Paul House & Health Cr Ctr

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision for a resident with a known elopement risk. This failure resulted in R2 exiting the facility and falling near the exit door sustaining an abrasion to the nose and bilateral knees with swelling to the left forehead. The facility also failed to revise R2's care plan after the elopement and fall that occurred on 06/15/26. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that one totally dependent resident (R1) with skin breakdown was repositioned every two hours. This failure has the potential to affect eight residents with pressure ulcers.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that one (R504) resident who depends on staff assistance for ADL (Activities of Daily Living) care was provided incontinence care and transfer assistance in a timely manner, demonstrating inadequate care in a sample of 55 residents. This failure resulted in R504 suffering psychosocial harm stating feelings of humiliation and embarrassment.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide clean bed and bath linens for residents with the need of assistance with daily hygiene, bathing, or showers. This failure affected two residents (R96, R504) out of three reviewed in the final sample of 55 residents, however, this failure has the potential to affect all 93 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse was scheduled for 8 consecutive hours daily, 7 days a week. This failure affected one (R504) resident reviewed for Registered Nurse coverage and has the potential to affect all 93 residents at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure foods were stored and labeled according to standards, failed to monitor refrigerator, freezer, and cooler temperatures daily; and failed to maintain dishwashing sanitizing water concentrations. This failure has the potential to affect all 93 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain garbage waste with a closed lid to prevent pest infestation and foul odor. This failure affects all 93 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough and accurate facility assessment. This failure has the potential to affect all 93 residents that reside within the facility.

Inspectors wroteOn 06/02/25 at 11:17 am, R86 was observed in bed awake and alert with feeding tube feeding in place running at 40 ml (milliliter) per hour and wound care dressing to R86's left ischium and sacral region. R86's door did not have an Enhanced Barrier Precaution (EBP) sign on R86's door or wall outside of R86's room. On 06/02/25 at 11:22 am, V16 (Licensed Practical Nurse, LPN) stated that residents with feeding tubes and wounds should have EBP signs on the residents door. V16 stated that if a resident who requires EBP does not have a EBP sign on the residents door then staff will not know to wear Personal Protective Equipment (PPE) (gown and gloves) when providing care to the resident and can transmit bacteria to residents and staff. V16 stated, I (V16) thought she (R86) had a sign on her (R86) door. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to clean the lint screens thoroughly, to provide a safe environment for the residents of the facility. This failure has the potential to affect all 93 residents living at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control that eliminated black flying insects in the kitchen. This failure has the potential to affect all 93 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide QAPI (Quality Assurance Performance Improvement) training to the staff. This failure has the potential to affect all 93 residents that reside within the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide compliance and ethics training to the staff. This failure affects has the potential to affect all 93 residents that reside within the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan meetings were conducted and failed to ensure residents/resident's family members participated in the development of the comprehensive care plan. This failure affects 4 residents (R49, R65, R83, and R354) out of a sample of 55.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nasal cannula was labeled with the date changed for 1 (R26) resident; failed to follow the prescribed oxygen flow rate for 2 (R26 and R42) residents; and failed to ensure oxygen was delivered to 1 (R12) resident. These failures affected 3 (R12, R26, and R42) residents reviewed for oxygen therapy in the total sample of 55 residents.

Inspectors wroteBased upon observation, interview, and record review the facility failed to ensure that sufficient nursing staff were available to meet the needs for one residents (R504) in the sample of 55 residents. These failures have the potential to affect all 24 residents on 2 East.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications during shift change; failed to ensure administration of controlled medication was documented; failed to ensure that the medication refrigerator had a temperature log sheets; and failed to ensure that staff do not store personal food items inside the medication refrigerator used for residents medication storage. These failures affected two residents (R99 and R104) and have the potential to affect all 47 residents on the 2 [NAME] unit.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the indwelling catheter drainage bag was covered for three residents (R18, R51 and R104) reviewed for dignity in the sample of 55 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call lights of residents are accessible as stated in the care plans. This failure has the potential to affect 3 residents (R74, R94, and R504) reviewed for accommodation of needs in a sample of 55 residents.

