St. Paul's Towers

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that one of three sampled residents (Resident 1) was treated with respect and dignity. While providing care to Resident 1, Resident 1 punched Certified Nursing Assistant (CNA) in the chest. CNA responded to Resident 1, If you hit me, I will hit you back. Resident 1's family member was in the room and heard CNA 1's comment. This failure had the potential to cause emotional distress to Resident 1 and/or Resident 1's family member. During a record review of the Resident 1's Face Sheet, dated July 28, 2026, the Face Sheet indicated diagnoses of dementia (diseased or injured brain cells that affect thinking, communication, and mood) and trouble with daily tasks. During an interview on 7/8/26 at 1:12 p.m., with CNA about the incident, CNA stated remembering the incident well. CNA stated Resident 1 was aggressive at times. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. A braising pan, a rolling pin, three storage bins, a citrus juicer, a kitchen drawer, and a juice dispenser machine had black particles/residue or chipped paint, 2. Nine balsamic dressing containers, cut lettuce, cut tomatoes, mayonnaise, bag of bread, mozzarella cheese, burrata cheese, and a bag of prosciutto had no use-by date or had beyond use-by-dates, 3. Three compartment sink's pipe had a leak and a toilet plunger was stored under the three-compartment sink (a sink with three compartments that allows kitchen staff to wash, rinse, and sanitize dishes), and 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when the dumpsters were not closed and a laundry bin was used as garbage receptacle. This failure had the potential of harborage and feeding of pest.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure standards of professional practice were maintained during medication administration for one of two sampled residents (Resident 80) when licensed nurse left Resident 80's Oxycontin tablet (a controlled substance used to treat moderate to severe pain) on top of the medication cart unattended. This failure had a potential for unauthorized access to the medication that could lead to harm or drug diversion (occurs when a medication is taken for use by someone other than whom it is prescribed).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 82) was free from unnecessary drug when Resident 82's PRN (pro re nata [a Latin phrase], meaning as needed, or as necessary) order for Oxycodone-Acetaminophen (a controlled substance used to help relieve moderate to severe pain) had no clear indications when to give one tablet versus two tablets. This failure had the potential to result in unnecessary use of Oxycodone-Acetaminophen medication without proper indication, placing Resident 82 at risk for adverse side effects and health safety issues.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 10) was free from unnecessary psychotropic drugs (medications that are capable of affecting the mind, emotions, and behavior) when Resident 10's PRN (pro re nata [a Latin phrase], meaning as needed, or as necessary) order for Temazepam (used on a short-term basis to treat difficulty falling asleep or staying asleep) had no end date and rationale for continued use beyond 14 days. This failure had the potential to result in unnecessary prolonged use of a psychotropic medication, placing Resident 10 at risk for adverse side effects and health safety issues.

Inspectors wroteBased on observation, interviews and record review, the facility failed to follow proper sanitation and food storage practices when: - The High temperature dishwasher was not within the required temperature range - Kitchen floor tiles had brownish residual discoloration - Juice dispenser had a brownish substance around the nozzle - Food prep refrigerator had brownish debris at the bottom shelf area. - One 5 LB (pound) can of creamy peanut butter was past the used-by-date 9/22/22 - Food steamer with brownish substance and crumbs at the bottom shelf area. These deficient practices had the potential to result in foodborne illness and did not ensure sanitary conditions.

Inspectors wroteBased on observation, interview, and record review, for two of two sampled residents (Resident 18 and Resident 23) who were unable to carry out activities of daily living, the facility failed to provide foot care and treatment as follows. 1. Resident 23's toenails were long and had jagged edges. This failure had the potential for toenail trauma and foot complications related to diabetes (blood sugar disorder). 2. Resident 18 did not receive podiatry services (services provided by a foot specialist doctor) for the resident's long, thick, and yellowish toenails as ordered by the physician. This failure had the potential for toenail trauma.

Inspectors wroteBased on observation, interview and record review, for one of one (Resident 76) investigated for accident hazards, the facility failed to ensure Resident 76's environment was free from accident hazards when personal belongings were not within reach. This failure had the potential to result in another fall episode.

Inspectors wroteBased on interview and record review the facility failed to have a Registered Nurse (RN) coverage for at least 8 consecutive hours a day on 10/2/22, 10/8/22, and 10/9/22. This deficient practice had the potential to cause delayed delivery of necessary assessment and treatment services for residents day-to-day care.

Inspectors wroteBased on observation, interview, and record review, for one of five residents (Resident 78) observed for medication pass administration, the facility failed to provide pharmaceutical services when calcium-citrate-magnesium tablets were not available for medication administration. This failure had the potential to result in low blood calcium levels for Resident 78.

