Health inspection·January 7, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review the facility failed to ensure enough clean linens, blankets, towels, and wash cloths were available for the residents. Residents Affected - Many This applies to all the 69 residents in the building reviewed for a homelike environment. Findings include: On 01/02/25 at 9:24 AM, V2 DON (Director of Nursing) stated the facility census is 69. Facility's Data Sheet dated 12/31/24 also indicated their total census is 69. On 12/31/24 at 10:56 AM, R1 stated that she has made a list of items that the facility doesn't have. R1 stated that there were no bed pads the previous night and facility staff had given her their last sheet. R1 stated there were no wash rags available and no Kleenex. R1's 12/30/2024 MDS (Minimum Data Set) showed R1 is cognitively intact. On 12/31/24 at 10:22 AM, R3 stated the facility did not have enough bed sheets. R3's 12/8/2024 MDS showed she is cognitively intact. On 1/02/25 at 10:47 AM, R5 stated the facility is short on linen. R5 stated they are supposed to change his linen every Monday and they have not been doing it. R5's 12/2/24 MDS showed he is cognitively intact. On 12/31/24 at 11:05 AM, R2 stated the facility does not have enough towels or linens. R2's 11/26/2024 MDS showed she is cognitively intact. On 12/31/24 at 9:10 AM, a tour was conducted with V2 (DON) on the first floor and the second floor. The facility did not have dedicated linen closets on the floors, instead, staff obtained linens from the linen carts on the floor. On 12/31/24 at 9:40 AM on second floor, one linen cart had six pillowcases, twelve sheets, and nine bath blankets. The cart contained no washcloths or towels. The other cart on second floor had three top sheets, one hospital gown, two blankets, five pillowcases, and five fitted sheets. No towels or washcloths were available. On 12/31/24 at 9:50 AM in the basement laundry area, two laundry aides were working (V3 and V4) and they were folding resident clothing. In the laundry area, there were a total of 5 bedsheets, one reusable bed pad, and 4 blankets. When asked where the facility keeps the surplus linen, V3 and V4 Page 1 of 3 145611 145611 01/07/2025 St James Wellness Rehab Villas 1251 East Richton Road Crete, IL 60417

F 0584 stated this is all we have. We are washing some. We already delivered the linens. Level of Harm - Minimal harm or potential for actual harm On 12/31/2024 at 10:18 AM, the first-floor linen cart held four towels and two washcloths, seven pillowcases, and seven bath blankets. Residents Affected - Many On 1/02/25 at 10:05 AM, R6 stated sometimes they don't have enough linens. R6 stated the facility needed a lot of linen, adding they change it only when it gets wet. At 10:23 AM, R4 stated that they don't change linens frequently. R4 stated he doesn't think they have enough linens. At 11:03 AM, R7 stated that facility is short of linens. On 12/31/24 at 10:35 AM, V5 (Maintenance Director/ Housekeeping Director) stated that he was aware that the facility needed surplus linen, stating We don't have any. V5 stated that the CNAs (Certified Nursing Assistants) were throwing the linen away. On 12/31/24 at 10:50 AM, V6 (CNA) and V7 LPN (Licensed Practical Nurse) were interviewed. V6 stated she doesn't know who is throwing linens and towels away, but they don't have enough towels to work with, and V7 agreed. On 01/02/25 at 10:01 AM, V16 (CNA) stated that we don't have enough linen. V16 stated that staff put the dirty linen in the trash bags and take it to the laundry. V16 stated that sometimes staff don't have linen until 2:00PM, so they cannot give their showers. On 01/02/25 at 10:20 AM, V18 (CNA) stated that staff don't have enough linens and towels, and every day what linen they do have, they get it late. V18 stated We are not throwing linens away. On 12/31/24 at 12:19 PM, V8 (CNA) stated how can we do showers if you don't have linen? V8 stated she does not throw away linens or towels. On 12/31/24 at 11:19 AM, V1 (Administrator) stated that the facility does not have any backup supplies of linens, blankets, or towels. V1 stated that the facility needs more supplies, especially in case of emergency. On 12/31/24 at 10:28 AM, V9 (CNA) stated that staff don't have enough linen to change beds. On 12/31/24 at 12:47 PM, V10 (Restorative Aid) stated they don't get linens and towels soon enough, and sometimes there is a delay. V10 stated it all depends on which supplies are needed, but there are times they are short. On 1/02/25 at 9:46 AM, V13 LPN (Licensed Practical Nurse) sometimes there is linen, and sometimes there is no linen. On 01/02/25 at 10:01 AM, V15 (CNA) stated some days there is linen and some days there is no linen, and most of the time, there is not enough clean linen. V15 stated that the Social Worker did an in-service about showers, and she told them we don't have enough towels, but she did not know what was done about it. On 01/02/25 at 9:55 AM, V14 (CNA) stated that sometimes we can't bathe the residents, or we don't have enough linens to make their beds. V14 stated she told V2 (DON) when V2 asked her why things were not done. V14 stated this just started since last year having a shortage. V14 stated she never 145611 Page 2 of 3 145611 01/07/2025 St James Wellness Rehab Villas 1251 East Richton Road Crete, IL 60417

F 0584 throws linens away unless they are stained very badly. Level of Harm - Minimal harm or potential for actual harm On 1/02/25 at 9:24 AM, V2 (DON) stated that she has asked Housekeeping and the Administrator to order more linen, and she has not seen any being ordered or purchased. V2 stated she didn't know if the funds were available to buy the linens. Residents Affected - Many The facility's Laundry Services Policy dated 01/2024 showed under #3 that laundry service will maintain sufficient inventory of clean linen and personal laundry in good repair to meet the needs of the residents. Under #15, this policy showed The Environmental Service Director shall be responsible for assuring quality assurance activities are performed in accordance with the facility's approved Quality Assurance Plan. 145611 Page 3 of 3