St. Pauls Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) was free from physical abuse when:Certified nursing assistant (CNA) 6 did not respect Resident 1's request for CNA 6 to stop touching her and to get out of her room. CNA 6 was assigned to provide care to Resident 1 after the resident had a prior complaint regarding CNA 6 and did not want the CNA as a caregiver. The facility received multiple complaints from residents regarding CNA 6's provision of care. The facility did not implement increased supervision of CNA 6 while providing resident care. As a result of these deficient practices:Resident 1 defended herself by grabbing CNA 6's hair to make her stop. CNA 6 attempted to remove the resident's hand causing a skin tear to the resident's left upper arm. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized written care plan for one of three residents (Resident 1) that addressed Resident 1's preference not to have care provided by certified nursing assistant (CNA) 6 after the resident made a complaint about CNA 6. This deficient practice had the potential to cause distress to Resident 1. Cross reference F 600.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive assessment and care plan were followed for one of three residents (Resident 1). As a result, Resident 1's activities of daily living (ADL) care was not provided in a manner that was consistent with her minimum data set assessment (MDS-a comprehensive assessment tool) and written ADL care plan. This had the potential to risk the resident's safety and to cause discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective monitoring, and evaluation of nutritional and hydration needs for 2 of 3 sampled Residents (Resident 2 and Resident 3).1.) Resident 2 experienced a change in oral intake when he was observed pocketing his food (holding food inside the mouth, without chewing or swallowing). The RD did not reassess Resident 2 to determine appropriate interventions, the IDT (IDT- an interdisciplinary team comprised of professionals from various disciplines who work in collaboration to address a resident with multiple physical and psychological needs) did not address Resident 2's change in dietary needs and possible risks to Resident 2's health. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents rights were honored for one of three sampled residents (Resident 5), when the facility asked Resident 5's representative to sign a waiver in response to missing dentures. This failure caused Resident 5 to experience delay in having her lost dentures replaced and had the potential for Resident 5's property to not be safeguarded against loss, theft, or misappropriation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oral care/dentures were provided prior to serving breakfast to one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to experience health complications including choking, aspiration (food enters airway and lungs).

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide a homelike environment for two of four sampled residents (Resident 1 and 2), when it did not maintain a comfortable temperature in one resident room. This failure had the potential to make residents uncomfortable.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (1) received continence care in accordance with professional standards, when staff applied two incontinence briefs improperly with the inner brief folded and a hole cut in the center through which the penis protruded. This failure resulted in swelling and pain for Resident 1 that required hospital evaluation and caused psychosocial harm related to embarrassment. Resident 1 was admitted to the facility on [DATE] with diagnoses of prostatic hyperplasia with lower urinary tract symptoms (and enlarged prostate that can block urine flow) and obstructive and reflux uropathy (urine blocked from leaving the body that flows backwards into the kidney) per the facility face sheet. A review of Resident 1's change in condition form, signed 8/3/25 at 12:37 P.M., by licensed nurse (LN) 1, indicated, . [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff were competent to provide continence care for 1 of 1 sampled residents (1) when competency validation records were not maintained for a night shift (NOC) certified nursing assistant (NOC CNA) from registry (a staffing agency) who was identified in the facility's internal investigation as having improperly applied incontinence briefs. This failure resulted in registry staff providing care without verified competency, which contributed to improper continence care, swelling, pain and psychosocial harm requiring hospital evaluation for Resident 1. [...]

Inspectors wroteBased on interview and record review the facility failed to provide a response and rationale for the Resident Council grievances and suggestions. This failure resulted in the members of the Resident Council voicing that their complaints were unheard, and they were afraid of retaliation from the facility if they filed a grievance.

Inspectors wroteBased on interview and record review, the facility failed to implement gradual dose reductions (GDR, stepwise tapering of a medication to determine if symptoms can be managed at a lower dose) for two of five sampled residents (Residents 17 and 28) on psychotropic (affecting brain activities associated with mental processes and behavior) medications. This failure had the potential for residents to receive unnecessary psychotropic medications which can lead to side effects, such as sedation and falls.

