Deficiency Records for St James Rehabilitation and Healthcare Center
Updated as of March 01, 2024
A list of the most recent deficiencies for St James Rehabilitation and Healthcare Center. 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 | 2022-06-27 | 2022-07-29 | 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 | 2022-06-27 | 2022-07-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-13 | 2021-11-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-16 | 2021-10-15 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-10-08 | 2019-12-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-08 | 2019-12-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-08 | 2019-12-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-08 | 2019-12-04 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-05-16 | 2018-07-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-16 | 2018-07-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-05-16 | 2018-07-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-11 | 2018-07-08 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-05-11 | 2018-07-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-05-11 | 2018-07-08 | 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 | 2018-05-11 | 2018-07-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-11 | 2018-07-08 | N |
