Inspection·November 17, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was unkempt and tangled. R65 said she did not know when her last shower was, that she showers at home and the staff do not help her wash her hair. R65's BATH AND SKIN REPORT SHEET for October 2023 showed her shower days are Wednesdays and Saturdays every week. The October bath sheet is blank and does not show a single bath or shower was given or refused. The November bath sheet showed a bath was given on Wednesday 11/1/23 and a shower was given on Saturday 11/4/23. No other showers, baths, or refusals have since been documented. No other shower/bath documentation was in R65's electronic Health Record. On 11/16/23 at 10:33 AM, V4 CNA (Certified Nurse Assistant) said when she gives a shower, bath, or shave she documents it in the shower book on that resident's shower/bath sheet. V4 said if the resident refuses their shower, bath, and/or shave, she will document the refusal on the shower/bath sheet. On 11/16/23 at 10:38 AM, V5 CNA said showers should be done twice a week on all residents and she documents showers on the shower/bath sheet kept at the nurse's station. V5 said if a resident refuses their shower, she will document the refusal on that resident's shower/bath sheet. The facility's BATH AND SKIN REPORT SHEET states Documentation of refusals and interventions must be recorded on the reverse of this report and in the resident record THIS DOCUMENT IS PART OF RESIDENT'S PERMANENT CLINICAL RECORD. The facility's policy titled, Shaving the Resident last revised March 2004 states, Purpose: The purpose of this procedure is to promote cleanliness and to provide skin care .Documentation: The following information should be recorded in the resident's medical record .1. The date and time that the procedure was performed. 2. The name and title of the individual(s) who performed the procedure .5. If the resident refused the treatment, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data . The facility's policy titled, Shower/Tub bath last revised August 2002 states, Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .Documentation: The following information should be recorded on the resident's ADL record and/or in the resident's medical record .1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data . 6. On 11/14/23 at 11:08 AM, R51 stated she had not been showered or had a bed bath in two weeks since the shower aid services had been discontinued. R51 said she felt dirty and stinky. R51 was noted to have a bad smell. On 11/16/23 at 12:00 PM, R51 restated she had not been showered in the previous weeks. R51 denied ever refusing showers. R51's diagnoses include morbid obesity, depression, unsteadiness on feet and weakness. R51's MDS (Minimum Data Set) dated 9/1/23 shows she is cognitively intact and requires extensive one person staff assistance with ADL (Activities of Daily Living). Review of resident's care plan dated 10/16/23 states R51displays a rejection of care. Review of R51's EMR (Electronic Medical Record) did not have documentation of resident's showers or refusals of showers. Facility did not provide EMR documentation of R51's showers or refusals of showers. Paper charting of showers and skin check in shower book for October and November were initially blank were returned to the surveyor partially completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145611 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James Wellness Rehab Villas 1251 East Richton Road Crete, IL 60417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 7. On 11/15/23 at 11:20 AM, R7 was noted to have a strong urine smell. Level of Harm - Minimal harm or potential for actual harm On 11/15/23 at 01:25 PM, R7 stated her shower days were on Tuesdays and Fridays but she still had not been showered. Residents Affected - Some On 11/16/23 at12:06 PM, R7 was noted with facial hair and urine smell. R7 stated she had not been showered since October. R7 denied refusing showers. R7 stated she preferred a real shower not bed baths. R7's diagnoses include respiratory failure, osteo arthritis, diabetes, morbid obesity, legal blindness, schizophrenia, hemiplegia, and hemiparesis. R7's MDS (Minimum Data Set) dated 10/23/23 shows she is cognitively intact and completely dependent on staff assistance with activities of daily living. R7's care plan dated 10/29/23 states R7's ability to perform ADLs is impaired due to decreased mobility and requires assistance in all aspects of ADLs secondary to diagnosis of hemiparesis/hemiplegia. Review of R7's EMR (Electronic Medical Record) had no documentation of resident's showers or refusals. Facility did not provide EMR documentation of R7's showers or refusals. R7's November shower sheets shows she has only received bed baths and not her preferred showers. On 11/15/23 at 01:35 PM, V12 CNA (Certified Nursing Assistant) stated she was not able to do showers because they were short staffed. V12 stated there had been past occasions she was not able to complete her showers. 