Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
observations, interviews and record reviews, the facility failed to implement physician's orders. This applies
to 4 of 4 residents (R1-R4) reviewed for history of UTIs (urinary tract infections).
Residents Affected - Some
The findings include:
1. R3's diagnosis includes UTI (urinary tract infection), prosthetic hyperplasia with urinary tract symptoms,
retention of urine, & acute kidney failure.
On [DATE] at 10:48 am, R3 was sitting in his wheelchair, his catheter bag was hanging from under the
chair, and the bag and tubing was touching the floor. The urine was dark and cloudy. At this time R3's said
that he had pain in his penis and testicles, and that he reported it to the staff. At 10:55 am V3 (Nurse) came
into the room and saw that the bag and tubing was on the floor and tried to reposition them off the floor. V3
said that she was going to put R3's leg bag on him. V3 said that earlier she put the catheter bag under the
wheelchair and R3 did tell her that his penis and testicles were hurting him. V3 said that she was going to
notify the doctor. V3 did not change R3's catheter bag or tubing as per R3's [DATE] Physician's order.
On [DATE] at 11:02 am, V7 (Nurse) was providing catheter care cleaning R3's penis and catheter tubing
with 4 X 4 gauze dressing wet with normal saline. V7 did not use soap and water. R3 complained of pain in
his penis and testicles. There was leakage around the opening of the penis and a brown substance both
dry and wet around the tubing near the opening. V7 did not change R3's catheter bag and or tubing as per
R3's [DATE] Physician's order.
On [DATE] at 12:33 pm V8 NP (Nurse Practitioner) said that her expectations are that the nurses changed
R3's catheters, bags, and tubing when it is clinically indicated such as when the urine was dark and cloudy,
when R3 complained of pain, and when R3's catheter was leaking, just as the [DATE] physician's order
shows.
R3's physician's orders showed:
[DATE] catheter care every shift.
[DATE] record output from urinary catheter every shift.
[DATE] change foley catheter for blockage and or leaking.
[DATE] change catheter, tubing or bag when clinically indicated as needed.
(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 8
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
01/31/2025
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
R3's EMARs (Electronic Medication Administration Records) were reviewed:
Level of Harm - Minimal harm
or potential for actual harm
November EMAR showed:
No documentation for R3's output from [DATE] day shift through [DATE] night shift.
Residents Affected - Some
R3's progress notes were reviewed, and no notes were found showing resident refused to wear a leg bag
or that the catheter was changed on [DATE] or [DATE].
On [DATE] at 12:41 PM V2 DON (Director of Nursing) verified the above findings while looking at R3's
electronic health records. V2 said that the nurse should have followed the orders to change the catheter
and tubing on [DATE] and [DATE] because if not it could lead to an infection. V2 said, while looking at R3's
lab results from [DATE] that it showed that R3 had bacteria in his urine.
2. R4's diagnoses include Type 2 diabetes, acute kidney failure, benign prostatic hyperplasia with lower
urinary tract symptoms, chronic kidney disease stage 3, urinary tract infections, and pyuria.
On [DATE] at 2:47 pm V5 (Nurse) provided catheter care for R4. When she cleaned R4's penis and catheter
tubing, she only used normal saline. V5 did not use soap and water.
R4's Physician's orders showed:
[DATE] catheter care every shift.
[DATE] catheter monitor output every shift.
R4's EMARs (Electronic Medication Administration Records) reviewed:
[DATE] EMAR showed:
No output done for [DATE]th, 2024, at 10:30pm through [DATE]th, 2024, at 630 am.
December EMAR showed:
On [DATE] the staff did not change catheter securement device.
On [DATE] at 12:41 pm V2 DON (Director of Nursing) while looking at R4's electronic health records,
verified that the above treatments were not provided. V2 said that by not providing proper catheter care and
not changing the securement device it can cause UTIs.
3. R2's diagnoses include type 2 diabetes, retention of urine, neuromuscular dysfunction of the bladder, and
UTIs.
On [DATE] at 1:07 pm V3 (Nurse) provided catheter care for R2. When she cleaned R2's penis, skin around
suprapubic catheter and the tubing, she only used normal saline. V3 did not use soap and water as R2
physician's order showed. When V3 removed the dressing from around the catheter the date on the
dressing showed 1/25.
R2's EMARs reviewed:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145611
If continuation sheet
Page 2 of 8
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
01/31/2025
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
November EMAR showed:
Level of Harm - Minimal harm
or potential for actual harm
No documentation showing R2's supra pubic dressing was changed on [DATE], [DATE] and [DATE].