Inspectors wrote2c. A review of Resident 50's admission record indicated the resident was admitted on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) following cerebral infarction (a type of stroke). Resident 50 had a physician's order, dated 6/12/25, for enoxaparin (generic for Lovenox, an anticoagulant) 40 milligrams (mg) injected under the skin every morning for deep vein thrombosis (DVT, life-threatening blood clots in the legs) prevention. During a concurrent interview and record review on 6/25/25 at 11:03 A.M. with Licensed Nurse 1 (LN 1), Resident 50's anticoagulant care plan, dated 5/6/25, was reviewed. The care plan indicated Resident is at risk for active bleeding [due to] use of anticoagulant meds. The care plan further indicated Observe for S/S [signs and symptoms] of bleeding (bleeding gums, epistaxis [nosebleed], hematemesis [vomiting blood] and report. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper pharmaceutical services when: 1. The documentation on Controlled Drug Record (CDR) and Medication Administration Record (MAR) did not reconcile for two of three randomly selected residents (Resident 23 and 45). This failure had the potential for diversion and/or inadequate pain management. 2. The facility did not verify the accuracy of outside medications for three residents (Resident 9, 25, and 306). This failure had the potential for inaccurate medications to be administered to the residents. 3. The medication storage room and its refrigerator temperature logs were missing entries. This failure had the potential for undetected inappropriate temperature storage which could alter the efficacy of medications.

Inspectors wroteBased on interview and record review, the facility failed to respond to the consultant pharmacist's monthly medication regimen review (MRR) recommendations for two of five sampled residents (Residents 17 and 28). This failure had the potential for unaddressed medication irregularities and inadequately monitored medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure four sampled residents (Residents 50, 32, 13, and 3) were free of unnecessary medications when: 1. Residents 50, 13, and 3 received anticoagulant (blood thinner) medications without staff monitoring for signs and symptoms of side effects; and 2. Resident 32 received an inappropriate dose of insulin and was not monitored for hypoglycemic (low blood sugar) side effects. These deficiencies had the potential to cause harm due to lack of monitoring for negative side effects of anticoagulant therapy, including excessive bleeding or bruising, and hypoglycemic side effects, including hunger, profuse sweating and tremors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications/biologicals were labeled and stored according to acceptable standards of practice when: 1. Medication and medication Vials were stored opened and undated. 2. There were expired vials and medications stored in medication carts and the medication storage room. 3. Medications in the medication room and medication refrigerator were not stored in the acceptable range of temperatures. 4. An unauthorized facility staff had access to the medications in the medication room. These failures had the potential for medications to be ineffective and potentially harmful to residents. In addition, the medications were not stored securely from unauthorized access.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate infection prevention and control practices when: 1. A nurse did not disinfect the rubber seal (the point of connection between the needle and the body of the pen) of a multi-dose insulin pen while preparing the medication for one resident. 2. A nurse did not clean the blood pressure machine after it was used for one resident. 3. Expired and opened intravenous (IV, into the vein) access supplies and wound treatment supplies were not removed from the carts. 4a. Staff did not provide an opportunity for hand hygiene for 12 residents (Resident 44, 6, 10, 309, 7, 24, 29, 23, 16, 47, 12, 255) before eating lunch. 4b. Two staff did not wash their hands after leaving an isolation room where a Resident (308) was positive for Clostridium difficile (C-diff, a bacteria that causes infectious diarrhea). 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a physician obtain informed consent (process in which a health care provider educates a patient about the risks, benefits, and alternatives of an intervention in order to obtain agreement or permission for care) for two of five sampled residents (Residents 17 and 28) on psychotropic (affecting brain activities associated with mental processes and behavior) medications. This failure had the potential for residents or their representatives to not be fully informed of the risks and benefits of psychotropic medications before receiving treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's (Resident 13) personal property (a jar of grape jelly) was treated with dignity and respect when the facility did not communicate the food storage policy to the resident prior to disposal of their property. This deficiency violated Resident 13's rights for dignity and respect.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary for one of three residents (Resident 5) during a closed record review. This failure had the potential for the receiving facility to not receive accurate and timely medical information regarding Resident 5's health status and needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing staff fed one of 12 residents (Resident 29) who required feeding assistance. As a result of this deficient practice, Resident 29 received feeding assistance from the Activity Coordinator (AC) who was not qualified. The resident could have experienced choking and was at risk for aspiration. (cross reference F689)

