Saint John Paul II Center

In the surveyor’s words

From the most serious findings on record at Saint John Paul II Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 20, 2022

  Based on clinical record reviews, observation, review of facility documentation, review of policy and interviews for one of two sampled residents (Resident #2) reviewed for abuse, the facility failed to ensure the resident was free from sexual abuse and the facility failed to ensure the safety of others following the alleged incident of sexual abuse resulting in a finding of Immediate Jeopardy. The findings include: Resident #2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan (RCP) dated April 2022 identified Resident #2 had impaired cognitive function, impaired thought processes and impaired communication related to dementia. […]

• Immediate jeopardy, isolatedF610Jul 20, 2022

  Based on clinical record review, review of facility's policy and interviews for one resident (Resident #1) who was reviewed for sexual abuse, the facility failed to initiate and thoroughly investigate a potential sexual abuse incident to ensure the safety of other residents from abuse. The findings include: Resident # 1's Admission Record identified the resident was admitted to the facility on [DATE] on a shared secure dementia unit. The nursing admission note dated 2/07/22 identified Resident #1 was an admission from a behavioral health institution with history of behavioral disturbance. […]

• Immediate jeopardy, isolatedF656Jul 20, 2022

  Based on clinical record review, review of facility documentation, review of facility's policy, and interviews for one of two sampled resident (Resident #1) reviewed abuse, the facility failed to develop and implement a comprehensive care plan to address Resident #1's sexually inappropriate behaviors. The findings include: Resident # 1's Admission Record identified the resident was admitted to the facility on [DATE] on a shared secure dementia unit. The nursing admission note dated 2/07/22 identified Resident #1 was an admission from a behavioral health institution with history of behavioral disturbance. […]

• Immediate jeopardy, isolatedF806Jun 8, 2021

  Based on clinical record reviews, review of facility documentation and policies and interviews for one of three sampled residents (Resident #1) who had food allergies, the facility failed to ensure the resident did not receive a food item that resulted in an allergic reaction that resulted in a finding of Immediate Jeopardy. During the on-site visit Immediate Jeopardy was verified as corrected when the facility implemented an immediate action plan to mitigate further risk to all residents. […]

• Actual harm, isolatedF689May 17, 2023

  Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 5 residents (Resident #91, 22 and 124) reviewed for accidents, for Resident #91, the facility failed to provide the physician ordered 1:1 supervision which resulted in a fall with injury, for Resident #22, the facility failed to provide adequate supervision to prevent a fall, and for Resident #124, the facility failed to ensure the bed was locked to prevent a fall, and for 1 of 5 residents (Resident #93) reviewed for unnecessary medications, the facility failed to ensure that pharmacy recommendations were reviewed and implemented for a resident with a history of multiple falls. The findings include: 1. […]