St Paul Elder Services, Inc

In the surveyor’s words

From the most serious findings on record at St Paul Elder Services, Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 25, 2021

  Based on observation, interview, and record review, the facility did not ensure that 1 Resident (R) (R1) of 3 residents reviewed had adequate supervision to prevent accidents during mechanical lift transfers. On [DATE], a Certified Nursing Assistant (CNA) attempted to transfer R1 from a shower chair to R1's bed with a Hoyer, full-body mechanical lift without a second staff member to assist as directed in R1's care plan. R1 fell to the floor from the lift sling and sustained subarachnoid and subdural hemorrhages (bleeding in the space between the brain and the surrounding brain membranes) from the fall. R1 was transferred to the hospital and expired three days later on [DATE] due to the brain bleed sustained in the fall. […]

• No harm, potential for more than minimal, widespreadF812Feb 9, 2022

  Based on observation and interview, the facility did not maintain a safe and sanitary environment in which food was prepared, stored, and distributed which had the potential to affect 95 of 96 residents at the facility. One resident received nutrition via tube feeding. Food Storage -Surveyor observed multiple expired and unlabeled food and drink items, in the dry storage and cooler areas, available for service in the main floor kitchen. -Surveyor observed multiple expired and unlabeled food and drink items, in the dry storage and cooler areas, available for service in the prep kitchen. […]

• No harm, potential for more than minimal, patternF600Jun 16, 2025

  Based on staff and resident interview and record review, the facility did not ensure the environment was free from abuse for 7 residents (R) (R2, R4, R10, R11, R3, R1, and R9) of 11 sampled residents. R2 was involved in 8 resident-to-resident altercations between 1/25/25 and 5/29/25. The facility added interventions to R2's care plan and moved residents who might trigger R2 off the unit in an attempt to prevent future incidents, however, the interventions implemented failed to prevent further resident-to-resident altercations and instances of abuse. Findings include: The facility's Resident Protection and Prevention and Investigation of Abuse, Neglect, Misappropriation, Exploitation, Caregiver Misconduct, and Injuries of Unknown Source policy, revised 10/2022, indicates: .4. […]

• No harm, potential for more than minimal, patternF812Apr 2, 2025

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect more than 4 of the 98 residents residing in the facility. Food items were not labeled with received, opened, or use-by dates. Staff did not the ensure the temperature of the activity freezer was monitored to ensure resident food was stored safely. Cook (CK)-F and CK-E did not wait two minutes to temp microwave reheated food to ensure the food was heated evenly. Findings include: During a continuous kitchen observation that began at 11:30 AM on 4/1/25, Director of Dining (DD)-D indicated the facility follows the Wisconsin Food Code. […]

• No harm, potential for more than minimal, isolatedF580Mar 26, 2026

  Based on staff interview and record review, the facility did not ensure a provider was notified of a change in condition for 1 resident (R) (R1) of 3 sampled residents.The facility did not notify a provider and obtain an order when staff increased R1's oxygen (O2) to 4 liters per minute (LPM).Findings include:The facility's Condition or Status Change policy, revised 7/2023, indicates: 1. The nurse notifies the resident's physician or on-call physician when there has been: .c. A significant change in the resident's physical, emotional, or mental condition, including diagnostic testing results that are abnormal.Between 3/25/26 and 3/26/26, Surveyor reviewed R1's medical record. […]