Inspection·September 8, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review the facility failed to notify a Physician for a resident change in condition. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for change in condition in a sample of 3. The findings include: On 9/8/24 at 9:50 AM, R1 stated that on last Friday, 8/30/24, from around 6pm - 630 pm, he began vomiting and having diarrhea until 8:00 AM the next morning. On 9/7/24 at 10:20 AM, V9 CNA (Certified Nurse's Assistant) stated that last Friday, 8/30/2024 she was R1's CNA for 1st and 2nd shift. V9 stated that during 2nd shift, R1 had 2 episodes of vomiting where she and V3 (Nurse) each emptied a wash basin of emesis. V9 stated that she also changed R1's linen 5 to 6 times because R1 had 4-5 episodes of diarrhea during 2nd shift and the last episode was around 10 pm 10:30 PM. V9 stated that she notified V3 of R1's episodes of vomiting and diarrhea and she recorded his bowel movements but the electronic charting only allows to chart bowel movement once per shift, so she recorded his bowel movements as large. On 9/7/24 at 3:17 PM, V3 (Nurse) stated that he did not recall calling R1's doctor about R1 having emesis and diarrhea on 8/30/24. R1 stated that if a resident has 2 episodes of vomiting and 4-5 episodes of diarrhea the nurse should assess the resident and call the doctor. On 9/7/24 at 3:45 PM, V4 (R1's Nurse Practitioner/NP) stated she was not informed on 8/30/24 nor any other time that R1 had vomiting and diarrhea. V4 stated that if a resident had 2 episodes of vomiting and 4-5 episodes of diarrhea, she would order labs, including C-diff and order Imodium (anti-diarrhea medication) for the resident. On 9/8/24 at 1:40 PM, V6 (R1's Physician) stated that he had no knowledge of R1 having diarrhea or vomiting on Friday 8/30/2024. On 9/7/24 at 4:12 PM, V2 DON (Director of Nursing) stated that she has no knowledge that R1 had diarrhea and vomiting on 8/30/24. V2 stated that if a resident has episodes of vomiting and four to five episodes of diarrhea her expectations are for the nurse to check the resident's vitals and call the doctor and if it is not resolved the resident should be transferred to the emergency room for evaluation. On 9/7/24 at 4:30 PM, V1 (Administrator) stated that he has no knowledge that R1 had episodes of (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 09/08/2024 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)