Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 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.
Failure to address significant weight loss for a resident. The RD was aware of the resident’s declining weights and documented discussions about supplements, but supplements were not ordered, the care plan lacked weight-loss interventions, and there was no order for weekly weights or appetite medication. The resident’s weights showed significant loss over 1, 3, and 6 months, and the facility’s weight management policy required weekly weights and updated care planning for significant weight changes.
Improper Food Labeling, Storage, and Hand Hygiene: Surveyors found multiple opened or prepared food items in the walk-in cooler without required labels, open dates, or use-by dates, and an expired barbecue sauce in dry storage. The Chef and DSD acknowledged the labeling and storage expectations. Surveyors also observed a Lead Cook wash hands for about 18 seconds and then touch the paper towel dispenser, which did not align with facility policy or CDC hand hygiene guidance.
Unlabeled medications were found in a pill cup with no resident name, room number, or secure closure in the only med cart on the 2nd floor. An RN was unsure what the pills were, and the DON stated meds should be pre-packaged, stored in the correct resident bins, and not kept in open pill cups because they are unidentified and may be confused with another resident. The facility policy required unlabeled or improperly closed meds to be removed from locked storage and disposed of.
Failure to use PPE in a contact precaution room and failure to perform hand hygiene during med pass. Surveyors observed a family member and staff member in a resident's contact isolation room without gowns and gloves, and another family member in a second contact isolation room without proper PPE. Surveyors also observed RNs administer meds to three residents without washing hands, with one RN using the same gloves while handling pill packets and another RN using a BP machine without disinfecting it between residents.
Improper Transfer Assistance and Failure to Use Gait Belt: A resident with a recent fall and femur fracture was observed being transferred from bed to wheelchair by a CNA who lifted the resident under the arms without using the gait belt that was available. The resident was unstable, unable to bear weight, and could not position the legs and feet to bear weight. Staff interviews showed the resident needed assist for transfers, with the RN and DON stating that a gait belt and possibly 2-person assist or a Hoyer were safer, while the MDS reflected total dependence for bed-to-chair transfers and was later clarified as having been assessed incorrectly.
Oxygen Tubing and Humidifier Not Changed as Ordered: A resident with COPD was observed receiving O2 via nasal cannula with tubing labeled with two dates and a humidifier dated several days earlier. An RN stated she did not know why the tubing was labeled that way or who labeled it, and confirmed the tubing and humidifier should be changed weekly and as needed per the resident's order and facility policy.
A resident’s Modafinil count did not match the controlled drug record during narcotics reconciliation. An RN said she administered the medication but forgot to document it right away, and the DON verified the mismatch between the bingo card and the controlled drug record. The facility policy required documentation of the time, date, and nurse signature for controlled meds.
Failure to offer influenza vaccine to a newly admitted resident. Record review showed a resident had no documentation of receiving the flu vaccine and no record of being offered or declining it, although the resident had received COVID-19 and pneumococcal vaccines. The ICN stated the resident did not need the flu vaccine because admission occurred near the end of flu season, while the DON stated residents should be offered the vaccine and refusals documented in writing per the facility immunization policy.
Missing MDS Discharge Assessment: A resident was discharged from the facility, but MDS staff did not complete the required discharge assessment. During record review and interview, the Administrator/ED confirmed the resident had moved to assisted living after leaving the SNF, and the omission affected resident tracking, monitoring, and records.
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 Address Significant Weight Loss
Penalty
Summary
The facility failed to follow its weight management policy for one resident, R5, by not ensuring significant weight loss was addressed with the ordered monitoring and interventions. R5’s documented weights showed a decline from 147.6 lbs on 10/02/2025 to 128.2 lbs on 03/01/2026, representing a 13.1% loss over 6 months, along with a 9.3% loss over 3 months and a 5.1% loss over 1 month. The dietician stated she was aware of R5’s weight loss and had discussed adding supplements with R5 and the POA, but also stated that supplements should have been ordered and were not ordered for some reason. Record review showed progress notes documenting weight loss concerns, including a 12/03/2025 note stating a weight warning and that the physician was informed, a 12/31/2025 note stating R5 was in agreement with supplements, a 01/05/2026 note recommending offering a supplement after meals, and a 04/02/2026 note stating R5 had significant weight loss over 180 days due to decreased appetite from a significant life change. However, the full care plan had no documentation of weight loss with appropriate interventions, the physician order sheet had no order for supplements or appetite medications, and there was no order for weekly weights. The facility policy stated residents with significant weight changes should be placed on weekly weights until stabilized or determined unavoidable by the interdisciplinary team, and the RD was responsible for documenting and updating care plans with new interventions.
