Initial Comments:
A focused fundamental survey was conducted on May 18-22, 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 202, and the sample consisted of 16 individuals.
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, 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 eight individuals in the sample. (Individuals #19, #22, #23, #24, #29, #30, #31, and #32)
Findings included the following:
A. Individual #19
1. A facility incident report and investigation dated March 11, 2026, was reviewed. The investigation revealed that Individual #19 was unable to complete a scheduled colonoscopy appointment on March 10, 2026.
2. Further review of the investigation revealed that physician's orders for the procedure directed that medications were to be administered with small sips of water only on the day of the examination.
3. Documentation and staff statements revealed that the Licensed Practical Nurse (LPN) administered the individual's medications with applesauce contrary to physician's orders. As a result, the colonoscopy appointment was canceled due to the improper administration of medications prior to the procedure.
4. The investigation further revealed that the colonoscopy appointment was rescheduled for May 7, 2026.
5. Individual #19 experienced a delay in medical care due to staff failure to follow physician's orders regarding pre-procedure medication administration. Neglect was confirmed.
B. Individual #22
1. A facility incident report and investigation report dated April 29, 2026, was reviewed on May 20, 2026. The investigation revealed that on April 29, 2026, a staff reported that Individual #22 was choking on a cheeseburger he received for his lunch.
2. The target of the investigation stated in his witness statement that the cheeseburger was cut into thirds when he left the individual's side to retrieve condiments for the cheeseburger. It was stated, "When I returned, #22 was coughing and gagging." Staff was positioned to perform the Heimlich maneuver when the individual coughed up the food item on his own.
3. Further review of the investigation revealed through witness statements and documentation that the Speech and Language pathologist and physician orders revealed that bread is to be cut into one-inch pieces prior to consuming. The individual was examined by the medical staff after the incident. A chest X-ray was ordered but refused by the individual. The individual remains stable without a cough and is eating well per nursing staff without difficulty.
4. Individual #22 experienced a choking episode due to staff failure to properly cut food items into the prescribed size. Neglect was confirmed, and the target of the investigation receiving retraining.
C. Individual #23
1. Individual #23 has the following diagnoses: Profound Intellectual Disability, spastic quadriplegia, Gastrostomy tube status, Dysphagia.
2. Review of a facility incident report and investigation on May 19, 2026, revealed on February 25, 2026, at 8:00 AM, Individual #23 was observed lying flat in his bed with his tube feeding running. The residential services aide (RSA) assigned to this individual was dressing him. Further review of Individual #23's chart revealed a physician's order for head of bed (HOB) to be positioned at a 45-degree angle at all times when tube feeding is running and that aspiration precautions are to be in place. Neglect was confirmed, and the target RSA of the investigation received retraining.
3. Record review on May 20, 2026, revealed that on February 28, 2026, (no time listed), Individual #23 became short of breath and was admitted to the hospital. He was diagnosed with multifocal pneumonia in the setting of aspiration and acute hypoxic respiratory failure. He was treated with oxygen and intravenous antibiotics. He was re-admitted to the center on March 2, 2026, on oral antibiotics for six additional days.
4. Interview with the Quality Assurance Risk Management Coordinator (QARMC) on May 21, 2026, at 8:30 AM confirmed staff did not follow Individual #23's physician's order to keep the HOB at a 45-degree angle to maintain aspiration precautions.
D. Individual #24
1. A facility incident report and investigation dated December 27, 2025, was reviewed. The investigation revealed that Individual #24 was found by the Registered Nurse lying flat in bed while receiving a tube feeding.
2. Further review of the Individual's Treatment Administration Record (TAR), safety profile, and health profile revealed physician orders and aspiration precautions requiring that the head of the bed always remain elevated at a 45-degree angle during tube feedings.
3. The investigation further revealed that the assigned second shift staff failed to check on Individual #24 at the beginning of the shift, resulting in this individual remaining in a flat position while feeding was in progress.
4. Due to concerns for possible aspiration, Individual #24 was transported to the emergency room for further medical evaluation. Individual #24 was placed at risk for aspiration due to staff failure to follow prescribed aspiration precautions and provide appropriate supervision and monitoring. Neglect was confirmed.
E. Individual #29
1. An investigation report, dated February 13, 2026, was reviewed on May 19, 2026. This review revealed that on January 6, 2026, at approximately 5:15 AM, Individual #29 was administered Ativan for supportive sedation for a dental appointment originally scheduled that morning at 7:30 AM.
2. Further review of the investigation report revealed that the dental appointment was canceled by the provider on December 24, 2025. Facility investigation determined that a rights violation had occurred when Individual #29 received sedation medication on January 6, 2026. Individual was medically assessed, and no injuries were noted.
F. Individual #30
1. An investigation report, dated April 14, 2026, was reviewed on May 19, 2026. This review revealed that on April 14, 2026, at approximately 7:30 AM, Individual #30 was fed breakfast despite NPO (nothing by mouth) orders being in place for a medical procedure that would take place that morning.