Residents Affected - Some
Monitoring R2's output ever shift was not done on [DATE] Evenings, [DATE] 10:30pm, [DATE] 630 am, &
[DATE] 2:30 PM.
December EMAR showed:
[DATE]th, 12th & 22nd no documentation for R2's urine output was done.
January EMAR showed:
On [DATE] at 10:30 pm no urine output documented. On [DATE] no output document for all three shifts.
On [DATE] at 9:00 am Bactrim DS 800-160mg was not given as ordered.
On [DATE] at 12:41 PM V2 DON, while looking at R2's electronic health records, verified that the above
treatments and medications were not provided. V2 said that the nurse should have used soap and water
when providing catheter care as the order and the facility policy shows. V2 said that by the nurse not giving
R2 his Bactrim as ordered could have caused him to get another UTI or his current UTI not be treated
appropriately as the doctor ordered. V2 said as she looked in R2's record, R2's [DATE] UA showed that his
urine was positive for bacteria, a moderate amount, and his [DATE] culture and sensitivity came back
positive for pseudomonas and E. coli (Bacteria). V2 said that she is noticing a trend with the residents
having UTI's and becoming septic.
4. R1 was discharged to the local community hospital on [DATE] for altered mental status and died on
[DATE]. R1's diagnoses included hydronephrosis with renal and ureteral calculous obstruction, retention of
urine, urinary tract infection, benign prosthetic hyperplasia with lower urinary tract symptoms, and kidney
failure.
R1's October EMAR showed:
On [DATE] day shift, [DATE] day shift and [DATE] day shift there was no recording of urine output for R1.
R1's November EMAR showed:
On [DATE] at 10:30 pm, [DATE] at 630 am, & [DATE] at 630 am no recording of urine output for R1.
R1's December EMAR showed:
On [DATE] and [DATE] no recording of urine output for R1.
On [DATE] at 12:41 PM V2 DON said that poor catheter care could be the cause of the UTI's and sepsis of
all four residents. V2 said that it is a facility's policy that all nurses follow physicians orders and believes that
the nurses do not follow the physician's orders it can contribute to the residents being hospitalized with
UTI's and septicemia.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145611
If continuation sheet
Page 3 of 8
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
01/31/2025
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 - Some
The facility's Catheter Care policy dated [DATE] showed: The purpose of this procedure is to prevent
infections of the resident's urinary tract. Be sure the catheter tubing and drainage bag are kept off the floor.
Ensure that the catheter remains secure with a leg strap to reduce friction and movement at the insertion
site, catheter tubing should be strapped to the resident's inner thigh. Report to the supervisor any
complaints the resident may have of burning, tenderness, or pain in the urethral area. Supplies soap and
water. For the male use a washcloth with warm water and soap to cleanse around the meatus. Use a clean
washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately
4 inches outward. Remove gloves and discard into designated container. Wash hands and dry thoroughly,
clean the bedside stand, wash and dry hands thoroughly. The following information should be recorded in
the resident's medical records the date and time that the catheter care was given, the name and title of the
individuals giving the catheter care all assessment data obtained when giving catheter care, character of
urine such as color and odor, any problems noted at the catheter urethral junction during perineal care such
as drainage, redness, bleeding, irritation, crusting, or pain.
The facility Suprapubic Catheter care policy dated [DATE] showed: The purpose of this procedure is to
prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. Maintain
an accurate record of the resident's daily output. Equipment: soap and water. Wash around the catheter site
with soap and water, note if the resident has a drainage sponge around the stoma site, remove the
drainage sponge before washing with soap and water, wash the outer part of the catheter tubing with soap
and water. Document the date and time the procedure was performed, the name and title of the individual
who performed the procedure, assessment data obtained during the procedure, character of the urine such
as color and odor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145611
If continuation sheet
Page 4 of 8
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
01/31/2025
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 - Some
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 catheter care for 4 of 4
residents (R1-R4) that were reviewed for catheter care.
The findings include:
1. R3's diagnoses includes UTI (urinary tract infection), prosthetic hyperplasia with urinary tract symptoms,
retention of urine, & acute kidney failure.
On [DATE] at 10:48 am, R3 was sitting in his wheelchair, his catheter bag was hanging from under the
chair, and the bag and tubing was touching the floor. The urine was dark and cloudy. At this time R3 stated
that he (R3) had pain in his penis and testicles, and that he reported it to the staff. At 10:55 am V3 (Nurse)
came into the room and saw that the bag and tubing was on the floor and tried to reposition them off the
floor. V3 stated that she was going to put R3's leg bag on him. V3 stated that earlier she put the catheter
bag under the wheelchair and R3 did tell her that his penis and testicles were hurting him. V3 stated that
she was going to notify the doctor. V3 did not change R3's catheter bag or tubing as per R3's [DATE]
Physician's order.