Inspectors wroteBased on interview and record review, the facility failed to transmit a minimum data set (MDS) assessment within required timeframes. This failure affects 1 resident (R354) in a sample of 55.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for obtaining resident weights for a resident with known weight loss and congestive heart failure. This failure affects 1 resident (R80) in a sample of 55.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress was set appropriately for 1 resident (R66), failed to ensure the low air loss mattresses were not layered with multiple layers for 2 (R52 and R66) residents; and failed to ensure a resident's wheelchair has cushion for 1 (R74) resident. These failures affected 3 (R52, R66, and R74) residents reviewed for pressure ulcer prevention and treatment in the total sample of 55 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the containers of the piston syringe were labeled with the dates these were changed for 3 (R24, R55, and R66) residents and failed to ensure the containers of the distilled water used for flushing the g-tubes (gastrostomy tubes) were labeled with open date for 2 (R55 and R66) residents. These failures affected 3 (R24, R55, and R66) residents reviewed for tube feedings in the total sample of 55 residents.

Inspectors wroteBased upon observation, interview, and record review the facility failed to ensure that one resident (R504) reviewed for medication administration remained free from significant medication errors in a sample of 55 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide communication training to the staff. This failure affects 1 resident (R354) out of 55 residents in the sample.

Inspectors wroteBased on interview and record review, the facility failed to deliver mail and not open mail without permission for one (R1) of four residents reviewed for resident rights. R1's clinical record indicates: R1 is a sixty-six-year-old man admitted with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, sleep apnea, type II diabetes, long term use of insulin, major depression, anxiety disorder, and essential hypertension. R1's minimum data set assessment section [C] indicates R1 is alert and oriented, able to make his needs known. On 4/12/25 at 10:58 AM, R1 stated, V2 (Director of Nursing/DON) opened up my mail, and she had no right opening up my personal mail. V2 opened my mail and took my pills, I don't know what the veteran pharmacy sent, how many, or nothing. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to answer a residents (R3) call light timely who is dependent for care. This failure affected 1 out 3 residents reviewed for call light response.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a functioning call device for a dependent resident (R3) who requires assistance from staff. This failure affected 1 out of 4 residents reviewed for resident call system.

Inspectors wroteBased on interview and record review, the facility failed to ensure that an overbed table was maintained in good working condition for one of three residents (R2) reviewed for accidents in the sample of four. This failure resulted in R2 sustaining a fall after the overbed table top she was leaning on detached from the table base. R2's incident report of 1/1/2025, documents in part, resident was sitting in the hallway by the nurses' station in 2E. She was leaning on the bedside table in front of her when the table broke. R2 fell on the floor hitting her right side. 1/21/2025, at 3:20 PM, V4 (LPN-Licensed Practical Nurse) said I was in a resident room with a resident when R2 fell. After I got through with my patient, V3 (Assistant Director of Nursing) told me she (R2) fell; the fall was witnessed by a CNA (Certified Nursing Assistant) and physical therapy. [...]

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff are aware of required LALM (Low Air Loss Mattress) settings, failed to ensure that LALM checks were conducted, failed to ensure the LALM is on the correct setting/mode, failed to implement care plan interventions, failed to turn/reposition dependent residents every 2 hours, failed to ensure that wound assessments were accurate & staged correctly, failed to follow physician orders, and/or failed to ensure that treatments were administered as ordered for four of four residents (R1, R2, R3, R4) reviewed for pressure ulcers. These failures resulted in R1 sustaining a (facility acquired) infected large sacrum decubitus which required surgical intervention and osteomyelitis (bone infection) of the sacrum/coccyx. [...]

Inspectors wroteBased upon record review and interview the facility failed to follow policy procedures, failed to ensure that care plans are accurate, and/or failed to ensure that comprehensive care plans include required problems/focus and/or approaches/interventions for four of four residents (R1, R2, R3, R4) in the sample.

