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Deficiency Records for St James Living Center
A list of the most recent deficiencies for St James Living Center. 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 Living Center. 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-11-09 | 2023-12-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-09 | 2023-12-08 | Y |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2023-06-02 | 2023-07-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-02 | 2023-07-16 | N |
| 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. | Health | 2023-06-02 | 2023-07-16 | N |
| 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. | Health | 2023-06-02 | 2023-07-16 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-06-02 | 2023-07-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-02 | 2023-07-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-02 | 2023-07-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-02 | 2023-07-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-02 | 2023-07-16 | 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 | 2023-06-02 | 2023-07-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-06-02 | 2023-07-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-06-02 | 2023-07-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-06-02 | 2023-07-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-02 | 2023-07-16 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-06-02 | 2023-07-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-02 | 2023-07-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-02 | 2023-07-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-02 | 2023-07-16 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-06-02 | 2023-07-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-02 | 2023-07-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-02 | 2023-07-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-02 | 2023-07-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-02 | 2023-07-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-02 | 2023-07-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-02 | 2023-07-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-02 | 2023-07-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-06 | 2023-02-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-26 | 2022-07-01 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-05-05 | 2022-05-31 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-12-08 | 2022-01-19 | N |
| 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. | Health | 2021-12-08 | 2022-01-19 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-12-08 | 2022-01-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-12-08 | 2022-01-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-08 | 2022-01-19 | N |
| Provide activities to meet all resident's needs. | Health | 2021-12-08 | 2022-01-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-08 | 2022-01-19 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-12-08 | 2022-01-19 | 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 | 2021-12-08 | 2022-01-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-08 | 2022-01-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-08 | 2022-01-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-08 | 2022-01-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-08 | 2022-01-19 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-12-08 | 2022-01-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-12-08 | 2022-01-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-12-08 | 2022-01-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-08 | 2022-01-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-08 | 2022-01-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-12-08 | 2022-01-19 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-12-08 | 2022-01-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-12-08 | 2022-01-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-08 | 2022-01-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-08 | 2022-01-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-08 | 2022-01-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-08 | 2022-01-19 | N |
| 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. | Health | 2024-07-17 | Not Fixed | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-07-17 | Not Fixed | N |
| Assess the resident when there is a significant change in condition | Health | 2024-07-17 | Not Fixed | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-07-17 | Not Fixed | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-07-17 | Not Fixed | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-17 | Not Fixed | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-07-17 | Not Fixed | N |
| Post nurse staffing information every day. | Health | 2024-07-17 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-17 | Not Fixed | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-07-17 | Not Fixed | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-07-17 | Not Fixed | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-07-17 | Not Fixed | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-07-17 | Not Fixed | 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 | 2024-07-17 | Not Fixed | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-17 | Not Fixed | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-17 | Not Fixed | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-17 | Not Fixed | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-07-17 | Not Fixed | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-07-17 | Not Fixed | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-17 | Not Fixed | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-17 | Not Fixed | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-07-17 | Not Fixed | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-17 | Not Fixed | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-07-17 | Not Fixed | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-07-17 | Not Fixed | N |
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