Deficiency Records for St James Wellness Rehab Villas

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Updated as of March 01, 2024

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
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 2021-09-23 2021-09-27 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-06-03 2021-06-04 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-05-17 2021-05-30 Y