3. On 11/14/23 at 11:38 AM during initial observation, R19 was observed with greasy, uncombed hair. R19's fingernails on the left hand had a dark colored substance underneath. On 11/15/23 at 1:15 PM R19's hair remained greasy and uncombed. On 11/16/23 at 9:02 AM R19's hair continued to be greasy and uncombed. On 11/15/23 at 1:15 PM V15 (Licensed Practical Nurse) said she is the regular nurse for R19, and she did not know when R19 was last showered or bathed. R19's face sheet showed R19 was admitted to the facility with the diagnoses including intervertebral disc degeneration lumbar region, abnormalities of gait and mobility, weakness, diabetes mellitus with diabetic neuropathy, dementia, major depressive disorder, and hypertension. R19's MDS dated [DATE] showed R19 had moderate impaired cognition. The same MDS showed R19 required total dependence with dressing, personal hygiene, eating, toileting, and bed mobility. R19's care plan updated 08/21/23 showed R19 required staff assistance for all ADL's. 4. On 11/15/23 at 1:28 PM R26 was observed with an accumulation of facial hairs. R26 said the staff shaves him after his shower. R26 reported that he had not had a shower in over a week, and his normal shower days are Tuesday and Friday. R26 stated that he has not had a bed bath and would like a shower and a shave. On 11/16/23 at 8:45 AM R26 still had an accumulation of facial hairs. R26's face sheet showed R26 was admitted to the facility with diagnoses of including diabetes mellitus with other circulatory complications, chronic obstructive pulmonary disease, hyperlipidemia, glaucoma, hypertensive heart disease with heart failure, dementia, polyneuropathy, muscle weakness, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145611 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James Wellness Rehab Villas 1251 East Richton Road Crete, IL 60417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some abnormalities of gait and mobility, and cognitive communication deficit. R26's MDS dated [DATE] showed R26 was cognitively intact. The same MDS showed R26 required partial/moderate assistance with personal hygiene, and supervision/touching assistance with lower body dressing and footwear. R26's care plan updated 09/12/23 showed R26 required staff assistance for ADL's. 5. On 11/14/23 at 12:05 PM R46 was observed wearing a pink night gown, soiled with a brown substance on the front. R46's fingernails on the right and left hands were long. R46 said she wanted her fingernails trimmed. On 11/15/23 at 1:40 PM R46 continued to have on the same soiled, pink night gown. R46's hair was greasy. R46 said her hair has not been washed since last week, and she had not received a shower in over a week. On 11/16/23 at 9:10 AM R46's hair remained greasy, and continued to have on the same soiled, pink night gown from two days ago. R46 said she still had not had a shower and would like to be showered. R46's face sheet showed R46 was admitted to the facility with diagnoses of cerebral infarction, chronic obstructive pulmonary disease, dementia, hypertensive heart disease with heart failure, polycythemia, atrial fibrillation, anxiety, and osteoporosis. R46's MDS dated [DATE] showed that R46's had moderately impaired cognition. The same MDS showed R46 required substantial/maximal assistance with personal hygiene, and partial to moderate assistance with dressing and footwear. On 11/16/23 at 12:37 PM V2 (Director of Nursing) said showers should be done two times per week, or more frequently per the resident or family requests. V2 said hair washing and nail care should be done with showers, or as needed. V2 said if a resident refuses a shower, the refusal should be documented, and the floor nurse and wound care nurse notified of the refusal. V2 said it is my expectation that all residents should be clean, tidy, and clothes changed every day. On 11/16/23 at 1:17 PM V4 (CNA) said she did not give R46 a shower, bed bath, changed clothes, or washed her hair this week. V4 said she was the day shift CNA for R46 this week (Tuesday, Wednesday, and Thursday) and was not aware of R46 wearing the same night gown all week. V4 said her responsibilities are to change, shower, and assist residents with ADL's. