Initial Comments:
A focused fundamental survey was conducted March 10, 11, and 12, 2026, to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I, Requirements for Intermediate Care Facilities. The census during the survey was four and the sample consisted of two individuals. Two deficiencies were identified as a result of the survey.
Plan of Correction:
483.430(e)(2) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
For employees who work with clients, training must focus on skills and competencies directed toward clients' health needs.
Observations:
Based on facility incident report review, facility investigation report review, record review, and staff interview, it was determined that the facility failed to ensure that staff demonstrated the necessary skills and competencies directed towards the health needs for one individual in the sample. (Individual #1)
A. Individual #1
1. Review of a facility investigation report dated October 21, 2025, regarding an incident of potential neglect which was conducted on March 11, 2026. This review revealed that on October 19, 2025, between 9:00 AM and 2:00 PM and between 3:00 PM and 8:00 PM facility staff failed to reposition Individual #1 in his wheelchair as per Individual #1's care plan. Further review also revealed that there was no documentation indicating that that Individual #1 had been toileted or checked for incontinence from 6:00 AM to 8:00 PM on October 19, 2025. The nurse assessed Individual #1 upon discovery of the incident on October 20, 2025, and subsequently sent Individual #1 for further evaluation at an urgent care center. An appointment with a wound care clinic was also scheduled and completed. Results from both appointments revealed that Individual #1 had not been negatively affected by the incident.
2. The facility investigation findings revealed staff did not follow the facility policy regarding Individual #1's positioning and toileting schedule and protocols. The allegation of neglect was confirmed. Staff were counseled, received disciplinary action, and retrained as a result of the incident.
B. Interview with the Program Director (PD) on March 12, 2026, at 11:30 AM revealed that facility staff failed to demonstrate the necessary skills and competencies directed toward the health needs for one Individual.
Plan of Correction:In regard to Item A, the facility determined through a certified investigation that on October 19, 2025, staff failed to follow Individual #1's repositioning and toileting protocol.
Upon discovery of the incident, Individual #1 was immediately assessed by the facility nurse. Due to Individual #1's vulnerability to skin breakdown, they were taken to urgent care for further evaluation. A follow-up appointment with a wound care clinic was also scheduled and completed. Results from both evaluations confirmed that Individual #1 did not experience any adverse outcomes related to the incident.
To prevent recurrence, on October 21, 2025, the facility nurse issued a memorandum for all staff regarding Individual #1's toileting and repositioning protocol. Along with the memorandum, a copy of the tracking sheet with instructions to dually document repositioning in Individual #1's chart on the iCareManager platform.
On October 24, 2025, the three staff members involved in the incident were disciplined in accordance with agency policy and retrained on Individual #1's care requirements, including check-and-change procedures, repositioning schedule, and abuse and neglect training.
Additional retraining will occur at the March 24, 2026 Tioga County team meeting. This retraining will cover Individual #1 and all other individuals protocols for toileting and repositioning. Staff will also be retrained on the importance of proper and timely documentation.
These interventions will benefit Individual #1 and all other individuals by no further reports of failure to follow individual care plans. The ICF Supervisor and Health Services Supervisor will have overall responsibility for this.
483.460(k)(1) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.
Observations:
Based on incident report review and staff interview, it was determined the facility failed to ensure that four individuals' medications were administered without error. (Individuals #1, #2, #3, and #4)
Findings included:
A. Individual #1
1. On May 26, 2025, 8:00 a.m. Diltiazem was omitted.
2. On June 23, 2025, Milk of Magnesia (MOM) was administered on the wrong day.
3. On July 27, 2025, wrong dose of MOM was given.
4. On August 26, 2025, one of four Divalproex capsules was omitted. The capsule was found on the floor.
5. On September 16, 2025, Gabapentin was omitted.
6. On October 5, 2025, Idolize was on hold but given.
7. On October 18, 2025, Diltiazem was omitted.
8. On October 20, 2025, Diltiazem was omitted.
9. On November 10, 2025, PRN medication Midrodrine was administered but not needed.
10. On November 12, 2025, Metroprolol was omitted.
11. On November 17, 2025, PRN medication Midrodrine was administered but not needed.
12. On December 4, 2025, Medication Metformin was on hold but administered.
13. On December 5, 2025, Medication Metformin was on hold but administered.
B. Individual #2
1. On June 2, 2025, Bactrim was omitted.
C. Individual #3
1. One August 8, 2025, MOM was not administered by protocol.
D. Individual #4
1. On November 18, 2025, Cephalexin was omitted.
C. Facility incident reports and documentation review revealed the above-referenced individuals did not experience any ill effects as a result of these medication errors.
D. The above-referenced errors resulted in a total of 16 medication administration errors, from March 26, 2025, to March 12, 2026.
E. Interview with the Program Director (PD) on March 12, 2026, at 11:30 AM revealed that facility staff failed to ensure that the individuals' medications were administered without errors.
Plan of Correction:The facility conducted a comprehensive review of medication administration errors identified for multiple individuals and implemented corrective actions as outlined below:
For Individual #1, multiple medication administration errors occurred between May and December 2025, including omitted medications, administration of medications when contraindicated, and errors related to inaccurate or untimely documentation. Medications involved included Diltiazem, Milk of Magnesia, Divalproex, Gabapentin, Midodrine, Metoprolol, and Metformin. Each incident was addressed promptly upon discovery.
Staff responsible for these errors were disciplined in accordance with agency policy and received retraining by the ICF Supervisor, Health Services Supervisor, or Day Program Supervisor, as applicable.
Retraining consistently included review of the ICF/ID Medication Administration Plan and Procedures and the Medication Pass Checklist. Emphasis was placed on verifying medications against the Medication Administration Record (MAR) and bubble packs, adhering to medication-specific parameters (including blood pressure thresholds and hold orders), and completing end-of-pass checks to ensure all medications were administered or held appropriately. In cases involving documentation errors, staff received additional retraining on timely and accurate documentation practices. Medication practicums were conducted as indicated to validate staff competency. One staff member was terminated due to a pattern of excessive medication errors. Dates for staff discipline and retraining in regard to Individual #1's incidents include: 6/6/2025, 6/20/2025, 8/2/2025, 8/28/25, 9/18/25, 11/17/25, 11/26/25, and 12/8/25.
Additional incidents involving Individuals #2, #3, and #4 were also reviewed. These included omitted medications and errors related to inaccurate documentation impacting medication administration.
Staff involved in these incidents were similarly disciplined and retrained, with focused education on documentation accuracy and adherence to individual-specific medication protocols. In select cases, additional disciplinary actions, including suspension and completion of medication practicums, were implemented. Dates for staff discipline and retraining include: 6/6/25, 8/29/25, 11/25/25.
In addition to the individual staff's discipline and retraining, a retraining with all staff on the Medication Administration Process, importance of prompt and accurate documentation, and the dangers of medication errors will occur at the March 24, 2026, Tioga team meeting.
To ensure ongoing compliance and prevent recurrence, the facility will continue to reinforce medication administration protocols through routine supervision and periodic retraining. Emphasis will remain on strict adherence to physician orders, accurate documentation, and utilization of the Medication Pass Checklist. The ICF Supervisor and Health Services Supervisor will maintain responsibility for oversight, monitoring, and ensuring sustained compliance with all medication administration standards.
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