Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Joseph Village Of Chicago during CMS and state inspections, most recent first.
A resident with left-sided weakness and cognitive impairment, identified as a fall risk, was not promptly assisted after requesting help. The CNA, occupied with routine tasks, left the resident unattended, resulting in the resident falling and sustaining a head injury. The care plan and facility policy required prompt response and specific fall prevention interventions, which were not effectively followed.
A resident with multiple medical conditions and cognitive impairment did not receive necessary care in accordance with their care plan. The resident required assistance with ADLs, including feeding and wound care, but was found with exposed wounds and no diaper. A CNA did not receive a report on the resident's needs, leading to neglect. The facility's policies for routine checks and communication between staff were not followed, resulting in inadequate care.
A resident with dementia and a history of wandering was inadequately supervised, leading to an incident where he entered another resident's room with his pants down. Staff interviews confirmed the resident's tendency to wander, and the facility's camera system was not operational, hindering incident review. The care plans for both residents emphasized safety and structured activities, but these were not effectively implemented.
A resident admitted with intact skin and redness on the buttocks and heel developed stage three pressure ulcers due to the facility's failure to implement timely interventions. Initial redness was noted, but no preventive measures were documented until 12 days later when the wounds had progressed. The facility's wound care nurse confirmed the absence of early treatments, and interventions were only ordered after the wounds were assessed as stage three.
A resident with vascular dementia and other conditions experienced two falls in a facility due to inadequate supervision and care planning. Despite severe pain and a fracture, no X-ray was performed. The care plan lacked necessary interventions, and the facility's fall prevention policy was not followed.
The facility failed to properly store and label fruits and vegetables in the walk-in cooler and did not adequately seal burger patties and processed turkey chili in the walk-in freezer. A discolored cantaloupe was found without a date, and celery was labeled with only a received date. Onions and carrots were stored without original packaging or date labels. In the freezer, turkey chili and burger patties were exposed due to improper sealing. The Food Services Director acknowledged these issues, which potentially affect all 42 residents consuming food orally.
The facility failed to reconcile controlled medications, resulting in discrepancies between the number of pills in bingo cards and the Controlled Drug Receipt/Record/Disposition forms for two residents. Staff interviews revealed that nurses did not document the removal of controlled substances immediately after administration, and there were lapses in the required joint count of narcotics at shift changes, as evidenced by missing nurse initials on verification forms.
A nurse left a medication cart unlocked and unattended, with loose tablets on top, in an LTC facility. Expired medications, including insulin and hydromorphone, were found on the cart. Staff acknowledged the risks and confirmed that expired medications should be discarded and carts locked when not in use.
A facility failed to conduct a new Level I PASARR screen for a resident with known mental illness, despite documented diagnoses of bipolar disorder and major depressive disorder. The resident's initial screening from 2018 showed no suspicion of mental illness, and there was no Level II PASARR screening documented. The facility's administrator and Social Services Director were unaware of who was responsible for conducting these screenings, contrary to the facility's policy requiring evaluations for serious mental illness, intellectual disability, and developmental disabilities.
Failure to Implement Fall Prevention Interventions Leads to Resident Fall
Penalty
Summary
The facility failed to implement interventions consistent with a resident's needs and current professional standards of practice to eliminate the risk of a fall for one resident. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the left side, unsteadiness on feet, muscle weakness, and cognitive symptoms, was identified as a fall risk and required prompt response to all requests for assistance. On the day of the incident, the assigned CNA was taking vital signs and meal orders and instructed the resident to wait after he requested something. The CNA left to attend to other residents and returned within five minutes, at which point the resident was found on the floor with a bump on his head. The resident was known to require frequent redirection and assistance, and his care plan included interventions such as frequent reminders to use the call light, bed in the lowest position, safety floor mats, and frequent rounds. Staff interviews revealed that the CNA prioritized routine tasks over the resident's immediate request, and the nurse was unaware that the resident had asked for assistance. The DON acknowledged that not fulfilling the resident's needs could lead to a fall, emphasizing that attending to residents' needs should be a priority. Documentation confirmed the resident's fall risk status and the need for prompt assistance. The facility's fall prevention policy called for an interdisciplinary approach and appropriate interventions to reduce fall risk, but these were not effectively implemented in this instance, resulting in the resident sustaining a fall.
