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Deficiency Records for St. Pauls Health Care Center
View the most recent health deficiencies and inspection results for St. Pauls Health Care Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for St. Pauls Health Care Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide enough food/fluids to maintain a resident's health. | Health | 2026-02-07 | 2026-03-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2026-02-07 | 2026-03-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2026-02-07 | 2026-03-06 | Y |
| 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 | 2025-12-09 | 2025-12-19 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2025-09-04 | 2025-10-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-09-04 | 2025-10-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-06-26 | 2025-07-26 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2025-06-26 | 2025-07-26 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2025-06-26 | 2025-07-26 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2025-06-26 | 2025-07-26 | N |
| Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Health | 2025-06-26 | 2025-07-26 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2025-06-26 | 2025-07-26 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2025-06-26 | 2025-07-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-06-26 | 2025-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-06-26 | 2025-07-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-06-26 | 2025-07-26 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2025-06-26 | 2025-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-06-26 | 2025-07-26 | 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 | 2025-06-26 | 2025-07-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-06-26 | 2025-07-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-06-26 | 2025-07-26 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2025-06-26 | 2025-07-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-06-26 | 2025-07-26 | 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 | 2025-06-26 | 2025-07-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-06-26 | 2025-07-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2025-06-10 | 2025-07-03 | Y |
| 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 | 2025-06-10 | 2025-07-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-06-03 | 2025-07-03 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2025-06-03 | 2025-07-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2025-05-02 | 2025-05-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-20 | 2024-07-20 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-04-07 | 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 | 2023-04-07 | 2023-05-16 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-04-07 | 2023-05-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-07 | 2023-05-16 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2023-04-07 | 2023-05-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-04-07 | 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 | 2023-04-07 | 2023-05-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-07 | 2023-05-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-07 | 2023-05-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-07 | 2023-05-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | 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 appropriate treatment and care according to orders, resident?s preferences and goals. | 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 |
| 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 | 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 |
| Keep residents' personal and medical records private and confidential. | 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 (including nights and weekends) 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 |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-29 | 2019-06-11 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-03-29 | 2019-06-11 | N |
| Use approved construction type or materials. | Fire Safety | 2019-03-29 | 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 | 2019-03-29 | 2019-06-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-03-29 | 2019-06-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-29 | 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 | 2019-03-29 | 2019-06-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-29 | 2019-06-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-03-29 | 2019-06-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | 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 |
| 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 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 |
| 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 |
| Ensure medication error rates are not 5 percent or greater. | 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 |
| 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 appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-29 | 2019-05-17 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-03-29 | 2019-05-17 | N |