Health inspection·December 12, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm sheet showed on 11/25/24 R1 continued to have a blister to the right heel that was black, hard, and closed. Physician orders for November were reviewed, no wound care orders. R1's progress notes showed no evidence of POA, or provider notified of right heel skin alteration. Treatment records for November 2024 were reviewed, no orders for right heel blister. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145611 If continuation sheet Page 2 of 5 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 12/12/2024 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide needed wound care treatment services and manage abnormal vital signs for a resident with Covid. This applies to 1 of 1 resident (R1) reviewed for improper nursing care. Residents Affected - Few The findings include: R1 was admitted to the facility on [DATE] with multiple diagnoses which included vascular dementia, schizophrenia, acute embolism and thrombosis of vein, muscle disorder, Covid-19, weakness. R1's MDS (Minimum Data Set) dated 10/14/24 showed R1 had moderate cognitive impairment. R1 was transferred to the hospital on [DATE] and was admitted . On 12/10/24 at 2:38 PM V2 (Director of Nursing) stated the nurses take vital signs and do a nursing assessment every shift for residents with Covid. The nursing assessment is documented in the progress notes every shift. We do not have a standard assessment. V2 stated R1 should have had some documentation regarding his condition. R1 had Covid and should have been screened. V2 stated the nurse documented on 11/30/24 that R1 had a heart rate of 110. She did not document anything. She should have notified the doctor or the NP (Nurse Practitioner) of the elevated heart rate. On 12/1/24 R1 was not found unresponsive but he was hypoxic with a lot of phlegm. On 12/11/24 at 10:05 AM V2 stated that she could not locate any documentation in R1's medical record regarding the right heel DTI (Deep Tissue Injury). The nurse who discovered the right heel DTI should have documented in the EMR (Electronic Medical Record), called the doctor/NP to get orders, and notified the family. With no one knowing about R1's right heel DTI, R1 could have developed an infection or sepsis, and the skin integrity would not be maintained. On 12/11/24 at 9:42 AM V4 (Wound Care Nurse) stated on 11/18/24 she first noticed that R1 had a black, hard, unmeasurable, closed area to his right heel. She did not call the doctor/NP because it was not opened. V4 stated they kept an eye on it to see if it would open or not. V4 stated she saw the right heel again on 11/25/24, and the area was the same as before, there were no changes. V4 stated she still did not call the doctor because it had no changes. V4 stated they did not apply a dressing or protective treatments to the right heel, they only put socks on R1. V4 stated after 11/25/24, she never saw R1's right heel again. V4 stated R1 never complained of pain. V4 stated the area on the right heel was a DTI. V4 stated she did not notify R1's POA (Power of Attorney) or family of the DTI to the right heel. On 12/11/24 at 1:40 PM V5 (Licensed Practical Nurse) stated she was the nurse taking care of R1 on 11/30/24. V5 stated R1 had a heart rate of 110 beats per minute that I documented in the EMR vitals. I did not call the physician. I should have called the physician to give him an update on the resident. I should have documented in the progress notes about the resident's condition. The resident could have had a heart attack with an elevated heart rate. The Covid policy is to do vitals every four hours and document the residents condition every shift. I should have had some form of progress notes in for the resident. V5 stated I assessed R1 on 12/1/24 around 11:30 PM, he was very congested, had a lot of phlegm, no fever, and he was coughing. He was alert, and not unresponsive. His oxygen saturations were 88-89 on room air. We sat him up, applied oxygen, and called 911. 