Deficiency Records for St James Wellness Rehab Villas
Updated as of July 01, 2019
This is not the most recent data for St James Wellness Rehab Villas. For the most recent information, click here.
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 safe, appropriate pain management for a resident who requires such services. | Health | 2019-05-21 | 2019-05-23 | Y |
| 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 | 2019-03-25 | 2019-04-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-25 | 2019-04-05 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-29 | 2019-02-19 | 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 | 2019-01-25 | 2019-02-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-25 | 2019-02-07 | 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 | 2019-01-25 | 2019-02-07 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-01-25 | 2019-02-07 | 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 ne | Health | 2019-01-25 | 2019-02-07 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2019-01-29 | 2019-02-04 | 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 | 2019-01-29 | 2019-02-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-01-29 | 2019-02-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-01-29 | 2019-02-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-29 | 2019-01-29 | 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 | 2018-11-09 | 2018-11-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-08-09 | 2018-08-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-05-30 | 2018-06-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-04-23 | 2018-04-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-23 | 2018-04-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-23 | 2018-04-25 | Y |
| 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 | 2018-04-23 | 2018-04-25 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-03-23 | 2018-03-26 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-02-06 | 2018-02-15 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2018-02-06 | 2018-02-15 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2018-02-06 | 2018-02-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-02-06 | 2018-02-12 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2018-02-06 | 2018-02-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-02-06 | 2018-02-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-02-06 | 2018-02-07 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2018-02-06 | 2018-02-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-06 | 2018-02-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-02-06 | 2018-02-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-02-06 | 2018-02-07 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-02-01 | 2018-02-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-02-01 | 2018-02-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-01 | 2018-02-02 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-26 | 2017-11-07 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-10-26 | 2017-11-07 | Y |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-10-26 | 2017-11-07 | Y |
| Provide a tasty and well-balanced diet that meets the nutritional needs of each resident. | Health | 2017-10-26 | 2017-11-07 | Y |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-10-26 | 2017-11-07 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-04-21 | 2017-04-26 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-04-21 | 2017-04-26 | Y |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2016-12-07 | 2016-12-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2016-12-07 | 2016-12-30 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2016-12-07 | 2016-12-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2016-12-07 | 2016-12-21 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-12-09 | 2016-12-20 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-12-09 | 2016-12-20 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-12-09 | 2016-12-20 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-12-09 | 2016-12-20 | N |
| Make sure that a working call system is available in each resident's room or bathroom and bathing area. | Health | 2016-12-09 | 2016-12-20 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2016-12-07 | 2016-12-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2016-12-07 | 2016-12-16 | 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 | 2016-12-07 | 2016-12-16 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2016-12-07 | 2016-12-16 | N |
| Install proper backup exit lighting. | Fire Safety | 2016-12-07 | 2016-12-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2016-12-07 | 2016-12-08 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2016-12-07 | 2016-12-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2016-12-07 | 2016-12-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2016-12-07 | 2016-12-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2016-12-07 | 2016-12-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2016-12-07 | 2016-12-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2016-12-07 | 2016-12-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2016-12-07 | 2016-12-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2016-12-07 | 2016-12-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2016-12-07 | 2016-12-08 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-09-16 | 2016-09-23 | Y |
