Deficiency Records for Chateau St. James Rehab and Retirement
Updated as of March 01, 2024
A list of the most recent deficiencies for Chateau St. James Rehab and Retirement. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-14 | 2024-01-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-14 | 2024-01-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-14 | 2024-01-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-14 | 2024-01-15 | 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 | 2023-12-14 | 2024-01-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-14 | 2024-01-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-14 | 2024-01-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-14 | 2024-01-15 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-12-20 | 2024-01-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-27 | 2023-07-27 | 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 | 2022-12-21 | 2023-01-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-21 | 2023-01-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-21 | 2023-01-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-21 | 2023-01-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-12-21 | 2023-01-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-21 | 2023-01-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-21 | 2023-01-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-21 | 2023-01-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-21 | 2023-01-19 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-12-21 | 2023-01-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-21 | 2023-01-19 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-12-21 | 2023-01-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-21 | 2023-01-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-21 | 2023-01-19 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-21 | 2023-01-19 | Y |
| 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 | 2022-12-21 | 2023-01-19 | Y |
| Post nurse staffing information every day. | Health | 2022-12-21 | 2023-01-19 | 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 | 2022-12-21 | 2023-01-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-21 | 2023-01-19 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-12-21 | 2023-01-19 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-07-07 | 2022-08-12 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-07-07 | 2022-08-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-07 | 2022-08-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-07 | 2022-08-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-02 | 2022-03-24 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-01-11 | 2022-03-02 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-01-11 | 2022-03-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-12 | 2022-02-16 | 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 | 2022-01-12 | 2022-02-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-12 | 2022-02-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-12 | 2022-02-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-29 | 2022-01-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-05 | Not Fixed | Y |