The Villas at St Paul

In the surveyor’s words

From the most serious findings on record at The Villas at St Paul, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 26, 2026

  Based on observation, interview, and document review, the facility failed to provide adequate supervision to prevent elopement for 1 of 1 residents (R37) who was reviewed for elopement. This resulted in Immediate Jeopardy (IJ) for R37 when she left the facility and was found approximately 4.5 miles away at her previous home by neighbors, which placed R37 at likelihood for serious harm or death. The IJ began on 8/30/25, when R37 exited the building without staff awareness. An unknown culinary staff had witnessed R37 outside and informed registered nurse (RN)-A who searched and was unable to find R37. […]

• Immediate jeopardy, isolatedF600Apr 12, 2021

  Based on observation, interview, and document review, the facility failed to protect residents from physical and verbal abuse for 2 of 3 residents (R5, R6) reviewed for abuse. This deficient practice resulted in an immediate jeopardy (IJ) when R4 hit R5 in the face while he lay in bed and later attacked R5 who fell out of his wheelchair, and verbally abused R6. The IJ began on 4/5/21, at approximately 11:24 p.m. when R4 punched R5 in the face; threatened to kill R6 and attacked R5, who fell out of his wheelchair. After the incident, R5 and R6 left to smoke and R4 was allowed in the smoking area with both R5 and R6 without any staff supervision. R5 was scared and asked R6 to protect him from R4 when R4 then verbally threatened R6 again. […]

• Actual harm, isolatedF689Jan 7, 2021

  Based on interview and document review the facility failed to ensure the safe use of hot packs and/or rice packs for 1 of 1 residents (R1) who sustained [CONDITION(S)] and required total assistance from staff for activities of daily living. This failure resulted in actual harm when R1 sustained a thermal [CONDITION(S)] to the right hand and required debridement for second degree [CONDITION(S)]. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R1 had medically complex condition that included [CONDITION(S)] (paralysis from a spinal cord injury which involves the arms, hands trunk, legs and pelvic organs). The MDS also indicated R1 had intact cognition. R1 had rejected cares less than daily (4-6 days in the look-back period). […]

• No harm, potential for more than minimal, widespreadF880Mar 4, 2025

  Based on observation, interview and document review, the facility failed to follow infection control guidelines to ensure beard nets were worn by staff who prepared food in the kitchen. This practice had the potential to affect all the residents, staff, and visitors who ate food prepared in the kitchen. Findings include: During an observation on 3/4/25 at 12:41 p.m., cook (CK)-A was observed working in the kitchen where food was being prepared by other staff. CK-A had a full beard, was not wearing a beard net and walked by where the food was being prepared. CK-A stated he worked preparing food on 3/4/25 and 3/5/25, without a beard net because the facility was out of them. CK-A stated he knew he was supposed to wear a beard net to prevent hair from getting into the food. […]

• No harm, potential for more than minimal, widespreadF886May 20, 2022

  Based on interview and document review, the facility failed to implement a system of surveillance to identify infection of agency staff during a COVID-19 outbreak for 4 of 4 agency staff reviewed (licensed practical nurse (LPN)-A, registered nurse (RN)-A, RN-B, RN-C). The agency staff providing direct care were not included in the facility wide testing, prior to the beginning of their shift, during a significant COVID-19 outbreak. Findings include: An email communication from the administrator on 5/19/22, at 3:42 p.m. noted the outbreak began on 5/5/22, when a staff member tested positive for COVID-19, another staff member was COVID-19 positive on 5/8/22, and three more tested positive on 5/9/22. […]