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F0835
F

Unqualified Social Service Director and Inadequate Suicide Risk Assessments

Itasca, Illinois Survey Completed on 11-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The administration failed to provide adequate oversight and leadership to ensure that the Social Service Director (SSD) was qualified for the position, as required by the facility's job description. The SSD was hired with only a high school education and did not possess a bachelor's or master's degree in social work, psychology, or sociology, nor a Licensed Clinical Social Worker's Certificate, as specified in the job requirements. The administrator was unable to confirm whether the SSD met the necessary qualifications, and the employment record lacked documentation of the required education or certification. Additionally, the administration did not ensure that self-harm and suicide risk screening assessments were completed accurately, timely, or individualized for residents identified as at risk. Multiple residents were affected by these deficiencies, as evidenced by concerns regarding the accuracy, timeliness, and individualized care plan interventions for several residents screened by the unqualified SSD. The lack of proper assessments and care planning impacted all 130 residents in the facility.

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