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145611 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James Wellness Rehab Villas 1251 East Richton Road Crete, IL 60417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews, and record reviews, the facility failed to place a bed in a safe position. This applies to 1 of 1 resident (R170) reviewed for falls in a sample of 24. Residents Affected - Few Findings include: On 11/14/23 at 11:55 AM, R170 was observed in her bed and her bed was in a high position. At 1:14PM V3 (Nurse) came into R170's room with the surveyor and observed R170's bed still in a high position. V3 lowered R170's bed to lowest position and said R170's bed should not be in that high position because she could fall, and that it is a fall risk. On 11/16/23 at 11:39 AM, V2 Director of Nurse's (DON) said that residents' beds should not be left in high positions when they are in it because they can fall out of the bed. R170's electronic health record showed that R170's mental status is severely impaired. R170's 11/2/23 fall risk observation showed a score of 11 making R170 a high risk for falls. R170's care plan showed R170 had a risk related to falling, related to impaired mobility, actual fall, and dementia, with approaches including, keep bed in lowest position with brakes locked, observe frequently, and place in supervised area when out of bed. The facility's Fall and Fall Risk Managing policy dated August 2008 showed, based on previous evaluations and current data the staff will identify interventions related to residents' specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145611 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James Wellness Rehab Villas 1251 East Richton Road Crete, IL 60417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide proper incontinence care for 2 of 2 residents (R30 and R52) observed for incontinence care in a sample of 24. Findings include: On 11/14/23 at 1:02 PM, R30 was observed in his room in his wheelchair. R30 was calling for help and said he needed his brief changed. At 1:08 PM, R30 was again heard calling for help and V7 & V8 CNAs (Certified Nurses' Assistants) were in the hall near R30's room. At 1:11PM again R30 is heard calling out for help and again V7 and V8 are observed by R30's room. At 1:24 PM, V3 calls V7 and V8 to R30's room to provide incontinence care for R3. At 1:27 PM, V7 and V8 came to R30 room and assisted R30 to his bed and with gloved hands removed his soiled pants. R30's pant legs had a large amount of liquid stool in them. V7 and V8 then opened his soiled brief. V8 began wiping around R30's penis and not folding or changing the wipe as she cleaned the area. R30's perineal area was observed reddish in color. V8 applied barrier cream to R30's perineal area and buttock area without changing her gloves and washing her hands. On 11/14/23 at 1:42 PM, V8 said she thought she did not have to get a new wipe after cleaning an area unless the wipe is visibly soiled. R30's electronic record review showed that R30 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including hydrocephalus, fracture of the right femur, chronic obstructive pulmonary disease, repeated falls, and weakness. R30's 8/18/23 care plan showed a risk for deterioration of ADL's (activities of daily living) related to decreased mobility and intellectual disability with approaches including, provide assistance for ADL. R30's 8/18/23 care plan showed he has episodes of bowel incontinence with a goal for no skin breakdowns, with approaches including use skin barrier after incontinent episodes. R30's 9/6/22 care plan showed risk for pressure ulcers related to incontinence and impaired mobility with a goal of skin to remain intact, and with approaches including keep clean and dry as possible provide incontinence care after each incontinent episode report any signs of skin breakdown, (sore, tender, red, or broken areas), and use moisture barrier products to perineal area. R30's 9/6/34 care plan shows resident is at risk for bladder incontinence related to restricted mobility with approaches including provide incontinence care after each incontinent episode. R30 8/7/23 MDS (minimum data set) section C showed R30's mental status is severely impaired. Section GG showed a score of 1 which shows he is total dependent for toileting hygiene. Section H shows he is always incontinent of urine and bowel and is not on a training program. On 11/14/23 at 11:00 AM R52 was observed in her bed and V6 CNA (Certified Nurse's Assistant) was providing perineal care. V6 was observed cleaning R52 rectal area with a wet towel not folding it after each wipe on rectal area and legs. After V6 provided perineal care, V6 put