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one (Resident 28) of two sampled resident's Low Air Loss (LAL) mattress was functioning properly. This failure had the potential for Resident 28 to experience skin breakdown and develop pressure ulcers.

Inspectors wroteBased on interview and record review, the facility did not ensure two of four Residents (3, 17) that were reviewed received Restorative Nursing Assistant (RNA) services as ordered by the physician. As a result, Resident 3 and Resident 17 had the potential to experience a further decline in range of motion (ROM).

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident 29) was provided a safe and physician ordered snack when the Activity Coordinator (AC) gave the resident baby teething crackers. As a result of this deficient practice, Resident 29 could have experienced choking and was at risk for aspiration. (cross reference F659)

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure 4 of 37 administered medications were given in accordance with the physician orders and manufacturer's instructions for two of six residents (Resident 33 and 50). This failure resulted in a 10.81% medication error rate and the potential to affect resident safety and medication effectiveness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety in dietary services were maintained for food storage according to standards of practice when the facility did not ensure the dry food storage room and two of three refrigerator (Unit 2 and Unit 6)temperatures were monitored consistently. These failures had the potential to cause food borne illness among the residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to identify and develop an ongoing QAPI (Quality Assurance and Performance Improvement) plan related to medication storage. (Cross reference F761) This failure had the potential for residents to receive expired medications and supplies.

Inspectors wroteBased on interview and record review the facility failed to prevent multiple significant medication errors when oxycodone/apap (a narcotic pain medication mixed with acetaminophen, also known as Percocet) was administered to one sampled resident (Resident 1), nine times without a physician's order. As a result, Resident 1 was placed at risk for serious adverse drug effects including, oversedation, respiratory depression, or medication interaction, due to repeated administration of a controlled substance without physician oversight or a valid prescription. In addition, the controlled drug record (CDR) used to record the Percocet administration was handwritten and lacked essential labeling information contributing to repeated errors and broader concerns with medication labeling and storage practices. (See tag F761)

Inspectors wroteBased on observation interview and record review the facility failed to ensure that controlled substances were properly labeled and stored for one of two sampled Residents (1) during a medication cart audit when: 1. The facility did not remove discontinued controlled medications from Resident 1's active stock in the north wing medication cart 2. The facility failed to secure and label a bottle of oxycodone/apap (a narcotic pain medication mixed with acetaminophen, also known as Percocet) brought into the facility by Resident 1 which allowed the narcotic to remain in the medication cart and be administered without a valid physician's order (PO, see F760). As a result, resident 1 was given an unprescribed narcotic and was placed at increased risk for administration of additional discontinued unprescribed narcotics due to improper labeling and storage.

Inspectors wroteBased on observation, interview and record review the facility failed to notify the attending physician of an abuse allegation for one of two sampled residents (Resident 1) reviewed for abuse. As a result, the attending physician was not aware of the abuse allegation placing Resident 1 at risk for further abuse. In addition, there was a potential for Resident 1 to not have appropriate safe interventions and physician evaluation.

Inspectors wroteBased on interview and record review the facility failed to comply with the current state regulation on maintaining a complete information as to past employment and qualifications. As a result, the facility had no record of employees' past employment history or references and qualifications.

