F888 in Illinois. Pick another state for the same tag.
Against expectation — 2023
Illinois cites F888 more often than its own record predicts
Versus expected share2.10×
2.10 times the share F888 takes of citations nationally.
Share of Illinois citations0.21%
Of every deficiency written in Illinois in 2023, this is the portion that was F888.
Illinois0.21%
National0.10%
Share of all citations that were F888.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F888 findings written in Illinois, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
G · Actual harm, isolatedOctober 24, 2022
Based on observation, interview and record review, the facility failed to follow their policy by ensuring all staff are vaccinated for COVID-19 or have a medical or religious exemption. The facility failed to develop a contingency plan for staff who are unvaccinated without exemptions in the sample of 29. This failure resulted in four residents (R28, R29, R30, R31) testing positive for COVID-19 infection on 9/19/2022.
Findings include:
The Facility's Healthcare Personnel COVID-19 Vaccination report provided on 10/17/22 documents there are six employees (V14, V16, V17, V18, V19, and V20) who have not completed their initial Covid-19 vaccine series consisting of either one dose of a single dose vaccine or both doses of a two-dose vaccine. …
F · No harm, potential for more than minimal, widespreadMay 12, 2023
Based on observation, interview, and record review, the facility failed to follow their policy on ensuring and monitoring all HCP (Healthcare Personnel) Covid-19 vaccination status, and failed to ensure all HCP had complete documentation and records as to Covid-19 vaccination status.
These failures have the potential to affect all 55 residents living in the facility.
Findings include:
On 05/09/2023 at 10:54 AM, V3 (Infection Prevention) submitted a document titled Covid-19 Staff Vaccination Status for Providers that listed 178 staff. V3 said it represents staff that are employees of facility. V3 was asked if the list includes contracted staff, agency staff, and providers. V3 said, Not all are included. …
C · No harm, potential for minimal, widespreadApril 27, 2023
Based on interview and record review the facility failed to track the vaccination status of contracted staff. This failure has the potential to affect all residents in the facility.
The findings include:
The facility Resident Census and Conditions of Residents (Form CMS-672) dated 4/25/23, showed 136 residents reside in the facility.
On 4/25/23 at 9:12 AM the facility's COVID-19 staff vaccination matrix was requested. The document was to be provided within 4 hours.
On 4/26/23 at 3:45 PM a meeting was held with V1 Administrator and V2 Assistant Administrator/Infection Preventionist. V2 stated she knows the survey is behind because of not having the infection control information. V2 state, the vaccination files were corrupt. V1 stated the files were backed up. …
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction