Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility
of F493 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F493 is cited
0.0% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J—
K—
L—
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D—
E1100.0%
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F493 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F493 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
K · Immediate jeopardy, patternOctober 13, 2017
Based on review of the Administrator's job description, review of the Director of Nursing's (DON) job description, medical record review, observation, and interview, the governing body failed to have an effective governing body that established and implemented policies and procedures that recognized concerns with hazards to health and safety, identified the root cause of the problems, and ensured systems and processes were developed and consistently followed by staff to address quality concerns. …
Based on observation, interview, record review, job description review, and policy review, the governing body failed to ensure the facility was managed in a manner that ensured the safe management and overall well-being for all forty-four residents in the facility. Findings include:
1. The following deficiencies were repeated deficiencies from the previous complaint and recertification survey on 12/7/16: F280, F314, F490, F493, and F520.
The following were newly cited deficiencies for the current survey: F278 and F360.
F · No harm, potential for more than minimal, widespreadFebruary 5, 2018
Based on interview and record review, the facility's governing body (GB), legally responsible for establishing and implementing facility policies, failed to effectively manage the facility when:
1. The GB failed to ensure the administrative staff followed the facility's abuse policy and procedures, and that a 43-page document, an investigative report regarding abuse (rough handling of residents and inappropriate use of Snapchat, images or videos sent via phone message) at the facility, available 12/22/17, was reviewed by the facility Administrator (Admin), Director of Nursing (DON), and Director of Clinical Services (DCS).
2. …
C · No harm, potential for minimal, widespreadSeptember 26, 2017
Based on record review and interview, the facility failed to provide a licensed administrator to oversee the operation and management of the facility. This has the potential to affect all 36 residents living in the facility.
Findings Include:
E1, Administrator stated on [DATE] at 1:00 PM that she had filed for a temporary extended license in August and sent all paperwork to the the Illinois Department of Financial and Professional Regulation (IDFPR) office. The web-site for IDFPR on [DATE] was unable to find an Administrator license active under E1's name. E1 verified that IDFPR had been called today, and that E1's Administrator License had expired. …
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