Inspection visit
Inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
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 provide timely incontinence care for residents
who require assistance with toileting and hygiene.
Residents Affected - Few
This applies to 3 of 4 residents (R1, R2, R3) reviewed for activities of daily living (ADL) care in the sample
of 19.
The findings include:
1. R1's Face sheet shows that R1 is [AGE] year-old who has multiple medical diagnoses including morbid
obesity, personal history of urinary tract infection, chronic pain, depression, unspecified (mood) affective
disorder, unsteadiness on feet, and weakness.
On March 18, 2025, at 10:28 AM, a very strong urine odor was coming from R1's room. R1 was lying in
bed, alert and oriented. R1's bed sheets, incontinence brief, and incontinence pad, were heavily saturated
with urine, and were all stained with brownish discoloration from the urine. R1 also said she has not been
changed yet this shift. R1 used the call light to ask for help, but the staff turned off the light stating she will
come back for her. R1 said she placed the bedpan underneath herself to move her bowel. R1 said she (R1)
has been lying on her bedpan for an hour now waiting for the CAN/Certified Nursing Assistant staff (V13) to
come and assist her.
On March 18, at 10:58 AM, V13 (CNA) stated that R1 can walk and go to the rest room but she's refusing.
Every morning the staff find her wet and won't get up to the washroom. R1 has behavior she goes to the
shower and ambulate to hallway when she wants to. R1 doesn't want to move, she wants staff to do
everything for her when she feels like it.
R1's Minimum Data Set (MDS) dated [DATE], shows R1 is alert and oriented, she's always incontinent, and
requires substantial to maximal assistance for toileting hygiene.
R1's care plan dated January 31, 2025, shows R1 has mixed bladder incontinence related to impaired
mobility and obesity. This same care plan shows multiple interventions including check and change every 2
hours and as needed, and clean peri-area with each incontinence episode.
2.R2's Face sheet shows R2 is [AGE] year-old who has multiple medical diagnoses including weakness,
unspecified dementia, non-pressure chronic ulcer of unspecified left lower leg limited to breakdown of skin.
On March 18, 2025, at 1:15 PM, R2 was lying in bed, stated that she was last changed early this
(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 6
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
03/21/2025
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 0677
Level of Harm - Minimal harm
or potential for actual harm
morning. She (R2) could not remember who changed her this morning because she was still half asleep.
R2 turned on the call light and V19 (CNA) responded and checked R2. V19 said the last time she changed
R2 was right after breakfast, because she was very busy getting up other residents. R2 was observed
heavily saturated with urine, with pervasive urine odor, which overflowed from the incontinence brief to her
incontinence pad. R2 also had a large bowel movement.
Residents Affected - Few
R2's Minimum Data Set, dated [DATE], shows that R2 is completely dependent on staff for her toileting and
personal hygiene. R2 was alert and oriented but forgetful.
3. R3's Face sheet shows R3 is [AGE] year-old who has multiple medical diagnoses including cerebral
infarction dur to unspecified occlusion or stenosis of left middle cerebral artery, morbid obesity, unspecified
mental disorder.
On March 18, 2025, at 1:34 PM, R3 was resting in bed. R3 was alert, oriented but has difficulty
understanding inquiries and instructions. R3 was heavily saturated with urine and had a bowel movement
which was dry and pasty. V19 said that she has not changed R3. V19 stated she usually waits for R3 to tell
her when she needed to be change. R3's MDS dated [DATE], shows R3 has short-term memory problem,
and is completely dependent on staff for toileting hygiene.
R3's care plan dated February 10, 20,25, shows R3 has functional bladder incontinence related to impaired
mobility, and physical limitations. This same care plan shows multiple intervention including check and
change every 2 hours and as needed, and to clean peri-area with each incontinence episode.
On March 19, 2025, at 9:16 AM, V4 (Regional Consultant Nurse) stated staff must check and change
residents for incontinence every 2 hours and as needed, to prevent skin breakdown, and promote comfort
and dignity.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145611
If continuation sheet
Page 2 of 6
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
03/21/2025
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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 physician orders for wound treatment
and wound dressing changes as needed.
Residents Affected - Few
This applies to 1 of 3 resident reviewed for wounds in the sample of 19.
The findings include:
R4's Face sheet shows R4 is [AGE] year-old who has multiple diagnoses including type 2 diabetes mellitus,
unspecified dementia, infection of intervertebral disc, sacral and sacrococcygeal region, and unstageable
pressure ulcer of the sacral region.
On March 19, 2025, around 6AM, R4 was lying in bed. She has a wound dressing to sacral region which
was heavily saturated with wound discharges and exudates. This wound dressing was dated 3/18/25 and
was detached from R4 exposing her unstageable sacral ulcer. Surrounding area of the wound was wet with
exudates. R4 was noted with a rectal tube that was leaking on the side with fecal matter near the exposed
wound. V10 (Certified Nursing Assistant/CNA) changed the brief and said he did not notify the nurse about
R4's need for dressing change because he was busy trying to complete his assignment.
On March 20, 2025, at 10:43 AM, V8 (Wound Care physician) stated that V4's wound dressing should be
change daily and as needed. When wound dressing becomes very soiled, the staff must immediately
change the dressing as the exudate can cause potential skin breakdown.
The weekly skin assessment dated [DATE], shows this unstageable wound is measured as Length (L)
10-centimeter (cm) x Width (W) 10 cm.
