🔎 St Paul Health Center
Inspection Results
Inspection Overview
St Paul Health Center has been cited for a total of 80 deficiencies since we began saving each survey.
In Colorado, the average facility has **29.64 deficiencies** in our database. This profile shows the longer-term view.
Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.
Understanding Deficiency Severity (A-L Scale)
The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**
| Severity (Harm) | Scope (Widespread?) | Code Range |
|---|---|---|
| No Actual Harm | Isolated to Pattern | A - C |
| No Actual Harm | Widespread | D - F |
| **Actual Harm** | Isolated | G |
| **Actual Harm** | Pattern | H |
| **Actual Harm** | Widespread | I |
| **Immediate Jeopardy** | Isolated | J |
| **Immediate Jeopardy** | Pattern | K |
| **Immediate Jeopardy** | Widespread | L |
Detailed Deficiency List (Most Recent First)
Scope/Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Scope/Severity: D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity: D
Ensure that residents are free from significant medication errors.
Scope/Severity: D
Allow residents to self-administer drugs if determined clinically appropriate.
Scope/Severity: D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Scope/Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Scope/Severity: D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Scope/Severity: E
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Scope/Severity: D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Scope/Severity: D
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Scope/Severity: D
Provide activities to meet all resident's needs.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: D
Provide safe, appropriate pain management for a resident who requires such services.
Scope/Severity: D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Scope/Severity: D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Scope/Severity: E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: E
Protect each resident from the wrongful use of the resident's belongings or money.
Scope/Severity: F
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Scope/Severity: D
Allow residents to self-administer drugs if determined clinically appropriate.
Scope/Severity: D
Respond appropriately to all alleged violations.
Scope/Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: D
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: D
Ensure medication error rates are not 5 percent or greater.
Scope/Severity: D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Scope/Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: F
Assure the security of all personal funds of residents deposited with the facility.
Scope/Severity: E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: E
Respond appropriately to all alleged violations.
Scope/Severity: E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Scope/Severity: D
Provide activities to meet all resident's needs.
Scope/Severity: D
Assist a resident in gaining access to vision and hearing services.
Scope/Severity: D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Scope/Severity: K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity: E
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Scope/Severity: E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Scope/Severity: E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity: E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Scope/Severity: F
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Scope/Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Scope/Severity: F
Have a plan that describes the process for conducting QAPI and QAA activities.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity: D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Scope/Severity: E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Scope/Severity: D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Scope/Severity: D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: E
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Scope/Severity: E
Allow residents to self-administer drugs if determined clinically appropriate.
Scope/Severity: D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Scope/Severity: C
The resident has the right to receive notices in a format and a language he or she understands.
Scope/Severity: C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Scope/Severity: E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Scope/Severity: D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Scope/Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Scope/Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: D
Provide activities to meet all resident's needs.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: E
Provide safe, appropriate pain management for a resident who requires such services.
Scope/Severity: C
Post nurse staffing information every day.
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity: D
Provide or obtain dental services for each resident.
Scope/Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Scope/Severity: D
Provide or get specialized rehabilitative services as required for a resident.
Scope/Severity: E
Provide and implement an infection prevention and control program.
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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**