Failure to Provide Adequate Care for Resident with Complex Needs
Penalty
Summary
The facility failed to meet the personal care and nursing needs of a resident, identified as R1, by not providing treatment and care in accordance with professional standards and the resident's goals of care. R1, who had a history of chronic obstructive pulmonary disease, hypertensive heart disease, rheumatoid arthritis, and multiple pressure ulcers, required substantial assistance with activities of daily living (ADLs) due to poor mobility and cognitive impairment. The care plan specified that R1 needed one-to-one assistance with feeding, toileting, and personal hygiene, as well as regular repositioning and wound care. On the day of the incident, V7, a Certified Nursing Assistant (CNA), did not receive a report about R1's needs and failed to provide necessary care, including feeding and cleaning. R1 was found with exposed wounds, no bandages, and no diaper, indicating a lack of proper incontinence care. R1's daughter discovered the neglect and assisted in cleaning and dressing the wounds. Interviews with staff revealed that there was a lack of communication and handoff reports between nurses and CNAs, leading to the oversight of R1's care requirements. The facility's policies and procedures for ADLs, routine resident checks, and perineal care were not followed, resulting in R1 being left unattended for extended periods. The Assistant Director of Nursing (ADON) acknowledged that the facility's expectations were not met, as CNAs should have been informed of residents' needs and conducted frequent rounds, especially for total care residents. The failure to adhere to these protocols contributed to the deficiency in R1's care.
Inadequate Supervision of Wandering Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident diagnosed with dementia, hypertensive heart disease, type 2 diabetes mellitus, cognitive communication deficit, and anxiety disorder, who is known to wander. This resident, with a Brief Interview of Mental Status score of 04, was observed by a surveyor wheeling himself around the unit and into other residents' rooms, including the room of another resident with a history of falling and multiple pressure ulcers. On one occasion, the wandering resident was found in the room of the other resident with his pants down, an incident witnessed by the family member of the resident whose room was entered. Staff interviews revealed that the wandering resident frequently enters other residents' rooms, and the facility's camera system was not functioning properly, preventing the retrieval of footage from the day of the incident. The facility's policy emphasizes the importance of resident safety and supervision, yet the breakdown in supervision allowed the wandering resident to enter another resident's room without detection. The care plans for both residents highlight the need for safety and structured activities to prevent wandering, but these measures were not effectively implemented, leading to the deficiency.
Failure to Prevent Pressure Ulcers in a Newly Admitted Resident
Penalty
Summary
The facility failed to implement timely interventions for a newly admitted resident, resulting in the progression of skin redness to stage three pressure ulcers on the buttock and heel. Upon admission, the resident's skin was noted to be intact with redness on the buttocks and left heel. However, no immediate interventions, such as barrier creams or heel protectors, were documented to prevent the worsening of these conditions. The resident's progress notes indicated the presence of redness and a sore on the foot, but it wasn't until 12 days later that the resident was seen by a wound care physician, by which time the wounds had progressed to stage three. The facility's wound care nurse, who is present only one day a week, confirmed that there were no treatments ordered for the initial redness observed upon admission. The physician order summary showed that interventions, including an air loss mattress and specific wound care treatments, were only initiated on the day the wounds were assessed as stage three. The facility's skin and wound care program aims to identify residents at risk and implement preventive strategies, but in this case, the lack of timely intervention led to the development of severe pressure ulcers.
Failure to Prevent Falls and Assess Injuries
Penalty
Summary
The facility failed to provide effective supervision, interventions, and monitoring to prevent falls for a resident who required maximal assistance with activities of daily living (ADLs). The resident, who was admitted for a short respite stay, had a medical history including vascular dementia, convulsions, and cerebral atherosclerosis. During the resident's stay, they experienced two falls within six days, resulting in severe pain and a fracture of the left femoral neck, which was only identified after discharge. The first fall occurred when the resident was found on the floor by an aide, and subsequent documentation noted the resident's complaints of severe pain in the left leg. Despite these complaints, no X-ray was performed to ascertain the extent of the injury. The facility's incident report and care plan failed to adequately address the resident's fall risk and need for supervision, as the care plan lacked specific interventions for transfers, positioning, and bed mobility, and did not include the resident's risk of elopement or wandering. Interviews with facility staff revealed inconsistencies in the resident's care plan and supervision. The Minimum Data Set (MDS) Coordinator acknowledged that the resident's care plan did not include necessary interventions for transfers and ambulation, despite the resident's need for extensive assistance. Additionally, the facility's policy on fall prevention and management was not followed, as the necessary actions following a fall, such as ascertaining injuries and addressing fall factors, were not adequately implemented.
