Paul's Run

In the surveyor’s words

From the most serious findings on record at Paul's Run, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Oct 18, 2024

  Based on observations, review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to implement enhanced barrier precautions for eight of eight residents reviewed (Resident R16, R48, R82, R88, R416, R4, R1 ) Findings Include: Review of facility policy dated November 2023 Enhanced Barrier Precautions revealed it is the policy of the facility to use enhanced barrier precautions with residents who are at risk for acquisition and colonization of multidrug resistant organisms (MDRO's). The use of Enhanced Barrier Precautions is indicated during high contact resident care activities for residents with chronic wounds and/or indwelling devices regardless of MDRO colonization. […]

• No harm, potential for more than minimal, isolatedF684Jul 22, 2026

  Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to provide care and services in accordance with professional standards for one of three residents reviewed (Residents R7).Findings Include: Review of Resident R7's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of Parkinsons's disease (progressive neurological disorder that primary affects movement), hypertension (high blood pressure), and atrial fibrillation (irregular heart rhythm). Review of Resident R7's medication regimen review, dated June 30, 2026, revealed Paroxetine together with apixaban may increase the risk of bleeding. The interaction may be more likely with kidney or liver disease. […]

• No harm, potential for more than minimal, isolatedF609Aug 29, 2025

  Based on review of clinical record, facility documentation, and interviews with staff, it was determined that the facility failed to report a resident's fall incident and bruise to the local State agency as required for one of four residents reviewed for falls (Resident R14).Findings include:Review of facility policy Investigating Incident Reports and Adverse Events, not dated, revealed all adverse events occurring to residents will be investigated for root cause and to rule out abuse and neglect. […]

• No harm, potential for more than minimal, isolatedF689Aug 29, 2025

  Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to ensure adequate assistance was provided during transfer for one resident which resulted in a fall incident for one of three residents reviewed for falls (Resident R14).Findings include:Review of facility policy Fall Prevention Protocol, not dated, revealed each resident residing at this facility will be provided services and care that ensures that the resident's environment remains as free from accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents. […]

• No harm, potential for more than minimal, isolatedF692Aug 29, 2025

  Based on review of clinical records, facility policy, and interviews with staff, it was determined that the facility failed to ensure the resident was assessed after a significant weight loss for one of three residents reviewed for weight loss (Resident R75). Review of facility policy Recording the Weight of Each Resident, dated 2024, revealed if the resident's weight has 5% or greater change from the previous month the nursing staff is responsible to re-weigh the resident within 48 hours. If after the re-weight is completed, the resident shows a 5% weight gain or loss, the dietitian will notify the IDT and complete proper documentation. The nursing staff or designee will alert the appropriate individuals of significant changes. […]