On [DATE] at 11:02 am, V7 (Nurse) was providing catheter care cleaning R3's penis and catheter tubing
with 4 X 4 gauze dressing wet with normal saline. V7 did not use soap and water. R3 complained of pain in
his penis and testicles. There was leakage around the opening of the penis and a brown substance both
dry and wet around the tubing near the opening. V7 did not change R3's catheter bag and or tubing as per
R3's [DATE] Physician's order.
On [DATE] at 12:33 pm V8 NP (Nurse Practitioner) stated that her expectations are that the nurses
changed R3's catheter, bag, and tubing when it is clinically indicated such as when the urine was dark and
cloudy, when R3 complained of pain, and when R3's catheter was leaking, just as the [DATE] physician's
order shows.
R3's physician's orders showed:
[DATE] catheter care every shift.
[DATE] record output from urinary catheter every shift.
[DATE] change foley catheter for blockage and or leaking.
[DATE] change catheter, tubing or bag when clinically indicated as needed.
R3's EMARs (Electronic Medication Administration Records) were reviewed:
November EMAR showed:
No documentation for R3's output from [DATE] day shift through [DATE] night shift.
R3's progress notes were reviewed, and no notes were found showing resident refused to wear a leg
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145611
If continuation sheet
Page 5 of 8
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
01/31/2025
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
bag or that the catheter was changed on [DATE] or [DATE].
Level of Harm - Minimal harm
or potential for actual harm
On [DATE] at 12:41 PM V2 DON (Director of Nursing) verified the above findings while looking at R3's
electronic health records. V2 stated that the nurse should have followed the orders to change the catheter
and tubing on [DATE] and [DATE] because if not it could lead to an infection. V2 stated, while looking at
R3's lab results from [DATE] that it showed that R3 had bacteria in his urine.
Residents Affected - Some
2. R4's diagnoses include Type 2 diabetes, acute kidney failure, benign prostatic hyperplasia with lower
urinary tract symptoms, chronic kidney disease stage 3, urinary tract infections, and pyuria.
On [DATE] at 2:47 pm V5 (Nurse) provided catheter care for R4. When V5 cleaned R4's penis and catheter
tubing, she (V5) only used normal saline. V5 did not use soap and water. V5 only cleaned her hands twice
while providing care. V5 washed her hands before she put on her gloves at the beginning of care, and after
she was done providing care, she removed her gloves and washed her hands the 2nd time. V5 did not
clean her hands after cleaning R4's penis and catheter tubing after she removed her gloves. V5 only
replaced her dirty gloves with clean gloves and continued drying R4's penis, then again removed gloves
and put on new gloves and attached the brief and placed R4's blanket on him with her dirty gloved hands.
R4's Physician's orders showed:
[DATE] catheter care every shift.
[DATE] catheter monitor output every shift.
R4's EMARs (Electronic Medication Administration Records) reviewed:
[DATE] EMAR showed:
No output done for [DATE]th, 2024, at 10:30pm through [DATE]th, 2024, at 630 am.
December EMAR showed:
On [DATE] the staff did not change catheter securement device.
On [DATE] at 12:41 pm V2 DON (Director of Nursing) while looking at R4's electronic health records,
verified that the above treatments were not provided. V2 stated that by not providing proper catheter care
and not changing the securement device it can cause UTIs.
3. R2's diagnoses include type 2 diabetes, retention of urine, neuromuscular dysfunction of the bladder, and
UTIs.
On [DATE] at 1:07 pm V3 (Nurse) provided catheter care for R2. When she cleaned R2's penis, skin around
suprapubic catheter and the tubing, she (V3) only used normal saline. V3 did not use soap and water as R2
physician's order showed. When V3 removed the dressing from around the catheter the date on the
dressing showed 1/25.
R2's EMARs reviewed:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145611
If continuation sheet
Page 6 of 8
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
01/31/2025
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
November EMAR showed:
Level of Harm - Minimal harm
or potential for actual harm
No documentation showing R2's supra pubic dressing was changed on [DATE], [DATE] and [DATE].
Residents Affected - Some
Monitoring R2's output ever shift was not done on [DATE] Evenings, [DATE] 10:30pm, [DATE] 630 am, &
[DATE] 2:30 PM.
