Health inspection·December 18, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its Covid-19 infection control policy and The State Agency guidelines on COVID-19 by having COVID-positive residents and asymptomatic/COVID-negative residents in the same room to prevent a potential outbreak. This applies to 4 of 8 residents (R1, R3, R5, and R7) reviewed in a sample of 9. Residents Affected - Some The findings include: R1 was a [AGE] year-old female admitted on [DATE] with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. R2 (R1's roommate) is a [AGE] year-old female admitted on [DATE] with mild cognitive impairment as per MDS dated [DATE]. On 12/15/23 at 2:10 PM, R2 was observed in her wheelchair in her room and stated, I tested COVID-19 positive almost two weeks ago. I remain in my room with my roommate (R1). Record review on laboratory report dated 12/01/23 documented COVID-19 positive test result for R2. On 12/15/23 at 12:10 PM, V2 (Director of Nursing / DON) stated, R1 was exposed to COVID-19 as her roommate (R2) tested positive on 12/1/23. We could not move R1 from her roommate with COVID-19, who tested positive, as we had no private rooms available. So, we separated R1 and R2 in the same room by pulling the privacy curtain. R1 remained in the same room until she transferred to a local hospital on [DATE]. R3 is an [AGE] year-old female admitted on [DATE] with moderate cognitive impairment as per MDS dated [DATE]. R4 is a [AGE] year-old female admitted on [DATE] with moderate cognitive impairment as per MDS dated [DATE]. Record review on laboratory report result dated 12/13/23 (collected 12/11/23) indicates that R3 has a negative COVID result. Record review on laboratory report result dated 12/13/23 (collected 12/11/23) indicates that R4 has a positive COVID result. On 12/15/23 at 10:10 AM, observed R3 and R4 sharing a room. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145611 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 12/18/2023 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)