Inspectors wroteBased on interview and record review the facility failed to correctly administer a wound treatment medication for one of four sampled residents reviewed for medication errors (Resident 1). As a result, wrong wound treatment medication was administered. In addition, this failure has the potential to delay Resident 1 ' s wound healing.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete post fall assessments and resident centered fall preventive measures for four of four residents reviewed for complete resident records. (Residents 1, 2, 3 and 4) This failure had the potential for residents to have repeated fall incidents.

Inspectors wrote2. A review of Resident 21's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Wegener's Granulomatosis with renal involvement (a rare blood vessel disease that can cause symptoms in the kidneys) and long term current use of anticoagulants (a blood thinning medication). On 4/4/23 at 3:15 P.M., an observation and interview were conducted with Resident 21. Resident 21 was in bed, on a low air loss mattress (a mattress designed to prevent and treat pressure wounds). Resident 21 was noted to have dark purple bruising from her elbow to her hand on her right side. Resident 21 had areas of redness on her mid forearm and two locations with steri-strips on her right side. Resident 21 was noted to have dark purple bruising from her wrist to her knuckles on her left side. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all nursing staff including registry staff (nursing staff provided by a staffing agency) had the necessary training and competencies (measurable pattern of knowledge, skills, abilities, and behaviors, and other characteristics to perform occupational functions successfully) to care for residents with a history of trauma and/or post-traumatic stress disorder (PTSD). In addition, staff providing care to Resident 2 and Resident 24 were unaware of the resident's PTSD diagnosis and history of trauma. This failure had the potential for residents with a history of trauma and/or PTSD to experience triggers and retraumatization that would compromise the residents' safety and their ability to achieve their highest practicable physical, mental, and psychosocial well-being. (Cross reference F699 and F838)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 3 of 5 residents (Resident 1, 42 and 9) were free from unnecessary use of psychotropic medications (any drug affecting behavior, mood, thoughts, or perception) when: 1. A Gradual Dose Reduction (GDR) was not completed for Resident 42. 2. Resident 1 and Resident 42 did not have an approved indications for the use of an antipsychotic medication. 3. Resident 9's sleepiness was not identified as a possible side effect of the resident's psychotropic medications. This failure had the potential for Residents to experience unnecessary side effects from the psychotropic medication.

Inspectors wroteBased on interview and document review, the facility failed to update the facility assessment to reflect the facilities staffing challenges, the usage of staffing agencies, and address the required training and competencies for agency staff, who cared for the facility residents. This failure had the potential to affect the residents' care due to agency staff's lack of training and knowledge. (Cross reference F-tag 699 and F-tag 741)

Inspectors wroteBased on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining, and improving safety and quality in nursing homes) did not identify areas of improvement in the facility's staff education with regard to Trauma Informed Care. (Cross reference F-tag 699 and F-tag 741) This failure placed any residents admitted to the facility with diagnosis of Post Traumatic Stress Disorder (PTSD - occurs in some individuals who have encountered a shocking, scary, or dangerous situation) and history of trauma at increased risk for emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to fully implement infection control standards of practice when hand hygiene (using alcohol-based hand gel or performing hand washing with soap and water) was not performed before and after direct contact with residents, before and after glove use, and before and after providing feeding assistance to a resident (Resident 29). In addition, a resident's oxygen tubing was not stored properly and did not have a date of when it was first used or changed. These failures had the potential to spread infection and disease among residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of 15 residents' (Resident 20, 40, 25, and 14) privacy and confidentiality was respected and maintained when: 1. Staff entered Resident 20 and Resident 40's private space without knocking or announcing themselves. 2. Resident 25 and Resident 14's clinical documentation was found within other residents' medical records. As a result of this deficient practice, the residents had the potential to feel disrespected. In addition, there was a potential for residents' private medical information to be accessed by unauthorized individuals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 15 residents (Resident 22), reviewed for homelike environment, had a landing mat (a cushioned device similar in shape and size to a mattress that was used to prevent injury if the resident were to fall out of bed) that was maintained in an acceptable condition. As a result, there was the potential for Resident 22's comfort and safety to become compromised.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide communication devices for two of four residents (Resident 24 and Resident 1) reviewed for communication. This failure had the potential for a lack of communication and residents' inability to have their needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate care for one of three residents (Resident 14) reviewed for hospice services. This failure had the potential for Resident 14 to suffer harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free of accident hazards for one of three residents (Resident 14) reviewed for accidents. This failure had the potential for Resident 14's to suffer harm from a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 16), had her suction equipment (system that removes/sucks up secretions) adequately maintained. This failure had the potential to result in inadequate clearance of Resident 16's oral secretions causing respiratory distress (trouble breathing).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure one of two residents (Resident 24) received Trauma Informed Care (TIC- an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health). This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure three of 30 administered medications were given in accordance with the physician orders. This failure resulted in 10% medication error rate. In addition, failure to administer medications in accordance with the physician order had the potential to affect resident safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food items in the kitchen and in a resident's room (Resident 3) were stored according to professional standards for food safety. As a result, there was the potential for residents to be exposed to contaminated food and/or experience foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to explain care to a resident in their native language for 1 of 13 sampled residents (10). As a result the facility did not identify language as a precipitating factor to Resident 10's combative behavior.