December EMAR showed:
[DATE]th, 12th & 22nd no documentation for R2's urine output was done.
January EMAR showed:
On [DATE] at 10:30 pm no urine output documented. On [DATE] no output document for all three shifts.
On [DATE] at 9:00 am Bactrim DS 800-160mg was not given as ordered.
On [DATE] at 12:41 PM V2 DON, while looking at R2's electronic health records, verified that the above
treatments and medications were not provided. V2 stated that the nurse should have used soap and water
when providing catheter care as the order and the facility policy shows. V2 stated that by the nurse not
giving R2 his Bactrim as ordered could have caused him to get another UTI or his current UTI not be
treated appropriately as the doctor ordered. V2 stated as she looked in R2's record, R2's [DATE] UA
showed that his urine was positive for bacteria, a moderate amount, and his [DATE] culture and sensitivity
came back positive for pseudomonas and E. coli (Bacteria). V2 stated that she is noticing a trend with the
residents having UTI's and becoming septic.
4. R1 was discharged to the local community hospital on [DATE] for altered mental status and died on
[DATE]. R1's diagnoses included hydronephrosis with renal and ureteral calculous obstruction, retention of
urine, urinary tract infection, benign prosthetic hyperplasia with lower urinary tract symptoms, and kidney
failure.
R1's October EMAR showed:
On [DATE] day shift, [DATE] day shift and [DATE] day shift there was no recording of urine output for R1.
R1's November EMAR showed:
On [DATE] at 10:30 pm, [DATE] at 630 am, & [DATE] at 630 am no recording of urine output for R1.
R1's December EMAR showed:
On [DATE] and [DATE] no recording of urine output for R1.
On [DATE] at 12:41 PM V2 DON stated that poor catheter care could be the cause of the UTI's and sepsis
of all four residents. V2 stated that it is a facility's policy that all nurses follow physicians orders and believes
that the nurses do not follow the physician's orders it can contribute to the residents being hospitalized with
UTI's and septicemia.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145611
If continuation sheet
Page 7 of 8
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
01/31/2025
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 - Some
The facility's Catheter Care policy dated [DATE] showed: The purpose of this procedure is to prevent
infections of the resident's urinary tract. Be sure the catheter tubing and drainage bag are kept off the floor.
Ensure that the catheter remains secure with a leg strap to reduce friction and movement at the insertion
site, catheter tubing should be strapped to the resident's inner thigh. Report to the supervisor any
complaints the resident may have of burning, tenderness, or pain in the urethral area. Supplies soap and
water. For the male use a washcloth with warm water and soap to cleanse around the meatus. Use a clean
washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately
4 inches outward. Remove gloves and discard into designated container. Wash hands and dry thoroughly,
clean the bedside stand, wash and dry hands thoroughly. The following information should be recorded in
the resident's medical records the date and time that the catheter care was given, the name and title of the
individuals giving the catheter care all assessment data obtained when giving catheter care, character of
urine such as color and odor, any problems noted at the catheter urethral junction during perineal care such
as drainage, redness, bleeding, irritation, crusting, or pain.
The facility Suprapubic Catheter care policy dated [DATE] showed: The purpose of this procedure is to
prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. Maintain
an accurate record of the resident's daily output. Equipment: soap and water. Wash around the catheter site
with soap and water, note if the resident has a drainage sponge around the stoma site, remove the
drainage sponge before washing with soap and water, wash the outer part of the catheter tubing with soap
and water. Document the date and time the procedure was performed, the name and title of the individual
who performed the procedure, assessment data obtained during the procedure, character of the urine such
as color and odor.
The facility's Handwashing/Hand Hygiene policy dated [DATE] showed that the facility recognizes hand
hygiene procedures as primary means to prevent the spread of infections among residents, personnel, and
visitors. Hand hygiene should be performed before direct contact with residents after direct contact with
residents before putting on gloves, before handling clean or soiled dressings gauze pads etc, before
moving from a contaminated body site to a clean body site during resident care, before and after putting on
PPE (personal protective equipment) including gloves, after contact with resident's intact skin, after
handling used dressings, potentially contaminated equipment, ect., after contact with objects such as
medical devices or equipment in the immediate vicinity of the resident that may be potentially
contaminated, after contact with potentially infectious material., and after removing gloves.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145611
If continuation sheet
Page 8 of 8
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the January 31, 2025 survey of ST JAMES WELLNESS REHAB VILLAS?
This was a inspection survey of ST JAMES WELLNESS REHAB VILLAS on January 31, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ST JAMES WELLNESS REHAB VILLAS on January 31, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, an..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.