Improper Food Storage and Labeling in Walk-in Cooler and Freezer
Penalty
Summary
The facility failed to properly store and label fruits and vegetables inside the walk-in cooler and did not adequately seal burger patties and processed turkey chili in the walk-in freezer. During an inspection, a discolored cantaloupe was found in the cooler without a date, and celery was labeled with only a received date but no discard date. Additionally, onions and carrots were stored in a plastic container without the original packaging or any date labels. In the walk-in freezer, turkey chili and approximately 27 burger patties were found on a large metal tray with plastic wrap that was not properly attached, leaving the food exposed to the environment. The facility's policy for food storage, dated December 7, 2020, requires that all food items be stored to prevent contamination and maintain safety. Perishable fruits and vegetables should remain in their original containers until empty and be sorted daily to remove spoiled pieces. Freezer foods must be wrapped tightly to prevent cross-contamination. The Food Services Director acknowledged the issues and indicated that staff are expected not to use improperly sealed food. The deficiency potentially affects all 42 residents who consume food orally.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to adhere to its policy for reconciling controlled medications, leading to discrepancies in the medication count for controlled substances. During an inspection of the 1st floor medication cart, it was observed that the number of pills in three bingo cards did not match the corresponding numbers on the Controlled Drug Receipt/Record/Disposition forms. Specifically, for one resident, the hydromorphone HCL 4mg bingo card showed 19 pills remaining, while the form indicated 20. Similarly, for another resident, the pregabalin 75mg bingo card showed 2 pills remaining, but the form indicated 3, and the oxycodone HCL 5mg bingo card showed 21 pills remaining, while the form indicated 22. These discrepancies were not signed out by the nurse when administered, indicating a lapse in documentation. Interviews with facility staff, including the Acting Director of Nursing and a Registered Nurse, revealed that the established procedure requires nurses to document the removal of controlled substances immediately after administration and to conduct a joint count of narcotics at each shift change. However, the review of Controlled Substances Count Verification forms for April, May, and June showed multiple lapses in documentation, with missing nurse initials for several days and shifts. This failure to maintain accurate records and perform required checks could lead to the loss or diversion of controlled substances, as the accountability of the inventory was not maintained as per the facility's guidelines.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as observed during a survey. On the first floor, a nurse left a medicine cup containing approximately 10 loose tablets and capsules unattended on top of a medication cart. The nurse also left the cart unlocked and out of view while attending to a resident in another room. Additionally, expired medications were found on the cart, including an unsealed Lantus insulin pen labeled with an expiration date that had passed, and a bottle of hydromorphone labeled as expired. These actions were confirmed through interviews with the nurse and other staff members, who acknowledged the potential risks associated with leaving medications unattended and the presence of expired medications. The nurse admitted to leaving the medication cart unlocked and unattended, acknowledging that medications should not be left on top of the cart due to the risk of unauthorized access, especially given that some residents have psychiatric diagnoses. The nurse also recognized that expired medications, such as the insulin and hydromorphone, should have been discarded to prevent potential medical issues. Other staff members, including the Acting Director of Nursing, confirmed that the medication cart should be locked when not in use and that expired medications should be removed to ensure resident safety.
Failure to Conduct PASARR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to initiate a new Level I PASARR screen for a resident with known mental illness. The resident, identified as R12, was admitted to the facility with diagnoses of bipolar disorder and major depressive disorder. Despite these diagnoses, the resident's Interagency Certification of Screening Results OBRA-I Initial Screen from 2018 indicated no reasonable basis for suspecting mental illness. The Minimum Data Set (MDS) from March 2024 documented active diagnoses of depression and bipolar disease, yet there was no documentation of a Level II PASARR screening for the resident. During the survey conducted on June 12, 2024, the facility's administrator, identified as V1, was unable to specify who was responsible for performing PASARR screenings at the facility. The Social Services Director, identified as V3, also stated she was not responsible for conducting these screenings. The facility's policy, dated June 2023, requires that all individuals entering Medicaid-certified nursing communities be evaluated for serious mental illness, intellectual disability, and developmental disabilities. The policy emphasizes that the nursing facility is ultimately responsible for ensuring the completion and documentation of the Level I PASARR screening.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Irving Park Living & Rehab Ctr | 1.5 mi | ★★★★★ | 0 | 0 |
| Pavilion Of Logan Square, The | 1.6 mi | ★★★★★ | 14 | 0 |
| Paul House & Health Cr Ctr | 1.7 mi | ★★★★★ | 1 | 0 |
| Community First Medical Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Central Nursing Home | 2.2 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.