on a new brief, and gown, and applied lotion to R52's legs and feet without removing her dirty gloves and cleaning her hands. V6 then removed 1 of 2 sets of gloves off of her hands and then applied more lotion to R52's legs and feet. Then V6 put socks and deodorant on R52 again with dirty gloved hands. V6 then place R52 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145611 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James Wellness Rehab Villas 1251 East Richton Road Crete, IL 60417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on the lift sling and used the mechanical lift control to lift R52 out of her bed and into her chair with the same dirty gloved hands. R52's electronic health record showed that R52 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including lack of coordination, repeated falls, weakness, type 2 diabetes, essential primary hypertension, and weakness. R52's 8/14/23 care plan showed a risk for pressure ulcers related to incontinence of bowel and bladder with a goal to keep resident skin intact, and with approaches including provide incontinence care after each incontinent episode. R52's MDS (minimum data set) showed under bath/shower a score of 1, dependent on care, and for toileting hygiene a score of 1, dependent on care. On 11/16/23 at 11:54 AM, V2 Director of Nursing (DON) said staff should not double glove, remove top set of gloves, and then continue providing personal care because it is not sanitary, and it is an infection control issue. V2 said staff should wash their hands when going from dirty to clean. V2 said staff should use multiple washcloths not the same towel when cleaning different areas. V2 said staff should wash hands after hygiene care before putting on clean gloves. V2 said that this is for infection control. V2 said that residents should not be left in stool because it is neglectful, and it can cause skin breakdowns and wounds. The Facility's Perineal Care policy dated August 2008 showed the purpose of perineal care is to provide cleanliness and comfort to the resident, to prevent infections and skin irritations, and to observe the residents skin condition. The facility's hand washing hand hygiene policy dated November 2023 showed that it is the policy of the facility to assure staff practices hand washing hand hygiene procedures as a primary means to prevent the spread of infections among residents . Staff must wash their hands when the hands are visibly dirty or soiled with blood or other bodily fluids, after contact with blood body fluids ,or non-intact skin, after handling items potentially contaminated with blood, bodily fluids, or secretions. The policy showed that when hands are not visibly soiled employees must use alcohol-based hand rub before direct contact with residents, after direct contact with residents, . before putting on gloves, before moving from a contaminated body site to a clean body site during resident care, and after removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145611 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James Wellness Rehab Villas 1251 East Richton Road Crete, IL 60417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to contain reusable nebulizer treatment masks, and BIPAP masks (bilevel positive airway pressure). This applies to 3 residents (R3, R20, & R45) reviewed for respiratory care in a sample of 24. Residents Affected - Few Findings include: 1. On 11/14/23 at 12:31 PM, a BIPAP mask and a nebulizer mask was observed on R3's bedside drawer, not covered. R3's electronic health record showed that R3 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease. R3's care plan showed R3's has a risk for respiratory distress related to chronic obstructive pulmonary disease (COPD), with approaches including provide medication as ordered. R3's Physician Order Sheet showed an order dated 8/31/21 for CPAP/BIPAP at bedtime, on 8/31/23 order for Nebulizer with mask, and an order for Albuterol sulfate solution for nebulization every 4 hours. 2. On 11/14/23 at 10:45 AM, a nebulizer mask was observed not covered or contained on R20's bedside table. R20 said the last time he had used it was the day before. R20's electronic health record showed that R20 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cerebral infarction, heart failure, type 2 diabetes, lack of coordination, hypertension, muscle weakness and need for assistance with personal care. R20's 10/23/23 physician order showed and order for albuterol sulfate 2.5mg/3ml for nebulization every 8 hours. 