Deficiency Records for St James Wellness Rehab Villas
Updated as of September 01, 2021
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? |
|---|---|---|---|---|
| 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 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-02-19 | 2021-02-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-02-03 | 2021-02-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-02-02 | 2021-02-05 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-01-12 | 2021-02-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-12-14 | 2020-12-21 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-12-14 | 2020-12-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-12-14 | 2020-12-21 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2020-12-07 | 2020-12-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-12-07 | 2020-12-21 | Y |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2020-12-07 | 2020-12-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-11-10 | 2020-11-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-09-21 | 2020-09-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-09-21 | 2020-09-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-08-14 | 2020-08-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-16 | 2020-03-26 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-03-14 | 2020-03-16 | Y |
| Provide family notifications of emergency plan. | Fire Safety | 2020-02-11 | 2020-02-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-11 | 2020-02-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-02-11 | 2020-02-14 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2020-02-11 | 2020-02-14 | 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 | 2020-02-11 | 2020-02-14 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-02-11 | 2020-02-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-11 | 2020-02-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-11 | 2020-02-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-06 | 2020-02-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-06 | 2020-02-11 | 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 | 2020-02-06 | 2020-02-11 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-02-06 | 2020-02-11 | 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 | 2020-02-06 | 2020-02-11 | 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 | 2020-02-06 | 2020-02-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-23 | 2019-08-27 | Y |
| 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 necessary and PRN use is limited. | 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 |
| 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 an enclosure around a vertical opening shaft. | 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 |
