Inspection Reports for
St. James Villas Wellness, Rehab Villas
1251 East Richton Road, Crete, IL, 60417
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Inspection Report — Mar 21, 2025
Date: Mar 21, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type. The report is a Statement of Deficiencies for St James Wellness Rehab Villas.
Findings
The facility was found to have multiple deficiencies including failure to provide timely incontinence care, failure to follow physician orders for wound care, failure to ensure proper medication administration, and failure to repair leaking equipment.
Deficiencies (4)
F0677 - The facility failed to provide timely incontinence care for 3 of 4 residents reviewed, resulting in residents being heavily saturated with urine and not changed as required.
F0686 - The facility failed to follow physician orders for wound treatment and dressing changes for 1 of 3 residents reviewed, resulting in an unstageable sacral pressure ulcer with soiled dressing.
F0755 - The facility failed to ensure a physician order for self-administration of an inhaler medication and failed to ensure accurate medication administration for 2 of 7 residents reviewed, including mixing medications in food without proper identification.
F0908 - The facility failed to repair a leaking ice machine in the nourishment room, creating a slipping hazard for 7 residents who are ambulatory and have impaired cognition.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 7
Inspection Report — Jan 31, 2025
Date: Jan 31, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to provide proper catheter care for four residents, resulting in inadequate catheter maintenance, lack of documentation, and failure to follow physician orders, which may have contributed to urinary tract infections and sepsis.
Deficiencies (2)
F0684 - The facility failed to implement physician's orders for catheter care for four residents, including failure to change catheter bags and tubing when clinically indicated and lack of documentation of catheter output.
F0690 - The facility failed to provide proper catheter care for four residents, including inadequate hand hygiene, failure to use soap and water during catheter care, failure to change catheter securement devices, and failure to administer prescribed medications.
Report Facts
Residents affected: 4
Inspection Report — Jan 7, 2025
Date: Jan 7, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to ensure enough clean linens, blankets, towels, and washcloths were available for the 69 residents in the building, resulting in minimal harm or potential for actual harm.
Deficiencies (1)
F0584 (Honor the resident's right to a safe, clean, comfortable and homelike environment) - The facility failed to ensure enough clean linens, blankets, towels, and washcloths were available for the residents, affecting all 69 residents in the building.
Report Facts
Residents affected: 69
Inspection Report — Dec 12, 2024
Date: Dec 12, 2024
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type. It is a deficiency report for St James Wellness Rehab Villas dated 12/12/2024.
Findings
The facility failed to notify the resident's POA and physician of changes in condition, failed to provide appropriate wound care and manage abnormal vital signs for one resident with Covid-19, and lacked documentation of skin assessments and treatment orders for a right heel deep tissue injury.
Deficiencies (2)
F0580 - The facility failed to notify the Power of Attorney and physician of changes in condition for one resident with a right heel deep tissue injury.
F0684 - The facility failed to provide needed wound care treatment services and manage abnormal vital signs for one resident with Covid-19, including failure to notify the physician of elevated heart rates and failure to document skin assessments and treatment orders.
Report Facts
Residents affected: 1
Inspection Report — Dec 6, 2024
Annual Inspection
Date: Dec 6, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies related to inadequate activities of daily living care, fall prevention interventions, incontinent care, and catheter care. The facility failed to provide timely and appropriate care to several residents, resulting in potential minimal harm.
Deficiencies (3)
F0677 - The facility failed to provide adequate activities of daily living care including nail care, skin care, hygiene, and bathing for 5 residents observed with long jagged nails, dry flaking skin, and unmet hygiene needs.
F0689 - The facility failed to provide adequate fall prevention interventions for 4 residents at high risk for falls, including failure to provide proper footwear, fall mats, and adequate supervision.
F0690 - The facility failed to provide timely and appropriate incontinent care and failed to properly position indwelling catheter drainage bags during wound care for 6 residents, increasing risk of urinary tract infections and skin infections.
Report Facts
Residents affected: 5
Residents affected: 4
Residents affected: 6
Sample size: 30
Inspection Report — Dec 6, 2024
Annual Inspection
Date: Dec 6, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to provide timely notification of hospital transfers, inadequate bed hold notifications, insufficient assistance with activities of daily living, inadequate fall prevention measures, improper incontinent care, failure to provide ordered oxygen therapy, medication storage and ordering issues, food safety and sanitation problems, infection control lapses, malfunctioning kitchen equipment, and non-functioning resident call light systems.
Deficiencies (11)
F0623 (State Form) - The facility failed to provide timely written notification to residents, their representatives, and the ombudsman regarding hospital transfers for 6 of 6 residents reviewed.
F0625 (State Form) - The facility failed to notify residents or their representatives in writing about the bed hold policy and duration at the time of hospital discharge for 6 of 6 residents reviewed.
F0677 (State Form) - The facility failed to provide adequate activities of daily living care, including nail and skin care, bathing, and shaving for 5 residents dependent on such care.
F0689 (State Form) - The facility failed to provide adequate fall prevention interventions, including proper footwear and fall mats, for 4 residents at high risk for falls.
F0690 (State Form) - The facility failed to provide timely incontinent care and proper catheter care, including positioning of catheter drainage bags, for 6 residents.
F0695 (State Form) - The facility failed to ensure oxygen was administered as ordered for 2 residents, including failure to maintain oxygen delivery devices properly.
F0761 (State Form) - The facility failed to obtain physician orders for over-the-counter medications and failed to ensure medications were stored properly in resident rooms for 6 residents.
F0812 (State Form) - The facility failed to maintain food safety and sanitation standards in the kitchen, including improper food labeling, storage of employee food, inadequate cleaning, and improper hair covering by staff.
