A list of the most recent deficiencies for St. Pauls Health Care 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? |
|---|---|---|---|---|
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-04-10 | 2023-05-16 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-04-10 | 2023-05-16 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-04-10 | 2023-05-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-10 | 2023-05-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-10 | 2023-05-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-10 | 2023-05-16 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2023-04-10 | 2023-05-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-04-10 | 2023-05-16 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2023-04-10 | 2023-05-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-10 | 2023-05-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-04-07 | 2023-05-05 | 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 | 2023-04-07 | 2023-05-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-04-07 | 2023-05-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-07 | 2023-05-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-07 | 2023-05-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-07 | 2023-05-05 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-04-07 | 2023-05-05 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-04-07 | 2023-05-05 | 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 | 2023-04-07 | 2023-05-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-07 | 2023-05-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-07 | 2023-05-05 | 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 | 2023-04-07 | 2023-05-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-04-07 | 2023-05-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-07 | 2023-05-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-07 | 2023-05-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-07 | 2023-03-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-10 | 2022-06-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-12 | 2021-12-21 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-06 | 2021-08-02 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-04-11 | 2019-06-11 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-04-11 | 2019-06-11 | N |
| Use approved construction type or materials. | Fire Safety | 2019-04-11 | 2019-06-11 | 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 | 2019-04-11 | 2019-06-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-04-11 | 2019-06-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-11 | 2019-06-11 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2019-04-11 | 2019-06-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-11 | 2019-06-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-11 | 2019-06-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-03-29 | 2019-05-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-29 | 2019-05-17 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-03-29 | 2019-05-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-29 | 2019-05-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-29 | 2019-05-17 | 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 | 2019-03-29 | 2019-05-17 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-03-29 | 2019-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-29 | 2019-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-29 | 2019-05-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-03-29 | 2019-05-17 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Develop a communication plan. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-04-19 | 2018-05-17 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2018-04-19 | 2018-05-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-04-19 | 2018-05-17 | 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 | 2018-04-19 | 2018-05-17 | 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 | 2018-04-19 | 2018-05-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-04-19 | 2018-05-17 | 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 | 2018-04-19 | 2018-05-17 | 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 | 2018-04-19 | 2018-05-17 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-04-19 | 2018-05-17 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2018-04-19 | 2018-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-19 | 2018-05-17 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-04-19 | 2018-05-17 | N |
