St Paul's Senior Community

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 18, 2024

  Based on interview and record review the facility failed to ensure proper transfer techniques to prevent falls and injuries for one of 7 residents (R2) reviewed for supervision to prevent falls in the sample of 7. This failure resulted in an Immediate Jeopardy when V8, Certified Nurse's Aide (CNA) transferred R2 incorrectly causing R2 to sustain bilateral femur (thigh) fractures and expiring on 04/14/24. This past non-compliance occurred from 04/11/24 to 04/12/24. The Immediate Jeopardy began on 4/11/24, when V8 attempted to transfer R2 by herself, and R2 falling and sustaining bilateral femur fractures. On 4/17/24, at 2:17 PM, V1, Administrator, V25, Regional Corporation Nurse and V26, Director of Clinical Operations were notified of the Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF684Dec 5, 2023

  Based on interview and record review, the facility failed to maintain residents' highest practicable physical well-being by assessing and providing timely care and treatment of fractures for 1 of 3 residents (R22) reviewed for quality of care in the sample of 43. This failure resulted in R22 not receiving timely care and treatment for three days after a fall. When R22 was sent to the hospital for treatment, it was identified that he had bilateral femur fractures and a dislocated knee. The Immediate Jeopardy began on 11/23/23 when R22 had a syncope episode during a transfer by V14, Certified Nurse's Aide (CNA) with a sit-to stand lift. The facility did not conduct an assessment after this incident to ensure the safest mode of transfer for R22. […]

• Immediate jeopardy, isolatedF689Dec 5, 2023

  A. Based on interview and record review, the facility failed to assess for and provide safe transfer techniques to prevent falls/injury for 1 of 14 residents (R22) reviewed for safe transfer techniques to prevent injury/falls in the sample of 43. This failure resulted in an Immediate Jeopardy when the facility failed to reassess R22 for the safest mode of transfer after having syncope episodes while being transferred with a sit-to stand lift. R22 sustained severely displaced fracture of the right proximal femur shaft, severely comminuted distal left femoral fracture with displacement of the knee joint. […]

• Actual harm, isolatedF695Feb 24, 2025

  Based on observation, interview, and record review the facility failed to ensure respiratory care needs met current standards of practice for 5 of 6 (R1, R2, R4, R5, R6) reviewed for respiratory care. This failure resulted in R1 experiencing chest pain and tightness, shortness of breath and decreased oxygen saturations after R1 did not receive ordered nebulizer treatments. Findings include: 1.R1 was admitted to the facility on [DATE] with diagnoses of, in part, acute on chronic congestive heart failure (CHF), lymphedema and chronic obstructive pulmonary disease (COPD). R1's Minimum Data Set (MDS) dated [DATE], documented R1 is cognitively intact, and is on oxygen therapy. […]

• Actual harm, isolatedF550Feb 10, 2025

  Based on interview, observation, and record review, the facility failed to maintain residents' pride and dignity for 3 of 5 residents (R1, R3, R5) reviewed for resident dignity in the sample of 5. This failure resulted in expressed feelings of embarrassment and frustration. The Findings Include: 1. R1's Admission Record, dated 2/5/25, documents R1 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Malignant Neoplasm of bronchus or lung, Hypertension (HTN), Morbid Obesity, Diverticulosis, Sleep Apnea, Nicotine Dependence, Lymphedema, Pulmonary HTN, Congestive Heart Disease (CHF), and Peripheral Vascular Disease (PVD). […]