3. On 11/14/23 at 12:49 PM, a nebulizing mask was observed on R45's dresser, uncovered. R45's electronic health record showed that R45 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including COPD (chronic obstructive pulmonary disease). R45's 10/30/23 care plan showed R45 a risk for easily fatigued and shortness of breath related to a diagnosis of COPD, with approaches including providing respiratory therapy as ordered nebulizer. Physician order dated 10/27/23 showed nebulizer with mask, and Ipratropium-albuterol 0,5mg-3mg solution for nebulization every 6 hours. On 11/16/23 at 12:26 PM, V2 DON (Director of Nurses) said that nebulizer mask and BIPAP mask should be covered in bags. The facility's Aerosolized Medication Therapy policy dated February 2020 showed that after use . return respiratory equipment to respiratory bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145611 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James Wellness Rehab Villas 1251 East Richton Road Crete, IL 60417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observations, interviews, and record reviews, the facility failed to appropriately store medications and biologicals safely for 2 residents (R34, R173) in a sample of 24. Findings include: 1. On 11/15/23 at 11:00 AM, one 3-ounce bottle of antifungal powder with miconazole Nitrate 2% was observed on R34's dresser. R34's electronic health record did not show an order for self-medication or to have medications at bedside. R34's 8/18/23 order showed an order for miconazole nitrate powder 2% to be applied under skin folds twice daily 8am and 4pm. 2. On 11/14/23 at 12:53 PM, one prescription bottle of antifungal powder with R34's name on it (R34 stays in a different room), and one prescription tube of Menthol-zinc oxide ointment with R173's name on it, was observed on R173's dresser. R173's 11/17/23 physician order sheets did not show any orders for self-medication, to have medications at bedside, or orders for Antifungal powder 2% or Menthol-zinc oxide ointment. On 11/16/23 at 11:22 AM, V2 Director of Nurses said that residents should not have medications at their bedside if they do not have an order and have not had an observation/assessment for self-medication. V2 said this is for safety because the resident could die, overdose, or use the medications inappropriately. At 11:43 AM V2 said that other residents' medications should not be in other resident rooms because it is dangerous, and residents could die. The facility storage of medication policy dated 10/25/14 showed that medications and biologics are to be stored safely, securely, and properly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145611 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James Wellness Rehab Villas 1251 East Richton Road Crete, IL 60417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. On 11/14/23 at 11:58 AM, a used washbasin with no name on it and not covered, and 3 bottles of body wash & shampoo with no names on them, were observed in R1 and R40's shared shower room Residents Affected - Many 3. On 11/14/23 at 11:49 AM a used washbasin, with no name on it and not in a container, was observed in R44 and R169 shared shower room. On 11/16/23 at 11:13 AM, V2 (Director of Nurses) said wash basins should be labeled and in a bag because of infection control. 4. On 11/14/23 at 1:27 PM, V7 & V8 (Certified Nurse's Assistants) were observed providing incontinent care for R30. V8 was observed with gloved hands cleaning R20's perineal area. V8 then removed her gloves and then put on clean gloves not washing her hands. V8 then applied barrier cream to R20 skin. V8 again removed her gloves and put on new gloves again not cleaning her hands, and then attaching R20's new brief. V8 then removed her gloves and put new gloves on and adjusted R20 in his bed, and touching R20's bed control, adjusted R20's bed. V8 then pulled R20's sheets and blanket up on R20, and then put the bed in a low position. On 11/14/23 at 1:42 PM, V8 said that she knew that she was to wash her hands after taking off gloves and before putting on clean ones, but she forgot. On 11/16/23 at 12:09 PM, V2 Director of Nurses said that hands should be washed after removing gloves when going from dirty to clean, because it is infection control. 