Inspectors wroteBased upon record review and interview the facility failed to ensure that competent nursing staff are available to meet the needs for four of four residents (R1, R2, R3, R4) reviewed for wound care. The facility failed to ensure that the Wound Care Nurse is certified, failed to ensure that wound assessments are accurate, failed to stage wounds correctly, failed to ensure that all Nursing staff are aware of LALM (Low Air Loss Mattress) use requirements, failed to in-service all Nursing staff for LALM use, failed to follow physician orders, failed to ensure that treatment administration is documented on the TAR (Treatment Administration Record), failed to administer treatments as ordered, and failed to follow policy procedures.

Inspectors wroteBased upon record review and interview the facility failed to follow policy procedures and failed to ensure that the Physician, family and/or responsible parties were notified of change in condition for one of four residents (R1) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was labeled, dated, and discarded after use by date and failed to ensure equipment has been immersed in the sanitizer sink for a full minute and then air-dried before use. These failures could potentially affect 100 residents who were to receive meals from the kitchen on 7/16/24.

Inspectors wroteBased on observation, interview, and record review the facility failed to dispose garbage properly in a contained dumpster; ensure garbage receptacles were covered and keep the dumpster area clean and free of garbage or waste to maintain a sanitary condition and to prevent harborage and feeding of pest. These failures could potentially affect all 102 residents that reside in the facility as of census 7/16/24.

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit MDS (Minimum Data Set) records to CMS system using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 10 (R11, R16, R20, R32, R33, R39, R41, R49, R59, R90) of 10 residents reviewed for resident assessment in a sample of 24.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to refrigerate unopened insulin, discard loose tablets and expired medications, defrost medication refrigerators, and double-lock controlled medications from 2 of 2 medication rooms and 3 of 3 medications carts reviewed during medication storage observations.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow their policy to ensure proper infection control guideline practices are followed related to personal protective equipment was not worn prior to entering a contact isolation room for 1 resident (R403), failed to use standard precautions during incontinence care and perform hand washing/hand hygiene for 2 residents (R10, R50), failed to follow their policy to ensure proper infection control guideline practice are followed related to the use of a nasal cannula that was picked up from the floor and was placed in the nostrils of 1 resident (R6) reviewed for infection control in a sample of 24. Findings Include: 1. On 07/17/2024 at 09:45 AM, surveyor observed R403's room had contact isolation sign on her door. [...]

Inspectors wroteBased on record review and interviews the facility failed to offer, educate, and document the benefits and risks of Influenza and Pneumococcal vaccines to 4 (R80, R401, R403, R404) of 5 residents reviewed for vaccinations.

Inspectors wroteBased on record review and interviews the facility failed to offer, educate, and document the benefits and risks of the COVID-19 vaccines to 4 (R80, R401, R403, and R404) of 5 residents reviewed for vaccinations.

Inspectors wroteBased on observation and interview, the facility failed to ensure that a resident's call light was within reach for one resident (R94), in the sample of 24.

Inspectors wroteBased on interviews and record reviews, the facility failed to have an order for a code status for one resident (R153) out of a total sample of 24 residents reviewed for advanced directives.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure incontinence care was provided in a timely manner for 2 (R10 and R50) residents who needed assistance with toileting; and failed to ensure personal hygiene assistance was provided for 1 resident (R51) after returning from the hospital. This failure affected 3 residents (R10, R50, R51) reviewed for ADL (activities of daily living) care in a sample of 24.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to re-evaluate the necessity of a resident's (R83) enteral feeding for one out of a total sample of 24 residents reviewed for nutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen tubing and bubbler were dated and changed and failed to administer oxygen as ordered for 2 residents (R49 and R71) reviewed for respiratory care in a sample of 24.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that one resident (R79) received medication as ordered out of a total sample of 24 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication error rate of less than 5% during medication administration observations. The facility had four medication errors out of 37 opportunities resulting in a 10.81% medication error rate.

