Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Paul Elder Services, Inc during CMS and state inspections, most recent first.
A resident with pneumonia and dependence on supplemental O2 had a provider order for 3 LPM via nasal cannula to maintain O2 saturation above 90%, with required documentation of liters per minute and saturation on the TAR. Over multiple shifts, staff documented the resident receiving 4 LPM of O2 with saturations in the low 90s, and a progress note stated the resident remained on 4 LPM to keep saturation above 90%, but there was no evidence of provider notification or an updated order authorizing this increase. Two PAs stated they would have expected notification when O2 was increased for a resident with pneumonia, and the DON confirmed staff should have contacted the provider and obtained an order when the O2 was raised to 4 LPM.
A resident with dementia and behavioral symptoms was involved in multiple physical altercations with other residents, resulting in injuries and distress. Despite updates to the care plan and various interventions, staff did not consistently provide supervision or effective prevention, leading to repeated incidents of abuse and an unsafe environment for several residents.
Surveyors found that food and drink items in several dining room refrigerators and freezers were not labeled with received, opened, or use-by dates, and undated items were served to residents. The activity room freezer was consistently above the required temperature, with staff unaware of proper monitoring procedures. Additionally, cooks reheated food in the microwave without waiting the required two minutes to ensure safe temperatures before serving.
Two residents had inaccuracies in their MDS 3.0 assessments: one was incorrectly coded as having an unhealed stage 3 pressure injury despite staff assessment showing it had resolved, and another's assessments failed to indicate receipt of prescribed opioid medications, even though the DON confirmed the medications were administered during the assessment periods.
A resident with diabetes and impaired cognition developed an open toe wound that was reported to staff, but no wound assessment, documentation, or wound care orders were completed. Staff failed to implement Enhanced Barrier Precautions, did not update the care plan, and did not apply ordered compression stockings. The wound was not checked or treated for several days, and required care was only provided after the issue was identified by a surveyor.
Three residents with significant respiratory and cardiac conditions did not have oxygen therapy documented in their care plans, and two lacked physician orders for changing oxygen tubing. Interviews with the DON and NHA confirmed that these omissions were not in line with facility policy, resulting in a failure to provide necessary respiratory care and services.
Staff did not follow infection control protocols for two residents requiring transmission-based precautions. In one case, two CNAs removed their N95 masks before exiting the room of a resident on airborne precautions, against facility policy. In another case, two CNAs failed to wear gowns during high-contact care for a resident on enhanced barrier precautions, despite clear signage and policy requirements. Both incidents were acknowledged by the staff involved and confirmed by facility leadership.
A resident with moderate cognitive impairment alleged that a CNA removed and returned their Fentanyl patch. The facility's policy requires immediate reporting of such incidents to the State Agency, but this was not done because the patch was returned the same evening. The local police were notified, but the failure to report to the State Agency constitutes a deficiency.
Failure to Notify Provider and Obtain Order for Increased Oxygen Flow
Penalty
Summary
The deficiency involves the facility’s failure to notify a provider and obtain an order when nursing staff increased a resident’s supplemental oxygen beyond the prescribed level. The facility’s Condition or Status Change policy required the nurse to notify the physician or on-call physician when there was a significant change in the resident’s physical condition. The resident, who was cognitively intact and their own decision maker, had pneumonia and dependence on supplemental oxygen. On 10/12/25, after low oxygen saturation readings and abnormal lung sounds, the provider was notified and ordered oxygen at 3 LPM via nasal cannula to maintain oxygen saturation above 90%, along with documentation of liters per minute and oxygen saturation three times daily on the TAR. Review of the TAR showed that on 10/14/25 and into 10/15/25, staff documented the resident was receiving 4 LPM of oxygen each shift, with oxygen saturation levels ranging from 92% to 94%. A progress note on 10/14/25 at 2:39 PM also indicated the resident remained on 4 LPM of oxygen to keep saturation above 90%. However, the medical record contained no evidence of physician notification, no progress note documenting provider communication about the increase to 4 LPM, and no updated order authorizing this change in oxygen flow. Interviews with two PAs confirmed they would have wanted to be notified if a resident with pneumonia already on oxygen had their oxygen increased and why, and the DON verified that staff should have contacted the provider and obtained an order when oxygen was increased to 4 LPM.