5. On 11/14/23 at 11:00 AM R52 was observed in her bed and V6 CNA (Certified Nurse's Assistant) was providing perineal care. V6 was observed cleaning R52 rectal area with a wet towel not folding it after each wipe on rectal area and legs. After V6 provided perineal care, V6 put on a new brief, and gown, and applied lotion to R52's legs and feet without removing her dirty gloves and cleaning her hands. V6 then removed 1 of 2 sets of gloves off of her hands and then applied more lotion to R52's legs and feet. Then V6 put socks and deodorant on R52 again with dirty gloved hands. V6 then place R52 on the lift sling and used the mechanical lift control to lift R52 out of her bed and into her chair with the same dirty gloved hands. On 11/16/23 at 11:54 AM, V2 Director of Nursing (DON) said staff should not double glove, remove top set of gloves, and then continue providing personal care because it is not sanitary, and it is an infection control issue. V2 said staff should wash their hands when going from dirty to clean. V2 said staff should use multiple washcloths not the same towel when cleaning different areas. V2 said staff should wash hands after hygiene care before putting on clean gloves. V2 said that this is for infection control. 6. On 11/14/23 at 12:02 PM R53's urinal was observed on R53's over the bed side table with a small amount of yellow liquid in it. Next to the urinal was R53's breakfast tray, untouched. The over the bedside table was out of R53's reach, by the door. A 2nd urinal was observed on a 2nd over the bedside table with a small amount of yellow liquid in it. R53 said that he had just woken up, he had an appetite, and he still wanted his breakfast. At 12:22 PM V7 (Certified Nurse's Assistant) came into R53's room and removed R53's untouched breakfast tray and replaced it with his lunch tray. V7 set the tray on the over the bedside table next to the urinal. At 1:19 PM V3 Nurse went into R53's room with the surveyor and observes the urinal on the over the bedside table next to R53's untouched lunch tray. V3 removes the urinal from the over the table and takes it to R53's washroom and cleans it and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145611 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James Wellness Rehab Villas 1251 East Richton Road Crete, IL 60417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many leaves it in the washroom. V3 then removes the untouched lunch tray. V3 said that the urinal should not be there because it is unsanitary, and an infection control issue. V3 said that the food can get bacteria from cross contamination from the urinal. On 11/16/23 at 11:46 AM, V7 (Certified Nurse's Assistant) said that she will ask R53 if she can remove his urinal before she puts his meal trays down. V7 said she should have removed the urinal first and then put the lunch tray down. V7 said she didn't move the urinal because she didn't realize it was there. On 11/16/23 at 11:29 AM, V2 Director of Nurses said that urinals should not be on bedside tables next to meal trays unless the resident wants them there. V2 said that it is an infection control issue. On 11/16/23 a review of R55's electronic care plan did not show that he wanted his urinal kept on his over the bed side table. The facility's Infection Control policy dated January 2023 showed staff are to wash hands thoroughly with soap and water before any procedure, before resuming any procedures, .any time they become soiled with bloody, bodily fluids, after changing or removing gloves, or after completing a task or procedure . The facility's hand washing hand hygiene policy dated November 2023 showed that it is the policy of the facility to assure staff practice recognized hand washing hand hygiene procedures as a primary means to prevent the spread of infections among residents' personnel and visitors. Staff must wash their hands when the hands are visibly dirty or soiled with blood or other bodily fluids after contact with blood body fluids or non-intact skin, after handling items potentially contaminated with blood bodily fluids or secretions. When hands are not visibly soiled employees must use alcohol-based hand rub before direct contact with residents, after direct contact with residents, but prior to direct contact with another resident, before putting on gloves, before moving from a contaminated body site to a clean body site during resident care, and after removing gloves. The facility's Bedpan Urinal policy dated March 2014 showed if the resident keeps his urinal at his bedside check it frequently empty and clean it as necessary. Note on the residence care plan his request to keep the urinal at his bedside. The facility's Perineal Care Policy dated August 2008 showed the purpose of this procedures are to provide cleanliness and comfort to the residents to prevent infections and skin irritations and to observe the residents skin condition. Based on observations, interviews, and record review. The facility failed to conduct water testing and monitoring to prevent waterborne pathogens, this applies to 71 of 71 residents that reside in the facility. The facility also