St James Wellness Rehab Villas

Penalties

• Dec 6, 2024 — IDPH fine (Nursing Home Care Act) ($500)

Inspection findings

1. Mar 21, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Mar 24, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Mar 24, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 24, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0908 Environmental Deficiencies

     Keep all essential equipment working safely.

     Corrected Mar 26, 2025 · CMS health inspection

2. Jan 31, 2025 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Feb 4, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Feb 4, 2025 · CMS health inspection

3. Jan 7, 2025 Health · 1 finding
   • Not serious Scope/severity F Complaint

     F0584 Resident Rights Deficiencies

     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.

     Corrected Jan 9, 2025 · CMS health inspection

4. Dec 12, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Dec 13, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Dec 13, 2024 · CMS health inspection

5. Dec 6, 2024 Fire Safety · 40 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0013 Emergency Preparedness Deficiencies

     Develop Emergency Preparedness policies and procedures.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0025 Emergency Preparedness Deficiencies

     Create arrangements with other facilities to receive patients.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0029 Emergency Preparedness Deficiencies

     Develop a communication plan.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0036 Emergency Preparedness Deficiencies

     Establish emergency prep training and testing.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity E

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Dec 13, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0625 Resident Rights Deficiencies

     Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

     Corrected Dec 13, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Dec 13, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Dec 13, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Dec 13, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Dec 13, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Dec 13, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Dec 13, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 13, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0908 Environmental Deficiencies

     Keep all essential equipment working safely.

     Corrected Dec 31, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0919 Environmental Deficiencies

     Make sure that a working call system is available in each resident's bathroom and bathing area.

     Corrected Dec 13, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0225 Egress Deficiencies

     Have stairways and smokeproof enclosures used as exits that meet safety requirements.

     Corrected Jan 7, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0271 Egress Deficiencies

     Have exits that are accessible at all times.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jan 7, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jan 3, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jan 9, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Jan 6, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jan 30, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Jan 2, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0362 Smoke Deficiencies

     Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

     Corrected Jan 6, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jan 7, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0531 Services Deficiencies

     Have elevators that firefighters can control in the event of a fire.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0911 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the installation and maintenance of electrical systems.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Dec 30, 2024 · CMS fire safety

   • Not serious Scope/severity C

     Type C Illinois Nursing Home Care Act violation

     Type C: less than minimal harm (1-132). Sections of the Illinois Administrative Code cited: 300.615e), 300.615f), and 300.661). This instance in accordance with 300.282f) and j) of the Code is assessed a fine due to the violation of the sections of the Code with a high-risk designation: 300.615e), 300.615f), and 300.661).

     Statement of deficiencies (PDF)

6. Sep 8, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Sep 13, 2024 · CMS health inspection

7. Dec 18, 2023 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 5, 2024 · CMS health inspection

8. Nov 17, 2023 Fire Safety · 13 findings
   • Not serious Scope/severity F

     E0037 Emergency Preparedness Deficiencies

     Establish staff and initial training requirements.

     Corrected Dec 13, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Dec 11, 2023 · CMS fire safety

   • Not serious Scope/severity E

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Dec 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Dec 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Dec 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Dec 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Dec 13, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Dec 13, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Dec 15, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0362 Smoke Deficiencies

     Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

     Corrected Dec 11, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Dec 11, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Dec 11, 2023 · CMS fire safety

9. Mar 16, 2023 Health · 10 findings
   • Not serious Scope/severity D

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected Mar 23, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Mar 23, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Mar 23, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected Mar 23, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Mar 23, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0808 Nutrition and Dietary Deficiencies

     Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

     Corrected Mar 23, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0133 Construction Deficiencies

     Install a two-hour-resistant firewall separation.

     Corrected Mar 24, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Mar 24, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Mar 24, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Mar 24, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• ARONIN, DAVID — corporate director, NOT APPLICABLE, since 04/01/2014
• HOLLOWAY, SEKENA — adp of the snf, NOT APPLICABLE, since 01/20/2025
• HOLLOWAY, SEKENA — operational/managerial control, NOT APPLICABLE, since 01/20/2025
• MIRETZKY, STEVEN — corporate director, NOT APPLICABLE, since 04/01/2014
• WALLACE, LANCE — operational/managerial control, NOT APPLICABLE, since 04/01/2014
• WALLACE, LANCE — adp of the snf, NOT APPLICABLE, since 04/01/2014
• ADAMS VALES ACCUMULATION TRUST — 5% or greater direct ownership interest, 9%, since 04/01/2014
• ADAMS VALES ACCUMULATION TRUST — trustee of the snf, NOT APPLICABLE, since 04/01/2014
• B & Z GRANDCHILDREN TR — 5% or greater direct ownership interest, 20%, since 04/01/2014
• B & Z GRANDCHILDREN TR — trustee of the snf, NOT APPLICABLE, since 04/01/2014
• DANIEL ROTHNER ACCUMULATION TRUST — trustee of the snf, NOT APPLICABLE, since 04/01/2014
• DANIEL ROTHNER ACCUMULATION TRUST — 5% or greater direct ownership interest, 9%, since 04/01/2014
• EXTENDED CARE CLINICAL LLC — adp of the snf, NOT APPLICABLE, since 04/01/2014
• EXTENDED CARE CONSULTING LLC — adp of the snf, NOT APPLICABLE, since 04/01/2014
• KATHRYN VALES ACCUMULATION TRUST — 5% or greater direct ownership interest, 9%, since 04/01/2014
• KATHRYN VALES ACCUMULATION TRUST — trustee of the snf, NOT APPLICABLE, since 04/01/2014
• KIMBERLY VALES ACCUMULATION TRUST — 5% or greater direct ownership interest, 9%, since 04/01/2014
• KIMBERLY VALES ACCUMULATION TRUST — trustee of the snf, NOT APPLICABLE, since 04/01/2014
• MELISSA ROTHNER ACCUMULATION TRUST — trustee of the snf, NOT APPLICABLE, since 04/01/2024
• MELISSA ROTHNER ACCUMULATION TRUST — 5% or greater direct ownership interest, 9%, since 04/01/2014
• N & S ROTHNER TRUST — trustee of the snf, NOT APPLICABLE, since 04/01/2024
• N & S ROTHNER TRUST — 5% or greater direct ownership interest, 9%, since 04/01/2014
• NATHAN AND SHIRLEY ROTHNER FAMILY TRUST — 5% or greater direct ownership interest, 9%, since 04/01/2014
• NATHAN AND SHIRLEY ROTHNER FAMILY TRUST — trustee of the snf, NOT APPLICABLE, since 04/01/2024
• RACHEL ROTHNER ACCUMULATION TRUST — trustee of the snf, NOT APPLICABLE, since 04/01/2024
• RACHEL ROTHNER ACCUMULATION TRUST — 5% or greater direct ownership interest, 9%, since 04/01/2014
• ROTH & CO, LLP — adp of the snf, NOT APPLICABLE, since 04/01/2014
• WILLIAM ROTHNER ACCUMULATION TRUST — trustee of the snf, NOT APPLICABLE, since 04/01/2024
• WILLIAM ROTHNER ACCUMULATION TRUST — 5% or greater direct ownership interest, 9%, since 04/01/2014