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Deficiency Records for St James Wellness Rehab Villas
A list of the most recent deficiencies for St James Wellness Rehab Villas. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for St James Wellness Rehab Villas. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-12-18 | 2024-01-05 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-30 | 2023-12-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-17 | 2023-12-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-17 | 2023-12-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-17 | 2023-12-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-17 | 2023-12-13 | N |
| 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. | Health | 2023-11-17 | 2023-12-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-17 | 2023-12-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-11-17 | 2023-12-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-11-30 | 2023-12-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-30 | 2023-12-11 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-11-30 | 2023-12-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-30 | 2023-12-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-30 | 2023-12-11 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-26 | 2023-07-12 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-03-21 | 2023-03-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-21 | 2023-03-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-21 | 2023-03-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-21 | 2023-03-24 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-03-16 | 2023-03-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-16 | 2023-03-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-16 | 2023-03-23 | N |
| 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. | Health | 2023-03-16 | 2023-03-23 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-16 | 2023-03-23 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-03-16 | 2023-03-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-21 | 2023-02-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-29 | 2022-01-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-29 | 2022-01-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-29 | 2022-01-07 | Y |
| 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. | Health | 2021-12-29 | 2022-01-07 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-12-29 | 2022-01-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-15 | 2021-11-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-08 | 2021-10-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-08 | 2021-10-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-08 | 2021-10-18 | N |
| 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. | Health | 2021-10-08 | 2021-10-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-08 | 2021-10-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-13 | 2021-10-18 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-10-13 | 2021-10-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-13 | 2021-10-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-13 | 2021-10-18 | N |
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