressed. The LPN confirmed that staff were still irrigating the SP tube with 30 mL of normal saline without aspiration, contrary to the new recommendations. The DON admitted that the staff should have addressed the urologist's recommendations on the day of the resident's appointment but could not explain why this was not done. The deficiency was only addressed after being brought to the facility's attention by the surveyor.
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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.
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Nursing homes near Newport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adviniacare Newport, Llc | 0.5 mi | ★★★★★ | 18 | 0 |
| Village House Nursing & Rehabilitation Center | 0.9 mi | ★★★★★ | 6 | 0 |
| John Clarke Senior Living | 2 mi | ★★★★★ | 2 | 1 |
| Grand Islander Center | 2.2 mi | ★★★★★ | 5 | 0 |
| Royal Middletown Nursing Center | 3.4 mi | ★★★★★ | 16 | 0 |
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