Inspectors wroteBased on observation, interview, and record review, 1 of 13 residents (7) was not correctly positioned when sitting in a wheel chair. As a result this practice had the potential for Resident 7 to develop a pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure call lights were answered in a timely manner to address resident needs for five residents interviewed on initial tour of the facility, and one resident from the confidential group interview. This failure had the potential to affect the physical and psychosocial well-being of these residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement procedures for the provision of pharmaceutical services to meet the needs of three of three residents (23, 17, and 99) reviewed during medication pass. 1. The facility failed to administer medications in accordance with the physician's order when metoprolol tartrate (medication used to treat high blood pressure) was administered at half the prescribed dose for more than one month to Resident 23. This failure posed the potential to have a negative effect on the resident's health. 2. The facility failed to ensure accurate documentation of Residents 17 and Resident 99's controlled medications. These failures posed the risk for diversion of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% when the physician's orders were not followed for two of 33 residents reviewed for medications (Residents 9 and 23). 1. Furosemide (medication used to treat fluid retention and swelling) was not available for administration for Resident 9 as ordered by the physician. 2. Metoprolol tartrate (medication used to treat high blood pressure) was not given to Resident 23 as ordered by the physician. These failures posed the potential to negatively affect the residents' health and resulted in a medication error rate of 6.06%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored as per the facility's policy and procedure when one of one medication storage rooms were observed. 1. An expired anti-diarrheal (loperamide) bottle, an expired triple antibiotic ointment box, and an expired container of 10% Zinc Oxide Adult Barrier Spray were removed from the medication storage room. 2. One vial of opened Influenza vaccine Afluria 5 ml was not dated when opened. These failures had the potential to result in unsafe administration of medications.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide palatable food at a desired temperature for 5 of 12 residents interviewed during initial tour. This failure had the potential to affect the residents' meal intake and enjoyment of their meals.

Inspectors wroteBased on observation, interview and record review, the facility did not assure fresh (within food safety guidelines) produce was available for use when preparing residents meals. This created the potential for unsafe food consumption.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented for 1 of 13 residents (97) who had a catheter (hollow flexible tube used to drain urine from the bladder) when Resident 97's urine drainage bags were not properly positioned. This failure created the potential for Resident 97 to be exposed to germs in his urinary tract.

Inspectors wroteBased on interview and record review the facility failed to ensure one of five sampled residents (39) received the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations upon admission to the facility. This failure had the potential to place Resident 39 at risk for acquiring, transmitting, or experiencing complications from pneumococcal disease (bacteria which causes pneumonia - infection in the lung).