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure an environment free from abuse for seven residents, as evidenced by multiple resident-to-resident altercations involving a resident with Alzheimer's disease and other cognitive impairments. This resident, who exhibited physical and verbal behavioral symptoms directed toward others, was involved in at least eight altercations over a five-month period. The incidents included physical aggression such as hitting, slapping, and pushing other residents, often in response to triggers like loud environments, direct tones, or perceived disrespect. Despite the resident's care plan being updated with new interventions after each incident, these measures did not prevent further occurrences of abuse. Several of the altercations resulted in physical harm or distress to other residents, some of whom also had severe cognitive impairments and were unable to fully understand or recall the events. In one instance, a resident was struck on the head after yelling at the aggressive resident, while in another, a resident was punched in the chin and fell, sustaining a cut. Other incidents involved residents being hit during meals or in common areas, leading to fear, anxiety, and psychosocial distress among the victims. Staff interviews confirmed that the interventions in place, such as redirection, engagement, and intermittent 1:1 support, were not consistently effective or documented, and the day room was not always monitored as required. The facility's own policy required appropriate steps to prevent harm from resident-to-resident altercations, but staff acknowledged that supervision and interventions were not always consistently implemented or documented. Staff shortages and competing demands sometimes made it difficult to provide the necessary supervision, and 1:1 support was provided only intermittently or after incidents occurred. As a result, the environment was not free from abuse, and residents continued to be exposed to the risk of physical and psychological harm.
Deficient Food Storage, Temperature Monitoring, and Reheating Practices
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, as required by professional standards and the Wisconsin Food Code. Surveyors observed multiple food and drink items in various dining room refrigerators and freezers that were not labeled with received, opened, or use-by dates. These included undated containers of drinks, cheese dip, chicken soup, beef vegetable soup, lemon-flavored juice, and other beverages. Staff confirmed that these items were not labeled or dated according to facility policy, and an undated drink was served to a resident during meal service. Additionally, the facility did not ensure that the temperature of the activity room freezer was properly monitored. Temperature logs for the activity room freezer showed that the freezer was above the required 0 degrees Fahrenheit on nearly all days in January, February, and March, with recorded temperatures reaching as high as 28 degrees Fahrenheit. The staff member responsible for the logs was unaware of the correct temperature requirements and did not know who was responsible for monitoring the freezer temperatures. Surveyors also observed improper reheating practices in the kitchen. Cooks reheated food in the microwave but did not wait the required two minutes after heating to ensure the food reached and maintained the necessary temperature of 165 degrees Fahrenheit, as specified by the Wisconsin Food Code. Food was stirred and temped, but the two-minute standing time was not observed before serving the food to residents. Staff confirmed that the correct microwave reheating procedure was not followed during the observed meal service.
Inaccurate Coding of MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) 3.0 assessments for two residents. For one resident, the Admission MDS assessment indicated the presence of an unhealed stage 3 pressure injury, based on hospital discharge paperwork. However, upon the facility's own assessment, staff determined that the pressure injury had resolved prior to the assessment, and the Clinical Nurse Coordinator acknowledged the MDS was coded inaccurately. For another resident with a diagnosis of left humerus fracture, physician orders documented the administration of opioid medications, including hydrocodone-acetaminophen and tramadol, during the relevant assessment periods. Despite this, both the Discharge-Return Anticipated and Admission MDS assessments failed to indicate that the resident had received opioid medication. The Director of Nursing confirmed that the resident had been prescribed and had taken opioid medication during the assessment periods, and acknowledged the MDS assessments were not coded correctly.
