A list of the most recent deficiencies for St Paul Health Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-01-11 | 2024-02-23 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-11 | 2024-02-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-11 | 2024-02-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-12 | 2023-12-21 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-11-06 | 2023-12-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-12 | 2023-11-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-06 | 2023-11-16 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-11-06 | 2023-11-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-12 | 2023-11-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-10-12 | 2023-11-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-12 | 2023-11-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-12 | 2023-11-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-12 | 2023-11-11 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-10-12 | 2023-11-11 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-12 | 2023-11-11 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-10-12 | 2023-11-11 | N |
| Provide activities to meet all resident's needs. | Health | 2023-10-12 | 2023-11-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-12 | 2023-11-11 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-10-12 | 2023-11-11 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-10-12 | 2023-11-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-12 | 2023-11-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-12 | 2023-11-11 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-12 | 2023-11-11 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-06-01 | 2023-07-01 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-02 | 2022-08-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-14 | 2022-08-18 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-08-02 | 2022-08-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-02 | 2022-08-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-02 | 2022-08-18 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-08-02 | 2022-08-18 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-07-14 | 2022-08-12 | N |
| Respond appropriately to all alleged violations. | Health | 2022-07-14 | 2022-08-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-14 | 2022-08-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-07-14 | 2022-08-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-14 | 2022-08-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-14 | 2022-08-12 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-07-14 | 2022-08-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-14 | 2022-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-14 | 2022-08-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-04 | 2021-06-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-05-04 | 2021-05-21 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-04-15 | 2021-05-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-15 | 2021-05-14 | N |
| Respond appropriately to all alleged violations. | Health | 2021-04-15 | 2021-05-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-04-15 | 2021-05-14 | N |
| Provide activities to meet all resident's needs. | Health | 2021-04-15 | 2021-05-14 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-04-15 | 2021-05-14 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-04-15 | 2021-05-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-15 | 2021-05-14 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-04-15 | 2021-05-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-15 | 2021-05-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-04-15 | 2021-05-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-04-15 | 2021-05-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-04-15 | 2021-05-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-15 | 2021-05-14 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-04-15 | 2021-05-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-15 | 2021-05-14 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-04-15 | 2021-05-14 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-04-15 | 2021-05-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-15 | 2021-05-14 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-04-15 | 2021-05-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-15 | 2021-05-14 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-04-15 | 2021-05-14 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-04-15 | 2021-05-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-15 | 2021-04-30 | N |