Inspectors wroteBased on interviews and record review, the facility did not follow their policy and procedure for Medication Regimen Review (MRR) and failed to act upon the Consultant Pharmacist's (CP) report of the medication irregularities for two (Resident 20 and 75) sampled residents when; 1. Resident 20, had CP recommendations to taper and decrease or discontinue use of Metformin ER (extended release medication to treat diabetes, a blood sugar disorder), Jardiance (diabetes), Effexor ER, Wellbutrin (antidepressant) and Pramipexole (treats symptoms of Parkinson's disease, a disorder of the central nervous system that affects movement, tremors) did not include the physician's medical/clinical rationale for continuing or disagreeing with the MRR recommendations. 2. For Resident 75, the CP recommendation was not acted upon in a timely manner. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure two sampled residents (Resident 13 and 20) were free from unnecessary drugs when; -Resident 13 was administered Olanzapine (Zyprexa-an antipsychotic) medication without appropriate indication for use. -Resident 20 was administered Rexulti and Bupropion HCL ER (antidepressants) without adequate monitoring of behavior manifestations. {Psychotropic drug is any drug that affects brain activities associated with mental processes and behavior} {According to the manufacturer, Zyprexa is not approved for use in older adult with dementia-related psychosis}. [Reference: https://www.drugs.com/pro/zyprexa.html]. This deficient practice had the potential for residents to receive unnecessary medications and adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed five percent (%) or greater when three medication errors were observed out of 25 opportunities for error that totaled 12%. The medication error rate was calculated as follows: three divided by 25, then multiplied by 100, which equaled 12%. 1. a. For Resident 75, the Licensed Vocational Nurse (LVN) 5 did not give instructions on how to use Spiriva (an inhaler medication to treat asthma [a condition when a person's airways become inflamed, narrow and swell which makes it difficult to breathe]) prior to handing the medication to Resident 75 for administration. b. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure proper garbage and refuse disposal when bags of garbage were stored in a dumpster without lids outside the kitchen area. This failure had the potential for foul odors and attract unwanted pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the policy and procedure and act upon the pharmacist's identified medication irregularities on the Medication Regimen Review (MRR) report for three (Residents 1, 6, 26) of 15 sampled residents as follows: 1. For Resident 1, the monitoring of digoxin (heart medication) to ensure maximal efficacy and minimal risk for digoxin toxicity. 2. For Resident 26, the monitoring of serum blood levels of potassium and magnesium related to digoxin therapy, including the blood pressure (BP) hold (do not give) parameters ordered by the physician which was not implemented. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist and provide one (Resident 22) of 15 sampled residents with dental services in a timely manner. This failure resulted in Resident 22's denture discomfort, the inability to eat preferred foods, and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared and stored in a sanitary manner when: 1. Inside the walk-in refrigerator # 1 and # 2, there were multiple food items that were stored beyond their use-by date. 2. The walk-in (#3) freezer had a frosty interior with build-up of formed ice from the ground and up to the ceiling. Multiple boxes inside the freezer were also frosty that included 11 containers of beef broth. A container of multiple packages of beef liver was on the freezer floor. 3. A dietary staff entered the kitchen and walked back and forth near the trayline without wearing a hair cover. 4. The ice machine in the kitchen was not sanitized according to the manufacturer's instructions. These failures had the potential to result in food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for three (Residents 1, 6, 22) of 15 sampled residents when staff did not develop a plan of care for Resident 1's Chronic Congestive Heart Failure [CHF -heart does not pump blood adequately] and monitor for digoxin (heart medication) toxicity, Resident 22's dental issues and concerns that could effect the nutritional intake, and monitor Resident 6's Seroquel (antipsychotic medication used to treat hallucinations, delusions, severe depression .) for potential side effects. These failures had the potential for Residents 1, 6, and 22 to not receive individualized care based on their medical and nursing assessments and planned accordingly to meet the residents' care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication and biologicals were current and safe for use on residents when one bottle of Aspirin (medication used for pain, inflammation or blood thinning), and two bottles of glucometer (a blood glucose monitoring device) control solutions were expired. This failure had the potential to put the residents at risk for receiving medication that was not effective beyond their expiration dates, and inaccurate test results from using expired glucometer control solutions.

Inspectors wroteBased on observation, interview, and record review, for one of 12 sampled residents (Resident 6), the facility failed to ensure that Resident 6 was given antipsychotic (medication that treats psychosis) medication for a specific documented condition when Resident 6 was given Seroquel (an antipsychotic) without an identified target behavior. This failure had the potential to result in the unnecessary continued use of antipsychotic medication without a clear medical indication for its use and had the potential for adverse side effects.