Paul House & Health CR CTR

In the surveyor’s words

From the most serious findings on record at Paul House & Health CR CTR, in the surveyor’s own words.

• Actual harm, isolatedF677Jun 5, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure that one (R504) resident who depends on staff assistance for ADL (Activities of Daily Living) care was provided incontinence care and transfer assistance in a timely manner, demonstrating inadequate care in a sample of 55 residents. This failure resulted in R504 suffering psychosocial harm stating feelings of humiliation and embarrassment. Findings include: On 06/02/25 at 11:00am, R504 was observed, in his (R504) room, sitting on the side of bed with a walker in front of him, and R504's call light was wrapped on the bedside table behind R504 not within reach of R504. Surveyor observed urine on the floor below R504 with his (R504) foot lying in the puddle of urine. […]

• Actual harm, isolatedF686Oct 31, 2024

  Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff are aware of required LALM (Low Air Loss Mattress) settings, failed to ensure that LALM checks were conducted, failed to ensure the LALM is on the correct setting/mode, failed to implement care plan interventions, failed to turn/reposition dependent residents every 2 hours, failed to ensure that wound assessments were accurate & staged correctly, failed to follow physician orders, and/or failed to ensure that treatments were administered as ordered for four of four residents (R1, R2, R3, R4) reviewed for pressure ulcers. […]

• Actual harm, isolatedF686Jul 3, 2024

  Based on interviews and record review, the facility failed to properly assess one resident (R1) for skin breakdown; and failed to prevent, recognize and treat a new wound that was acquired in the facility for 1 resident (R1) out of 7 residents reviewed for nursing care. This failure resulted in R1 being sent out to the hospital on 5/29/24 for altered mental status in which it was discovered R1 had a unstageable wound to the sacrum and again R1 was evaluated in the hospital on 6/5/24 where R1's sacral wound extended to the anus and required surgical debridement. […]

• Actual harm, isolatedF677Oct 21, 2023

  Based on observation, interview, and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for four of four residents (R1, R2, R3, R4) reviewed for ADL care. This failure resulted in R1 expressing feelings of shame. Findings include: On 10.21.2023 at 11:33 AM, R1 was observed awake, alert, lying in bed. R1 said he was soiled. 1) R1's medical record (Face Sheet) documents R1 is a [AGE] year-old admitted to the facility on 2.20.2020 with diagnoses including but not limited to: Parkinson's Disease, Venous Insufficiency (Chronic) (Peripheral), Acute Kidney Failure, and Weakness. […]

• Actual harm, isolatedF600Jun 17, 2022

  Based on observation, interview and record review the facility failed to follow abuse policy as follows: Preventing a resident (R2) with cognitive impairment from entering another resident's room without her (R1's) consent and supervision. Resident (R1) has physical limitations and was unable to avoid physical contact. Failures involved 2 out of 3 residents (R1 and R2) for a total of 3 residents reviewed for abuse. These failures resulted to R1 experiencing fear and was placed in a threatening environment. […]