Saint John Paul Ii Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

#1's right arm/wrist at which time Resident #1 stated why are you grabbing me, don't touch me and NA #1 dropped Resident #1's arm/wrist. LPN #1 indicated she went to report this to the nursing supervisor, RN #1, and Resident #1 accompanied her to report the incident. Interview with NA #1 on 8/20/25 at 10:47 AM identified he did get into a verbal altercation with LPN #1, but NA #1 identified he did not abuse anyone.

Interview with the nursing supervisor, RN #1, on 8/20/25 at 11:52 AM identified on 7/26/25, LPN #1 and Resident #1 reported that NA #1 had grabbed Resident #1's right arm/wrist. RN #1 identified it was reported after NA #1 got into a verbal argument with LPN #1, Resident #1 came out of his/her room and that was when NA #1 grabbed Resident #1. RN #1 identified NA #1 was immediately sent home, the police were notified, and the provider was notified. RN #1 identified Resident #1 had no injury. Interview and clinical record review with the Director of Nursing (DON) on 8/20/25 at 12:56 PM identified it was reported that on 7/26/25, NA #1 grabbed Resident #1's right arm/wrist after he/she came out to find out why NA #1 had been arguing and yelling at LPN #1 in the hallway. The DON identified the administrator initiated an investigation and NA #1 was placed on the do not return list. The DON identified interviews were done with staff members as well as other residents on the unit. The DON identified the facility policy was zero-tolerance for abuse, and it was the responsibility of all staff to ensure the policy is followed. The DON identified NA #1 did not follow the facility policy as he had been upset. Although attempted, an interview with LPN #1 was unable to be obtained. Review of the facility policy titled Abuse and Neglect, undated, directed, in part, it is the policy of the facility to prevent any form of abuse or neglect towards a resident or residents whenever possible and to promptly and completely investigate and act upon the incident.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Saint John Paul II Center

33 Lincoln Avenue Danbury, CT 06810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Interview with the Medical Director, MD #1, on [DATE REDACTED] at 12:55 P.M. identified his expectations when a resident who is a full code was found unresponsive, not breathing, without a pulse, that 911 was called, and CPR is initiated. MD #1 identified that on [DATE REDACTED] when Resident #2 was found unresponsive, not breathing, without a pulse, and CPR was initiated, 911 should have been called so EMS personnel could have pronounced Resident #2's death. MD #1 identified on [DATE REDACTED] that Resident #2 did not have a physician's order that directed an RN pronouncement of death and RN #2 should not have pronounced Resident #2's death. Interview with the Director of Nursing (DON) on [DATE REDACTED] at 1:25 P.M. identified on [DATE REDACTED] when Resident #2 was found unresponsive and CPR was initiated, RN #2 should have called 911, so EMS could have pronounced Resident #2's death. The DON identified RN #2 should not have pronounced Resident #2's death and RN #2 should have known that an RN pronouncement requires a physician's order.

Interview with LPN #1 on [DATE REDACTED] at 3:35 P.M. identified on [DATE REDACTED] RN #2 notified her Resident #2 was unresponsive and thought Resident #2 had expired. LPN #1 identified that Resident #2 was a full code, so

she immediately went down to Resident #2's room with RN #2. LPN #1 indicated when she entered the room, Resident #2 was unresponsive, not breathing with an arm dropped down to the side and Resident #2 was blue. LPN #1 identified she and RN #2 immediately started CPR, continued performing CPR together for approximately 20-30 minutes, then RN #2 left the room to make phone calls to the family and on-call provider, and she continued CPR until the family arrived. Review of facility cardiopulmonary resuscitation (CPR) policy; in part, identified if a patient does not have a do not resuscitate order (DNR), CPR certified staff will initiate CPR and emergency medical services (EMS) will be activated. CPR should also be discontinued when a provider, including a nurse (RN) or nurse practitioner (NP) pronounces death provided

they have the authority to do so.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Saint John Paul II Center

33 Lincoln Avenue Danbury, CT 06810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

5:20 AM, 5:50 AM, 6:20 AM and 6:50 AM, LPN #2 documented Resident #2 was asleep, and had stopped evaluating Resident #2's neurological status. The neurological evaluation flow sheet was completed again at 7:20 AM on 7/20/25 at 7:20 AM to 2:00 AM on 7/21/25 indicating Resident #2's neurological status was assessed. Interview with RN #1 on 8/21/2025 at 11:12 AM identified on 7/22/25 at approximately 2:50 AM, LPN #1 notified him Resident #2 had a fall and was lying on the floor in his/her room. RN #1 indicated when

he entered the room Resident #2 was lying on his/her back on the floor next to the bed and Resident #2 was alert and responsive, denied hitting his/her head, denied any pain, and no injuries were noted. RN #1 identified he assessed Resident #2's neurological status, Resident #2's neuros were within normal limits, and initiated neuro checks. Interview with the 11PM-7AM nurse aide, Nurse Aide (NA) #4, on 8/21/25 at 11:19 AM identified on 7/22/25 at approximately 2:50 AM, LPN #2 yelled to her to come down to Resident #2's room. NA #4 identified when she entered the room Resident #2 was on his/her back lying on the floor next to the bed with his/her head next to the bottom of the bed. NA #4 indicated Resident #2 was alert, awake, and talking and after RN #1 assessed Resident #2, they assisted Resident #2 back into bed using a mechanical lift. Interview with LPN #2 on 8/21/25 at 11:30 AM on 7/22/25 at approximately 2:50 A.M.

Resident #2 was yelling out for help, so she ran down to the room and observed Resident on his/her back

on the floor next to his/her bed with his/her head at the bottom of the bed. LPN #2 indicated she notified RN #1 who came to assess Resident #2 and no injuries were noted. LPN #2 identified Resident #2 was assisted back into bed by RN #1 and the nurse aides via a mechanical lift. LPN #2 identified she evaluated Resident #2's neurological status every fifteen (15) minutes from 2:50 AM until 4:50 AM but at approximately 5:20 AM Resident #2 fell asleep, so she did not wake Resident #2 up the remainder of her shift to evaluate Resident #2's neurological status and left at 7:00 AM. Interview and clinical record review with the Director of Nursing (DON) on 8/21/25 at 1:25 PM identified her expectations are anytime a resident has an unwitnessed fall neurological evaluations are initiated and conducted per the frequency on the neurological flow sheet until complete. The DON identified on 7/20/25 when Resident #2 was sleeping, LPN #2 should have woken up Resident #2 and assessed Resident #2's neurological status. Although requested, a facility neurological assessment policy was not provided.

Event ID:

Facility ID:

If continuation sheet