Deficiency Records for Mount Carmel Senior Living - St Charles, LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Mount Carmel Senior Living - St Charles, LLC. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-31 | 2023-12-14 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| 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 | 2022-11-22 | 2023-01-27 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-11-22 | 2023-01-27 | 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 | 2022-11-22 | 2023-01-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Meet other general requirements. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-28 | 2022-11-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-28 | 2022-11-28 | N |
| 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 | 2022-10-28 | 2022-11-28 | 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 | 2022-10-28 | 2022-11-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-28 | 2022-11-28 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-10-28 | 2022-11-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-28 | 2022-10-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-28 | 2022-10-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-20 | 2019-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-20 | 2019-11-01 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-09-20 | 2019-11-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-20 | 2019-11-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-20 | 2019-11-01 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-09-20 | 2019-11-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-07-27 | 2018-08-21 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2018-07-27 | 2018-08-21 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-07-27 | 2018-08-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-07-27 | 2018-08-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-27 | 2018-08-21 | 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 | 2018-07-27 | 2018-08-21 | 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 | 2018-07-27 | 2018-08-21 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2018-07-27 | 2018-08-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-27 | 2018-08-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-27 | 2018-08-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-07-27 | 2018-08-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-07-27 | 2018-08-21 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-07-27 | 2018-08-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-07-27 | 2018-08-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-07-27 | 2018-08-21 | N |
| 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 | 2018-07-27 | 2018-08-21 | N |
| Install resident room doors of proper design and width. | Fire Safety | 2018-07-27 | 2018-08-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-07-27 | 2018-08-21 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-07-27 | 2018-08-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-07-27 | 2018-08-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-07-27 | 2018-08-21 | N |