F0880 (State Form) - The facility failed to implement infection prevention and control practices including hand hygiene, proper PPE use, disposal of PPE, and wound care procedures for 8 residents.
F0908 (State Form) - The facility failed to maintain the kitchen dishwasher and sink in good repair, resulting in use of disposable plates and unsanitary conditions.
F0919 (State Form) - The facility failed to ensure the residents' call light systems were functioning properly for 2 residents.
Report Facts
Residents affected: 6
Residents affected: 6
Residents affected: 5
Residents affected: 4
Residents affected: 6
Residents affected: 2
Residents affected: 6
Residents affected: 80
Residents affected: 8
Residents affected: 80
Residents affected: 2
Inspection Report — Sep 8, 2024
Date: Sep 8, 2024
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type.
Findings
The facility failed to notify a physician of a resident's change in condition involving vomiting and diarrhea. The facility's Notification of Change Guidelines require prompt notification to the physician and resident representative for significant changes in condition.
Deficiencies (1)
F0580 - The facility failed to notify a physician for a resident's change in condition involving vomiting and diarrhea on 8/30/24, affecting 1 of 3 residents reviewed.
Report Facts
Residents affected: 1
Inspection Report — Dec 18, 2023
Date: Dec 18, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, the inspection type is classified as 'other'.
Findings
The facility failed to follow its COVID-19 infection control policy and State Agency guidelines by having COVID-positive residents and asymptomatic/COVID-negative residents sharing rooms due to lack of private rooms. Family preferences influenced rooming decisions despite infection risks.
Deficiencies (1)
F0880 (Infection Prevention and Control Program) - The facility failed to prevent co-mingling of COVID-positive residents with asymptomatic or negative residents in shared rooms, increasing risk of outbreak among some residents.
Report Facts
Residents affected: 4
Inspection Report — Nov 17, 2023
Annual Inspection
Date: Nov 17, 2023
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to provide adequate personal hygiene assistance, unsafe bed positioning, improper incontinence care, unsafe medication storage, infection control lapses, failure to conduct water testing for pathogens, and unsafe environmental conditions such as a broken window with sharp edges in a resident's room.
Deficiencies (7)
F0677 - Provide care and assistance to perform activities of daily living for any resident who is unable - The facility failed to provide personal hygiene assistance to meet the needs of residents, including failure to provide showers, baths, shaving, and nail care for multiple residents.
F0689 - Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents - The facility failed to place a resident's bed in the lowest position, creating a fall risk.
F0690 - Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections - The facility failed to provide proper incontinence care, including improper glove use and hygiene during care for two residents.
F0695 - Provide safe and appropriate respiratory care for a resident when needed - The facility failed to contain reusable nebulizer and BIPAP masks properly, leaving them uncovered and exposed.
F0761 - 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 - The facility failed to appropriately store medications and biologicals safely, allowing residents to have medications at bedside without orders and medications belonging to other residents in rooms.
F0880 - Provide and implement an infection prevention and control program - The facility failed to conduct water testing to prevent waterborne pathogens, failed to properly store resident personal care items, and failed to perform proper hand hygiene during incontinence care, leading to infection control risks.
F0921 - Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public - The facility failed to provide a safe environment by allowing a resident's bedroom window to have a sharp, jagged broken frame that posed a safety hazard.
Report Facts
Residents affected: 8
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 71
Residents affected: 7
Residents affected: 1
Inspection Report — Jun 26, 2023
Date: Jun 26, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type. It is a statement of deficiencies for St James Wellness Rehab Villas dated 06/26/2023.
Findings
The facility failed to maintain equipment in residents' rooms and bathrooms in functional and safe order, including broken toilet paper holders and a bed that would not operate. The maintenance director confirmed no work orders were entered for these repairs.
Deficiencies (1)
F0921 - The facility failed to ensure that equipment in residents' rooms and bathrooms was maintained in functional and safe order, including missing toilet paper roll spindles and a bed that would not operate for three residents.
Report Facts
Residents affected: 3
Inspection Report — Mar 16, 2023
Date: Mar 16, 2023
Visit Reason
The document is a CMS-2567 Statement of Deficiencies for St James Wellness Rehab Villas, dated March 16, 2023. The Initial Comment block naming the visit type is not present in the provided pages, so the inspection_type is set to 'other'.
Findings
The facility was cited for multiple deficiencies including failure to obtain informed consent for psychotropic medications, inadequate assistance with personal hygiene, improper hand hygiene and glove use during incontinence care, failure to provide adaptive equipment to prevent contractures, improper incontinence care risking urinary tract infections, and failure to provide therapeutic diets and fluid restrictions as ordered.
Deficiencies (6)
F0552 (Psychotropic Medication Consent) - The facility failed to ensure consents containing risk information for psychotropic medications were obtained prior to administration for 1 of 3 residents reviewed.
F0677 (Activities of Daily Living Assistance) - The facility failed to assist residents needing help with personal hygiene, including eye care, fingernail cleaning, shaving, and grooming for 3 of 3 residents reviewed.
F0684 (Hand Hygiene and Glove Use) - The facility failed to follow standard nursing practices for hand hygiene and glove changing during incontinence care for 4 of 4 residents reviewed.
F0688 (Range of Motion Care) - The facility failed to assess and provide adaptive equipment to prevent further reduction in mobility and range of motion for 1 of 2 residents reviewed.
F0690 (Incontinence Care) - The facility failed to provide incontinence care in a manner that would prevent potential urinary tract infection for 3 of 4 residents reviewed.
F0808 (Therapeutic Diets) - The facility failed to provide nutrition supplements and fluid restriction as ordered by the physician for 4 of 4 residents observed for dining.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 3
Residents affected: 4
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