Inspectors wroteBased on interviews and record review, the facility failed to properly assess one resident (R1) for skin breakdown; and failed to prevent, recognize and treat a new wound that was acquired in the facility for 1 resident (R1) out of 7 residents reviewed for nursing care. This failure resulted in R1 being sent out to the hospital on 5/29/24 for altered mental status in which it was discovered R1 had a unstageable wound to the sacrum and again R1 was evaluated in the hospital on 6/5/24 where R1's sacral wound extended to the anus and required surgical debridement.

Inspectors wroteBased on interview and record review the facility failed to provide requested medical records for one resident (R1) out of three residents reviewed for medical records request. R1 has a diagnosis which includes but not limited to: Alzheimer's disease, pressure ulcer of left heel stage 4, Alzheimer's disease with early, onset, dementia unspecified severity without behavioral. R1's Minimum Data Set (MDS) dated [DATE] shows no Brief Interview for Mental Status (BIMS) score for R1 which indicates that R1 has some memory impairments. On 01/16/23 at 1:41 pm, V10 (R1's Family Member) stated that R1's family requested R1's medical records from the facility in December 2023. V10 stated that V10 spoke with V1 (Administrator) regarding obtaining R1's medical records and V10 still has not received R1's medical records. [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide sufficient staffing to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for four of four residents (R1, R2, R3, R4) reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for four of four residents (R1, R2, R3, R4) reviewed for ADL care.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illness. This failure has the potential to affect the 87 residents that are served food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly contain waste in the dumpsters. This failure has the potential to affect all 73 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure liquid medications were properly labeled with an open date and ensure that one out of two medication carts reviewed were locked/secured while unattended. These failures have the potential to affect 27 residents residing in the facility. Findings Included: On 08/08/2023 at 9:39AM, an observation of the medication cart (Identified as 1 East Medication Cart) on the first floor of the facility with V4 (Registered Nurse/RN) present revealed the following medication to be opened and undated: Levetiracetam 100mg/ml with R66's name on it. V4 stated that she administered R66 the above medication this morning and that there should be an open date labeled on the medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility has the following failures related to infection prevention and control. The facility failed to clean and disinfect reusable equipment (blood pressure cuff device) used by four residents (R13, R51, R62, and R179). The facility also failed to follow appropriate infection control procedures after using a glucometer on one (R14) of one resident observed for a blood glucose reading in a total sample of 5 residents reviewed during medication administration. Facility also failed to provide access to perform hand hygiene for 1 out of 20 residents (R41) with multiple infections reviewed for facility infection control and prevention practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy to develop and implement a comprehensive person-centered care plan for one (R55) of five residents reviewed in a sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% for two (R13, R179) out of five residents reviewed for medication administration resulting in a 12.12% error rate. Findings Include: R179's Facesheet documents that R179 has diagnoses not limited to major depressive disorder, Parkinson's disease, chronic systolic heart failure, and paroxysmal atrial fibrillation. R179's medication administration record (MAR) dated 08/01/2023 - 08/09/2023 documents: Co Q 10 (Ubidecarenone) 30mg- 1 tab by mouth one time a day. Sertraline 100mg- 1 tablet by mouth one time a day. Review of R179's MAR documents that V9 signed the MAR to indicate that the above medications were given. This documentation does not align with direct observation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy taking in to account preferences of food and beverages for 3 of 3 residents (R53, R52, and R11) during dining observations. These failures have the potential to affect 3 residents (R53, R52, and R11) meal preference and consumption of food and beverage during meals.

Inspectors wroteBased on observations, interviews, and review of records, the facility failed to date and refrigerate food from outside source to 1 out of 1 resident (R41) reviewed for food on the bedside. These failures have the potential to affect 1 resident (R41) in consuming food that are not appropriate for consumption.

Inspectors wroteBased on review of observation, interview, and record review, the facility failed to follow policy on Antibiotic Stewardship Program on tracking antibiotic use of all residents taking antibiotics and indication of antibiotic use by prescriber for 3 out of 5 residents (R41, R49, and R228) reviewed for antibiotic stewardship. These failures have the potential to affect 3 residents (R41, R49, and R228) with the risk of developing resistance with antibiotic.