St. Pauls Health Care Center

In the surveyor’s words

From the most serious findings on record at St. Pauls Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600May 11, 2026

  Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) was free from physical abuse when:Certified nursing assistant (CNA) 6 did not respect Resident 1's request for CNA 6 to stop touching her and to get out of her room.CNA 6 was assigned to provide care to Resident 1 after the resident had a prior complaint regarding CNA 6 and did not want the CNA as a caregiver.The facility received multiple complaints from residents regarding CNA 6's provision of care. The facility did not implement increased supervision of CNA 6 while providing resident care.As a result of these deficient practices:Resident 1 defended herself by grabbing CNA 6's hair to make her stop. […]

• No harm, potential for more than minimal, widespreadF732Aug 12, 2026

  Based on interview and record review, the facility failed to post nursing staffing information which reflected the actual working hours of the staff responsible for resident care. As a result, the facility's staffing information reflecting actual hours worked were not reviewed and monitored by the facility. Findings: On 8/12/26 at 9:10 A.M., a record review and an interview were conducted with the Unit Coordinator (UC). UC stated he was responsible for the nursing staffing schedule. The facility's Census and Direct Care Service Hours Per Patient Day (DHPPD, also called form 612, official document used by skilled nursing facilities to ensure facilities meet state minimum staffing standards) was reviewed from April 2026 to August 2026. […]

• No harm, potential for more than minimal, widespreadF812Aug 12, 2026

  Based on observation, interview and record review the facility failed to maintain food storage in a sanitary manner.These failures had the potential to cause food borne illnesses for 55 residents. Findings:On 8/9/26 at 8:14 A.M., a concurrent inspection and interview was conducted with the Facility [NAME] (Cook 1). The following expired items were found in a reach-in refrigerator: 1) An unopened container of mozzarella cheese with a handwritten label indicated prepped 7/6/26; use-by 7/15/26. […]

• No harm, potential for more than minimal, patternF692Feb 7, 2026

  Based on observation, interview, and record review, the facility failed to ensure effective monitoring, and evaluation of nutritional and hydration needs for 2 of 3 sampled Residents (Resident 2 and Resident 3).1.) Resident 2 experienced a change in oral intake when he was observed pocketing his food (holding food inside the mouth, without chewing or swallowing). The RD did not reassess Resident 2 to determine appropriate interventions, the IDT (IDT- an interdisciplinary team comprised of professionals from various disciplines who work in collaboration to address a resident with multiple physical and psychological needs) did not address Resident 2's change in dietary needs and possible risks to Resident 2's health. […]

• No harm, potential for more than minimal, patternF565Jun 26, 2025

  Based on interview and record review the facility failed to provide a response and rationale for the Resident Council grievances and suggestions. This failure resulted in the members of the Resident Council voicing that their complaints were unheard, and they were afraid of retaliation from the facility if they filed a grievance. Findings: On 6/23/25 at 2:44 P.M., an interview was conducted with the Resident Council President (RCP). The RCP stated call lights issues have been frequently discussed in Resident Council and the facility is aware and don't do anything about it. […]