Failure to Assess and Treat Diabetic Toe Wound and Implement Enhanced Barrier Precautions
Penalty
Summary
A resident with a history of type 2 diabetes, diabetic chronic kidney disease, polyneuropathy, and impaired cognition developed an open wound on the left great toe. The resident reported the wound to staff, who applied ointment and a bandage, but there was no documentation of a wound assessment, wound care orders, or progress notes regarding the wound in the medical record. The wound was not added to the resident's care plan, and staff did not initiate Enhanced Barrier Precautions (EBP) as required by facility policy for residents with wounds. Despite care plan interventions to check the resident's skin and treat breaks promptly, staff failed to assess or document the wound, and the wound care nurse was not notified. The resident did not receive a wound assessment or appropriate wound care for several days, and the bandage applied by staff was not changed or checked during showers. The resident reported that no one had checked the wound since the initial bandage was applied, and the staff member responsible for daily diabetic foot checks and compression stocking application documented these tasks as completed when they were not. Interviews with facility staff confirmed that EBP should have been implemented immediately upon discovery of the wound, and that the wound should have been assessed and documented. The lack of communication and documentation resulted in the wound not being addressed according to facility policy, and the resident did not receive the ordered compression stockings or appropriate wound care until the surveyor brought the issue to staff attention.
Failure to Document and Manage Oxygen Therapy for Residents
Penalty
Summary
The facility failed to provide necessary and appropriate respiratory care and services for three residents who required oxygen therapy. For two residents with diagnoses including COVID-19, pulmonary fibrosis, sleep apnea, Lewy body dementia, and acute respiratory failure, their care plans did not indicate that they were receiving oxygen therapy, and there were no physician orders to change their oxygen tubing. Additionally, there was no documentation in their Medication Administration Record (MAR) or Treatment Administration Record (TAR) regarding the changing or scheduling of oxygen tubing. Interviews with the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that these omissions were not in accordance with facility policy and expectations for care planning and physician orders. A third resident, who had diagnoses including cerebral infarction, palliative care, congestive heart failure, and was on supplemental oxygen, also did not have oxygen therapy identified in their care plan. The DON and NHA acknowledged during interviews that oxygen therapy should have been included in the care plan for this resident as well. These findings were based on record reviews and staff interviews conducted by surveyors, and they directly reflect the facility's failure to ensure that respiratory care needs were properly documented and managed for residents requiring oxygen therapy.
Failure to Adhere to Infection Control Precautions for Residents on Airborne and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow established infection prevention and control protocols for two residents requiring transmission-based precautions. For one resident with a diagnosis of COVID-19 and on airborne precautions, two CNAs donned appropriate PPE, including N95 masks, gowns, goggles, and gloves before entering the resident's room. However, after providing care, both CNAs removed their N95 masks prior to exiting the room, contrary to the posted airborne precautions signage and facility policy, which required masks to be removed only after leaving the room. Both CNAs acknowledged this error during interviews, and the infection preventionist, DON, and NHA confirmed that the correct procedure was not followed. In a separate incident, another resident with a catheter and on enhanced barrier precautions (EBP) required staff to wear gowns and gloves during high-contact care activities. Two CNAs provided high-contact care, including transferring the resident, emptying a catheter bag, and performing peri-care, without wearing gowns as required by the EBP protocol and signage posted outside the resident's room. Both CNAs confirmed during interviews that they should have worn gowns during these activities, and the DON verified that these were considered high-contact cares necessitating gown use.
Failure to Report Misappropriation of Resident's Fentanyl Patch
Penalty
Summary
The facility failed to report an allegation of misappropriation involving a resident's Fentanyl patch to the State Agency as required. The incident involved a resident with moderate cognitive impairment who alleged that a Certified Nursing Assistant (CNA) removed and then returned their Fentanyl patch. The facility's policy mandates immediate reporting of such incidents to the Division of Quality Assurance within 24 hours, but this was not done because the patch was returned the same evening. The incident was initially reported to the Nursing Home Administrator (NHA) by the Nurse Manager after the patch was found missing. The resident identified the CNA as the person who removed and returned the patch. Despite the local police being notified and a case number assigned, the facility did not report the incident to the State Agency, which constitutes a deficiency in following the required protocol for reporting suspected misappropriation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kaukauna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Little Chute Health Services | 1.6 mi | ★★★★★ | 10 | 2 |
| Edenbrook Of Appleton North | 6.3 mi | ★★★★★ | 2 | 1 |
| Rennes Health And Rehab Center-appleton | 6.6 mi | ★★★★★ | 0 | 0 |
| Meadowbrook At Appleton | 6.7 mi | ★★★★★ | 2 | 0 |
| Oakridge Gardens Nur Ctr, Inc | 7.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.