Improper Food Labeling, Storage, and Hand Hygiene
Penalty
Summary
Food storage and sanitation practices were not followed in the kitchen, as multiple food items in the walk-in cooler were found without proper labeling or dating. During the kitchen tour, surveyors observed an opened carton of eggs with no open date, use-by date, or food label; a tray of sliced onions, green peppers, and red peppers wrapped in plastic wrap with no preparation date, use-by date, or food label; a bowl of beef steak wrapped in plastic wrap with no preparation date, use-by date, or food label; an opened container of sliced limes with a use-by date of 05/04/2026; and opened potatoes cut in halves and stored in water with no use-by date. In the dry storage area, a gallon container of barbecue sauce was found with an expiration date of 04/14/2026. The Dining Services Director and Chef stated that opened and prepared food items in the walk-in cooler should be labeled with the food item and dated, and that expired food items should not be stored in the dry storage area. Hand hygiene practices were also not performed according to facility policy and CDC guidance. The Lead Cook demonstrated handwashing for approximately 18 seconds and then touched the motion sensor paper towel dispenser twice with his hands after washing. The facility policy required proper hand hygiene for staff involved in direct resident contact, and the CDC guidance cited in the report states hands should be scrubbed for at least 20 seconds. The facility census documented 53 residents, and one resident was enteral feed only and did not receive food from the kitchen.
Unlabeled Medications Found in Medication Cart Drawer
Penalty
Summary
The facility failed to follow its medication storage policy when an unlabeled pill cup with no resident name, room number, or secure closure was found in the top drawer of the only medication cart on the 2nd floor. Surveyor observation showed the cup contained unknown and unidentified medications. When asked about the medications, an RN stated she thought they were blood pressure pills but was not fully sure, and stated that medications are to be discarded and not stored in the medication cart without proper closure and labeling. The DON stated that medications stored in the medication cart are supposed to be pre-packaged, delivered by pharmacy, and stocked by nursing staff in the correct resident bins. The DON also stated that medications should not be stored in pill cups in the drawers because they are unidentified, could be confused with another resident, and are not covered, which is an infection control issue. The facility policy stated that unlabeled medications and those without secure closures are to be immediately removed from the locked medication storage area and disposed of, and that each resident's medications are to be assigned to an individual cubicle, drawer, or other holding area to prevent mixing medications of several residents.
Failure to Use PPE in Contact Precautions and Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to utilize appropriate PPE in a room under contact precautions. Surveyors observed the contact isolation sign on the door to R2's room, but the door was open and a family member was inside the room without a gown or gloves, and a staff member was also inside without a gown or gloves. Surveyors later observed a family member in V30's room, which was also a contact isolation room, not wearing proper PPE. A CNA stated she was not sure what the contact isolation sign was for and said she was only dropping off an oxygen tank when she entered without a gown and gloves. The Infection Disease Nurse stated that staff should wear gowns and gloves before entering or exiting a resident's room on contact precautions, and the DON stated that gloves, gown, and a mask shield were required for a resident on contact precautions. The facility also failed to follow its hand hygiene policy during medication administration for three residents. Surveyors observed an RN pull medications for R13, put on gloves without washing hands, dispense the medications, discard pill packets with gloved hands touching the inside of the trash bag, and then administer the medications using the same gloves. Another RN dispensed medications for R5 without washing hands, used a blood pressure machine in the resident's room, administered the medications, exited without using hand sanitizer, returned to the nurse's station without washing hands, and did not wipe down the blood pressure machine. The same RN later dispensed medications for R19 without washing hands, approached the resident in the dining room without wiping down the blood pressure machine, took the resident's blood pressure, and administered the medications without washing hands or wearing gloves. The DON stated that hand hygiene is important during medication administration and that the blood pressure machine should be disinfected after use on a resident.
