St. Joseph Village of Chicago

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy to ensure significant weight loss is prevented in the facility for one (R5) out of three residents reviewed for nutrition in a sample of 14. This failure resulted in R5 not receiving suggested supplements and experiencing severe weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food storage practices as evidenced by a.) food not properly labeled, b.) food not properly stored, and c.) not practicing effective handwashing. These deficient practices have the potential to affect 52 residents receiving food prepared in the facility kitchen.

Inspectors wroteBased on observations, interviews and record reviews, facility failed to follow their policy to ensure medications are immediately removed from the locked medication storage area and disposed of for medications that are unlabeled and without secure closure. This failure has the potential to affect all the residents on the 2nd floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize appropriate PPE (Personal Protective Equipment) in a contact precaution room which affected two residents (R2, R30) reviewed for infection control in a total sample of 15 residents reviewed. The Facility also failed to follow their policy to ensure proper hand washing prior to medication administration for three (R13, R5, R19) out of five residents reviewed for medication administration in a total sample of 15 residents.

Inspectors wroteBased on observation, interviews, and review of records, the facility failed to correctly assess resident limitation and failed to follow their policy on using safety equipment for fall prevention of 1 out of 1 resident (R13) reviewed for accidents and hazards for a total of 15 residents in the sample. These failures have the potential to affect safety of 1 resident (R13) with history of falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change oxygen tubing and reservoir for one resident (R23) reviewed for oxygen therapy in a total sample of 15 residents.

Inspectors wroteBased on observations, interviews, and record reviews failed to follow their policy to ensure controlled medications are documented for 1 (R34) out of the 4 residents reviewed for narcotics reconciliation in a sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer an influenza vaccine to a newly admitted resident. This failure affects one resident (R40) in a total sample of 15 residents reviewed.

Inspectors wroteBased on review of records and interviews, the facility failed to provide required MDS (Minimum Data Set) discharge assessment for 1 out of 1 resident (R55) reviewed for resident assessments. These failures are not according to CMS instruction and affected 1 resident (R55) in determination of proper tracking of resident placement, monitoring and records.

Inspectors wroteBased on interview and record review 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 (R1) resident out of six residents reviewed for quality of care in a total sample of six. This failure resulted in R1 sustaining a fall without significant injury.

Inspectors wroteBased on interview and record review, the facility failed to meet personal care and nursing needs; and failed to ensure that a resident received treatment and care in accordance with professional standards of practice and in accordance with the resident's goals of care for one resident (R1) in a total sample size of three residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision for one resident (R2). This failure affected one resident (R1) and has the potential to affect all residents residing on the 3rd floor.

Inspectors wroteBased on observations, interview, and review of record the facility failed to properly store and label fruits and vegetables inside walk-in cooler. And failed to seal properly burger patties and processed turkey chili inside walk-in freezer in accordance with policy of the facility. These failures are potential to affect all 42 residents taking food by mouth.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow policy to reconcile controlled medications in order to prevent loss or diversion for one of two carts reviewed for medication labeling and storage.

Inspectors wroteBased on observation, interview and record review the facility failed to a) remove medications from the top of the cart when unattended, b) lock the cart when unattended and c) remove expired medications from the cart for one of two medication carts reviewed for medication labeling and storage.

Inspectors wroteBased on interview and record review, the facility failed to initiate a new Level I screen for residents with known mental illness for one (R12) resident reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 12 residents reviewed.

Inspectors wroteBased on interview and record review the facility failed to put interventions in place for a newly admitted resident (R199) in a sample of 12 residents. This failure resulted in R199's skin intact with redness progressed to stage three wounds of the buttock and heel.

Inspectors wroteBased on interviews and review of records the facility failed to provide effective supervision, interventions and monitoring to prevent falls per policy for a resident that needs maximal assistance with ADLs/Activities of Daily Living (bed mobility, transfers, and ambulation). Facility also failed to ascertain or to rule out injury had occurred due to the fall. These failures include 1 out of 1 resident (R49) in a total sample of 12 residents reviewed for accidents and hazard. This failure resulted in R49 having 2 falls for a period of 6 days in the facility. R49 sustained left leg/hip severe pain and left leg/hip (femoral) fracture that was determined the day after discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure for food and supply storage to ensure food and dairies in the main cooler were discarded after the expiration date. This failure has the potential to affect 42 residents in the facility who are receiving oral diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide turning and repositioning for a dependent resident (R28) for 1 of 20 residents reviewed for improper nursing care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide enteral feedings as prescribed by physician for 1 (R40) of 3 residents reviewed for nutrition in a total sample of 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure for oxygen administration to ensure that oxygen is administered under orders of a physician. This failure has the potential to affect one (R245) of three residents reviewed for respiratory care in a sample of 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard expired medications from their medication carts for 3 residents (R9, R29, R30) in 2 out of 2 medication carts reviewed in a sample of 20 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the meal ticket menu for 1 (R22) of 3 residents reviewed for nutrition in a total sample of 20 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary elevated toilet seat for 1 (R95) out of a total sample of 20 residents reviewed for homelike environment.