Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ST JAMES WELLNESS REHAB VILLAS
CRETE, IL · 110 certified beds · Last Life Safety survey December 6, 2024
CMS Certification Number 145611 · first certified January 1989
Ownership
Operated by EXTENDED CARE CLINICAL · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IL
38 citations — more than 92% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 28 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (November 2025 to January 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was December 2024. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
Get an email about ST JAMES WELLNESS REHAB VILLAS
One email when it happens. No account; stop it any time with one click.
2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
7 of the 38 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
10 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 38 Life Safety citations above. The Physical Environment Index
- F-0908 Keep all essential equipment working safely.
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 38 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 16, 2023 | 4 |
| November 17, 2023 | 6 |
| December 6, 2024 | 28 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-12-06 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2024-12-06 |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | 2 | 2024-12-06 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2024-12-06 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2024-12-06 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 2 | 2024-12-06 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-12-06 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2024-12-06 |
What the citations cover
- Smoke Deficiencies 13
- Emergency Preparedness Deficiencies 7
- Miscellaneous Deficiencies 6
- Egress Deficiencies 5
- Other 7
| Category | Citations |
|---|---|
| Smoke Deficiencies | 13 |
| Emergency Preparedness Deficiencies | 7 |
| Miscellaneous Deficiencies | 6 |
| Egress Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Services Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 6, 2024 — 28 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (December 30, 2024) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (December 30, 2024) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (December 30, 2024) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (December 30, 2024) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (December 30, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (December 30, 2024) |
| K-0222 | 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. | Deficient, Provider has date of correction (December 30, 2024) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (January 7, 2025) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (December 30, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (December 30, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (January 7, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (January 3, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 9, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (January 6, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (January 30, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (January 2, 2025) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (January 6, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 7, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 30, 2024) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (December 30, 2024) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (December 30, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 30, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (December 30, 2024) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (December 30, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (December 30, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 30, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 30, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (December 30, 2024) |
November 17, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (December 13, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (December 11, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (December 15, 2023) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (December 11, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (December 11, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 11, 2023) |
March 16, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (March 24, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 24, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (March 24, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 24, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.