911 arrived and transported him to the hospital. Stated resident never complained to her that his foot was in pain. V5 stated she was not aware of R1 having a DTI to his right heel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145611 If continuation sheet Page 3 of 5 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 12/12/2024 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/11/24 at 1:45 PM V3 (Infection Preventionist) stated the Covid protocol is vital signs every four hours and the Covid screening should be done every shift. The nurses document the Covid screening in the progress notes. If the resident does not have any changes or abnormalities, that should be documented in the progress notes. We do not have a standard form for Covid screening. for someone who has tested positive for Covid. We monitor every shift for any changes in vitals, mental status, level of consciousness. On 11/25/24 I tested all the residents in the building and R1 tested positive for Covid. He was put on transmission-based precautions. R1 had a change in condition on 12/2/24. He had an elevated heart rate, anxious, congestion, increased respiratory status. He was sent out 911. He was admitted to the hospital. On 12/11/24 at 3:05 PM V6 (Nurse Practitioner) stated she was not aware of R1 having a right heel DTI. V6 stated the nurse should have informed her of the resident having a DTI to the right heel. V6 stated R1 not having a treatment to the heel could have possibly caused a wound infection. V6 stated she was not informed of R1's elevated heart rate on 11/30/24. An elevated heart rate is a sign of progressing infection, R1 would have needed a further work up, and maybe an antiviral. V6 stated she expects the nurses to notify her with any changes in conditions the residents may have so they can receive the proper treatment. V6 stated R1 did not receive the proper treatment. R1's Physician Orders for November 2024 showed 11/25/24 educate patient's with Covid-19 about signs and symptoms of complicated disease. If they develop any of these symptoms, they will be referred immediately to the primary care provider. Transmission based precautions. Contact and Droplet Precautions dated 11/25/24. R1 Progress Notes dated 11/25/24 3:30 PM showed SWD (Social Worker Director) met with the resident's wife and daughter regarding isolation precautions. At the moment, all of the resident's wife and daughter's concerns and questions have been answered. SWD will remain available as needed. 11/25/24 10:40 PM IDT Note: resident tested + for COVID. Resident has been placed on transmission-based precaution (contact/droplet). Family/Provider/NOD (Nurse on Duty) aware. 11/29/24 11:35 AM ID NP (Infectious Disease Nurse Practitioner) Impression/Plan: -Monitor patient symptoms address as they occur. -Pt stable currently. No current signs or symptoms of respiratory distress. -Continue to monitor vital signs q4H. -Antiviral if needed. -Continue strict contact/droplet isolation precautions per CDC (Centers for Disease Control) and Facility protocol. -Contact ID if the resident experiences any changes in condition or worsening signs and symptoms of infection including fever or signs of respiratory distress. 12/02/24 12:19 AM Patient is + for Covid. He has congestion and heart rate elevated to 125, respiration rate 26. Oxygen sats were not obtained due to patient restlessness and could not keep the pulse ox on his finger. Provider called. Orders to send out patient to ER to evaluate. 911 called. DON, wife notified of transfer. No documentation in progress for interventions for elevated heart rate of 110 on 11/30/24 at 3:02 AM, and elevated heart rate of 107 on 12/01/24 at 10:53 AM. The facility unable to provide documentation. R1's Resident's Bath and Skin Report Sheet for October 2024 reviewed. The report sheet showed R1's skin was intact. Resident's Bath and Skin Report Sheet for November 2024 reviewed. The report sheet showed on 11/18/24 R1 had a blister to the right heel (DTI) that was black, hard, and closed. The same report sheet showed on 11/25/24 R1 continued to have a blister to the right heel that was black, hard, and closed. Treatment records for October and November 2024 were reviewed, no orders for right heel blister. No skin assessments in the EMR. The Facility's Acute Condition Changes - Clinical Protocol revised August 2008 showed: 1. The nurse shall assess and document/report the following: a. vital signs, f. onset/duration/severity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145611 If continuation sheet Page 4 of 5 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 12/12/2024 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The Facility's Pressure /Skin Breakdown- Clinical Protocol Effective January 2017 showed Policy Specifications: 2. In addition, the nurse shall assess and document/report the following: a. Full assessment of skin condition including but not limited to location, stage, or partial/full thickness, length, width and depth, presence of exudates or necrotic tissue. D. Current treatments, including support surfaces. 4. The physician will help the staff define the type of an ulceration. 7. The physician will authorize pertinent orders related to wound treatments, including pressure redistribution surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents. Event ID: Facility ID: 145611 If continuation sheet Page 5 of 5