failed to identify and properly store resident personal care items and perform hand hygiene during incontinence care. This applies to 7 of 7 residents (R1, R30, R40, R44, R52, R53, R169) reviewed for infection control in a sample size of 24. The findings include: 1. On 11/15/23 at 2:16 PM, V11 (Maintenance Director) stated the facility does not regularly test for legionella or other water borne pathogens. Water testing is only done if they have a suspicion there may be an issue. V11 did not provide any documentation for water testing conducted at the facility. V11 did not provide any water temperature logs or water system flushing records. On 11/16/23 at 1:01 PM, V14 (Infection Preventionist) stated the facility does not routinely test for legionella or other water borne pathogens. V14 did not know when water testing for pathogens was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145611 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James Wellness Rehab Villas 1251 East Richton Road Crete, IL 60417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 last completed. Level of Harm - Minimal harm or potential for actual harm On 11/16/23 at 2:28 PM, V1 (Administrator) stated maintenance is responsible for overseeing water testing. V1 did not know when water testing was last done in the facility. V1 did not provide any documentation for water testing conducted at the facility. Residents Affected - Many The facility policy Water Management Program dated 10/01/17 states data to be used in the risk assessment may include, but are not limited to lab reports, environmental culture results, rounding observation data, water temperature logs, water quality reports from drinking water provider, community infection control surveillance data. Testing protocols an acceptable range will be established for each control measure. Individuals responsible for testing or visual inspections will document findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145611 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James Wellness Rehab Villas 1251 East Richton Road Crete, IL 60417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews, and record reviews, the facility failed to provide a safe environment for 1 of 1 resident (R20) in a sample of 24. Residents Affected - Few Findings include: On 11/14/23 at 10:45 AM, R20's bedroom window frame was observed with about a six-inch sharp, jagged, pointed, broken piece of wood and outside light could be seen coming through. R20 said that he can see outside and that it was cold in his room last night because the air was coming through the broken window. On 11/16/23 at 9:27 AM, R20's window was observed with caulking around the window and a piece of foam around the broken jagged wood. R20 said that about 2-3 weeks ago he reported the window and the heat to V1 (Administrator). R20 said V1 told him he was going to send the maintenance man to his room, or he would put R20 in another room. R20 said that nobody came to fix it until about a week ago. R20 said he call the maintenance man to his room and told him about the window and the heat, and V11 said he was going to do something about it. On 11/16/23 at 2:48 PM, V1 (Administrator) said that about a week ago R20 told him about his window, but nothing about there not being heat. V1 said that he told R20 he would have the maintenance man come and check the window. V1 said that he informed the maintenance man about the window, but he did not make out a work order. V1 said that V11 told him he was going to seal R20's window. On 11/15/23 at 2:55 PM, V11 (Maintenance Director) said he tries to check every room quarterly, and that includes checking the windows. V11 said that he does not keep a log of it. V11 said that about a week ago R20 called him into his room to check the heat in his room. V11 said he check the heater but did not inspect the room. V11 said that R20's window is on the facility's plan for a window replacement. V11 said that if there is a safety issues, like sharp jagged wood, he fixes it immediately. Then at 3:08pm V11 and the surveyor went into R20's room and V11 and R20's wooden window frame was observed with broken wood, jagged and sharp. V11 said Yes these sharp edges are a safety concern, I am going to fix it right now. V11 said he did not know the last time he inspected R20's room. V11 reviewed the facility's work order reports for 11/15/22 - 11/15/23 with the surveyor, and no work order for R20's window was found. At 2:01 PM V11 said that he had moved R20 out of his room until the window is fixed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145611 If continuation sheet Page 13 of 13