Improper Transfer Assistance and Failure to Use Gait Belt
Penalty
Summary
The facility failed to correctly assess a resident’s limitations and failed to follow its policy on using safety equipment for fall prevention for a resident with a history of falls. The resident had fallen in the facility, was sent to the hospital, and was diagnosed with a left femur/upper leg fracture due to a mechanical fall before being readmitted. After readmission, the resident was observed lying in bed and waiting for therapy, alert and verbally responsive. A CNA transferred the resident from the bed to a wheelchair by lifting the resident under the arms while the resident’s legs dangled and the resident remained unstable, unable to bear weight, and unable to position the legs and feet to bear weight. Although the CNA had a gait belt wrapped around her waist, it was not used during the transfer. During interviews, the CNA stated she was not very familiar with the resident but knew the resident needed assistance with transfers, and she acknowledged that gait belts are safer but were not used because she believed the resident could pivot. An RN stated the resident had been having physical and psychological problems with transfers since the fall and that the resident could require one- or two-person assistance, with a gait belt being safer due to unsteady standing. The DON stated the resident needed one- to two-person assist, that non-weight-bearing residents need two persons or a Hoyer lift, and that the resident’s status was to stand and pivot using a gait belt. The resident’s MDS functional assessment dated after the fall indicated total dependence for bed-to-chair transfer and that the resident could not do any activity during transfers, and the DON later clarified that the assessment should have reflected bilateral lower extremity impairment rather than bilateral upper extremity impairment.
Oxygen Tubing and Humidifier Not Changed as Ordered
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when R23, a resident with COPD, was observed receiving oxygen therapy via nasal cannula connected to an oxygen concentrator, with the oxygen tubing labeled with two dates, 04/27/26 and 05/03/26, and the humidifier labeled 04/27/26. The surveyor observed this on 05/05/2026 while R23 was lying in bed. An RN in the room stated she was not sure why the oxygen tubing had two dates, did not label the tubing or humidifier, and did not know who did because there were no initials. The RN stated the resident's oxygen tubing and humidifier should be changed every week on Sundays and as needed, and that failure to change them as ordered could allow bacteria to build up in the humidifier and tubing and cause infection. The resident's POS ordered oxygen tubing to be changed weekly on Sundays with date and initials, and the facility policy stated the reservoir should be changed every 48 hours and the oxygen cannula and tubing every 7 days or as needed.
Controlled Medication Documentation Mismatch
Penalty
Summary
Failed to follow the facility’s controlled medication documentation policy for 1 resident, R34, during narcotics reconciliation. On 05/05/2026 at 12:40 PM, the surveyor observed R34’s Modafinil bingo card showing a count of 13, while R34’s Modafinil Controlled Drugs Receipt/Record/Disposition Form documented a count of 14. The discrepancy showed that the controlled medication count on the card did not match the controlled drug record. At the same time, V8, RN, stated that she was supposed to document the controlled medication in the Controlled Drug Receipt/Record Form when it was administered, but she had administered the medication and forgot to document it right away. On 05/06/2026 at 11:40 AM, V2, DON, verified that the bingo card did not match the Modafinil Controlled Drugs Receipt/Record/Disposition Form and stated that administered controlled medications must be documented to reconcile and maintain accurate records, including the time, date given, and nurse signature.
Failure to Offer Influenza Vaccine to Newly Admitted Resident
Penalty
Summary
The facility failed to offer an influenza vaccine to a newly admitted resident, R40. During record review on 05/06/2026, the surveyor noted that R40 had been admitted on [DATE] and that the immunization record contained no evidence of an influenza vaccine being given. There was also no documentation that R40 had been offered the influenza vaccine or had declined it. The immunization record showed that R40 had received the COVID-19 vaccine and both pneumococcal vaccines on 04/16/2026, but there was no influenza vaccine documented. During interview, the Infection Control Nurse stated that because R40 was admitted during the peak of the end of the season, R40 did not need the influenza vaccine. The DON stated that if a resident was admitted on [DATE], the resident should have been offered an influenza vaccination, and that staff educate the resident, provide a consent form, and document refusal if the vaccine is declined. The facility’s Immunization program policy, reviewed 09/01/2023, states that influenza immunizations are generally offered from October 1 through March 31 and that residents, responsible parties, or associates are required to either consent to receive or decline the vaccine in writing on the appropriate form.
Missing MDS Discharge Assessment
Penalty
Summary
The facility failed to provide the required MDS discharge assessment for one resident, R55, who was admitted on 12/12/2025 and discharged on 12/27/2025. During review of records and interview, the Administrator/Executive Director confirmed that R55 was no longer in the skilled nursing facility and was currently residing in assisted living, but stated that MDS staff did not complete the discharge assessment when the resident left the facility. The report states this was not in accordance with CMS instructions and affected the resident’s tracking, monitoring, and records.
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.
Illustrative
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Illustrative
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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 | ★★★★★ | 0 | 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 | ★★★★★ | 9 | 0 |
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