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Deficiency Records for Mount Carmel Senior Living - St Charles, LLC
A list of the most recent deficiencies for Mount Carmel Senior Living - St Charles, LLC. 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 Mount Carmel Senior Living - St Charles, LLC. 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 | 2024-06-06 | 2024-08-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-06 | 2024-07-21 | N |
| Respond appropriately to all alleged violations. | Health | 2024-06-06 | 2024-07-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-06-06 | 2024-07-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-06-06 | 2024-07-21 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-06-06 | 2024-07-21 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-06-06 | 2024-07-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-06 | 2024-07-17 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-06-06 | 2024-07-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-06 | 2024-07-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-06 | 2024-07-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-06 | 2024-07-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-06-06 | 2024-07-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-06 | 2024-07-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-06-06 | 2024-07-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-06-06 | 2024-07-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-06-06 | 2024-07-05 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-06-06 | 2024-06-25 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-06-06 | 2024-06-25 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-06-06 | 2024-06-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-06-06 | 2024-06-25 | N |
| Keep all essential equipment working safely. | Health | 2024-06-06 | 2024-06-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-31 | 2023-12-14 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-11-22 | 2023-01-27 | 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 | 2022-11-22 | 2023-01-27 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-11-22 | 2023-01-27 | 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 | 2022-11-22 | 2023-01-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Meet other general requirements. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-28 | 2022-11-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-28 | 2022-11-28 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-10-28 | 2022-11-28 | 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 | 2022-10-28 | 2022-11-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-28 | 2022-11-28 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-10-28 | 2022-11-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-28 | 2022-10-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-28 | 2022-10-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-20 | 2019-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-20 | 2019-11-01 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-09-20 | 2019-11-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-20 | 2019-11-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-20 | 2019-11-01 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-09-20 | 2019-11-01 | N |
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