Physician Order Summary (POS) with revision date of March 7, 2025, shows Cleanse sacrum with normal
saline, apply medihoney, and cover with dry dressing every day shift and Cleanse sacrum with normal
saline, apply medihoney, and cover with dry dressing as needed if dressing comes loose or becomes
soiled.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145611
If continuation sheet
Page 3 of 6
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
03/21/2025
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure that there is a physician order for
self-administration of an inhaler medication, and failed to ensure that medication was administered to
residents accurately as prescribed by physician.
This applies to 2 of 7 residents (R1 and R5) reviewed for medication administration in the sample of 19.
The findings include:
1. R1's Face sheet shows that R1 is [AGE] year-old who has multiple medical diagnoses including morbid
obesity, recurrent major depressive disorder, unspecified (mood) affective disorder, chronic obstructive
pulmonary disease, and asthma.
On March 18, 2025, at 10:28 AM, R1 was resting in bed, there was a Symbicort inhaler at her bedside. R1
said she needed it. However, her Physician Order Summary (POS), does not have evidence of
documentation that she may keep the medication at bedside. There was no updated care plan with regards
to R1's self-administration of medication.
2. R5's Face sheet shows that R5 is [AGE] year-old who has multiple medical diagnoses including type 2
diabetes mellitus, unspecified dementia, dysphagia, oral phase, Vitamin D deficiency, hypertension,
weakness, and cognitive communication deficit.
On March 19, 2025, at 9:00 AM, V14 (Restorative Aid) was observed feeding R5. There were unidentified
white very small circular granules, and some small pieces of irregular shape substances mixed and
sprinkled to R1's pureed bread. When surveyor asked what it was, V14 said that she doesn't know. V14 said
that she didn't know who set up the tray for R5.
On March 19, 2025, at 9:04 AM, V3 (Assistant Director of Nursing/ADON) said that the white substance
was substitute sugar. However, upon comparison of the sugar substitute to the unidentified substance,
there was a difference in appearance/consistency.
At around 9:10 AM, V6 (Nurse) who was the primary nurse of R5, was passing medication at the end of the
2-north hallway, far from the dining room. As V3 and surveyor approached V6, he (V6) informed surveyor
and V3 that the unidentified white substances were R5's medications which V6 mixed in the food when R5
refused the medications with apple sauce.
On March 18, 2025, at 12:55 PM, V19 said she had seen medications mixed in the residents' food when
she collects meal trays from the bedroom and dining room, but unable to tell specific residents. Sometimes
the resident does not eat, so the food is left untouched along with the meds. V19 said she had seen V6
(Nurse) do it.
On March 19, 2025, at 9:16 AM, V4 (Regional Consultant Nurse) said inhaler medication can be left at
bedside if there's an order and assessment of self-administration. The staff can mix the medication with the
resident's meal if they are the one who will feed the resident to ensure that the medications are taken by
the resident.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145611
If continuation sheet
Page 4 of 6
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
03/21/2025
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 0755
Facility's Medication Administration Policy dated October 25, 2014, shows:
Level of Harm - Minimal harm
or potential for actual harm
Policy: Medications are administered as prescribed in accordance with good nursing principles and
practices and only by persons legally authorized to do so. Personnel authorized to do so only after they
have been properly oriented to the medication management system in the facility. The facility has sufficient
staff and a medication distribution system to ensure sage administration of medications without
unnecessary interruptions.
Residents Affected - Few
Procedures:
7. The person who prepares the dose for administration is the person who administers the dose.
14. The residents are allowed to self-administer medication when specifically authorized by the attending
physician and in accordance with procedures for self-administration of medication.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145611
If continuation sheet
Page 5 of 6
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
03/21/2025
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 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to repair their leaking ice machine in
the nourishment room.
Residents Affected - Some
This applies to 7 of 7 residents (R13, R14, R15, R16, R17, R18, R19) who are ambulatory and with
impaired cognition.
The findings include:
The facility has nourishment room in each floor. On March 18, 2025, at 12:00 PM, the door of the
second-floor nourishment room was wide open, the doorknob was not equipped with a lock. The ice maker
machine that was inside the nourishment room was leaking water on the floor. A puddle of water was
observed.
On March 18, 2025, at 12:12 PM, V17 and V18 (Both Certified Nursing Assistant/CNA) said the ice
machine has currently been leaking for a week, and they reported it.
On March 19, 2025, at 7:06 AM, the nourishment room was unlocked. There were folded bedsheets on the
floor absorbing the water leaking from the base of the ice machine. As surveyor stepped on the sheets,
water squeezed out of the wet bedsheets. V6 (Nurse) said the sheets are for the leaking ice machine.
On March 19, 2025, at 10:13 AM, V5 (Maintenance/Housekeeping Director) stated that they repaired the
ice maker machine on the second floor because it was not making enough ice. He was aware that the ice
machine was leaking, and he was only notified the day before.
The second floor has residents who are identified as ambulatory and has impaired cognition based on their
most recent Minimum Data Set. These residents include R13, R14, R15, R16, R17, R18, R19. From March
18 to March 19, 2025, during observation on the second floor, there were residents observed ambulating in
the hallway and day area.
On May 19, 2025, at around 8:15 AM, R14 was observed wandering in the 2 North hallway where the ice
machine was located, entering one bedroom to another of other residents, and attempted to open closed
doors.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145611
If continuation sheet
Page 6 of 6
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Back to topCitations
4 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.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
FAQ · About this visit
Common questions about this visit
What happened during the March 21, 2025 survey of ST JAMES WELLNESS REHAB VILLAS?
This was a inspection survey of ST JAMES WELLNESS REHAB VILLAS on March 21, 2025. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ST JAMES WELLNESS REHAB VILLAS on March 21, 2025?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide care and assistance to perform activities of daily living for any resident who is unable."
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
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