A list of the most recent deficiencies for St Charles Health Campus. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-04 | 2023-11-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-15 | 2023-06-30 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-15 | 2023-04-14 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-03-15 | 2023-04-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-15 | 2023-04-14 | 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 | 2023-03-15 | 2023-04-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-15 | 2023-04-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-15 | 2023-04-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-15 | 2023-04-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-15 | 2023-04-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-15 | 2023-04-14 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-03-15 | 2023-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-07 | 2023-03-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-07 | 2023-03-31 | 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 | 2023-03-07 | 2023-03-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-07 | 2023-03-31 | Y |
| 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 | 2019-04-03 | 2019-04-16 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-04-03 | 2019-04-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-03 | 2019-04-16 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-04-03 | 2019-04-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-02-01 | 2018-03-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-02-01 | 2018-03-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-02-01 | 2018-03-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-02-01 | 2018-03-27 | 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 | 2018-02-01 | 2018-03-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-02-01 | 2018-03-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-01 | 2018-03-27 | 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 | 2018-02-01 | 2018-03-27 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-02-01 | 2018-03-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-02-01 | 2018-03-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-01 | 2018-03-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-14 | 2018-03-26 | N |