2. Further review of the investigation report revealed that the medical procedure scheduled for that morning needed to be cancelled due to Individual #30 being fed breakfast. Facility investigation determined that neglect had occurred when staff failed to follow physician's pre-appointment orders for Individual #30, resulting in the medical procedure being cancelled. Individual #30 showed no signs of distress, and the procedure was non-emergent. She was placed on a wait list for a new appointment.
G. Individual #31
1. An investigation report, dated March 3, 2026, was reviewed on May 19, 2026. This review revealed that on February 13, 2026, during first shift, Individual #31 was fed breakfast despite NPO orders being in place for a medical procedure that would take place that morning.
2. Further review of the investigation report revealed that the medical procedure scheduled for that morning needed to be cancelled and rescheduled due to Individual #31 being fed breakfast. Facility investigation determined that neglect had occurred when Individual #31 missed his scheduled medical procedure due to staff error. Upon medical assessment, Individual #31 appeared his usual self and showed no signs or symptoms of psychological abuse or distress.
3. A second investigation report for Individual #31, dated March 23, 2026, was reviewed on May 19, 2026. This review revealed that on March 6, 2026, Individual #31 was taken to the wrong office for his medical procedure. Individual #31 was NPO for the procedure, and the procedure was cancelled.
4. Further review of the investigation report revealed that this is the second time this medical procedure has been cancelled. The same procedure had been cancelled previously on February 13, 2026, due to being fed breakfast while having an NPO order prior to the procedure. Facility investigation determined that neglect had occurred when Individual #31 missed his scheduled medical procedure due to staff error. No ill effects were noted upon his return. Individual #31 was again placed on a cancellation list awaiting a new appointment.
H. Individual #32
1. An investigation report, dated May 5, 2026, was reviewed on May 19, 2026. This review revealed that Individual #32 was seen by the Physicians Assistant (PA-C) on April 22, 2026, for possible left ear pain. Staff reported Individual #32 was hitting herself, indicating possible ear pain. PA-C diagnosed Individual #32 with left otitis media and prescribed antibiotics and lab tests.
2. Further review of the investigation revealed that Individual #32 was seen by the audiologist on April 7, 2026. Audiologist noted that this individual had the start of a possible left otitis media. No treatment or antibiotics had been started by the provider on or since that date. Individual #32 was also sent to the emergency room for a fever on April 7, 2026, but was not admitted.
3. Facility investigation determined that neglect did occur when staff failed to implement timely treatment of an ear infection. Treatment was not started until 15 days after the audiologist first examined Individual #32, who was displaying symptoms of ear pain and reported she had the start of possible left otitis media.
I. An interview with the facility director was conducted on May 21, 2026, at 3:00 PM. The facility director confirmed that the facility failed to ensure staff effectively managed the health needs of eight individuals in the facility.
Plan of Correction:1. For Individual #19, the Nurse Manager (NM) will retrain target staff on the expectation that nursing staff are to adhere to administering medications as ordered by the provider. The completed training roster will be submitted to the Quality Assurance Risk Management Director (QARMD).
NM (I)
QARMD (M)
6-5-2026
2. The Nurse Manager will review and update the Medication Administration Policy, to clarify following providers' orders when administering medications. Updated policy will be submitted to the Clinical Services Director (CSD) for review and approval.
NM (I),
CSD (M)
6-12-2026
3. CSD will submit it to Facility Director (FD) for final approval.
CSD (I)
FD (M)
6-15-2026
4. The Staff Development Specialist 2 (SDS2) will ensure that all Nursing staff are trained on the updated Medication Administration Policy. SDS2 will track the training to ensure that all the above-mentioned staff are trained and submit the completed training rosters to the QARMD. The QARMD will ensure that all nursing staff are trained.
SDS2 (I)
QARMD (M)
7-13-2026
5. For individual #22 the Residential Services Supervisor (RSS) will retrain the target staff to properly cut food items into the prescribed sizes. The completed training rosters will be submitted to the Director of Residential Unit Managers (DRUM).
RSS (I)
DRUM(M)
6-12-2026
6. The Staff Development Specialist 2 (SDS2) will ensure that all Program Services Staff are trained to review dining cards prior to dining, including properly cutting food items into the prescribed sizes. SDS2 will track the training to ensure that all the above-mentioned staff are trained and submit the completed training rosters to the QARMD. The QARMD will ensure that all program services staff are trained.
SDS2 (I)
QARMD (M)
7-31-2026
7. Speech and Language Specialist (SLHS) will develop training and picture guide indicating appropriate food size cutting instructions.
Training will be submitted to the CSD for review and approval.
SLHS (I)
CSD (M)
6-19-2026
8. SLHS will provide in-person training to all direct care staff on appropriate food-size cutting instructions and submit the completed training rosters to SDS2. The SDS2 will ensure that all direct care staff are trained.
SLHS (I)
SDS2 (M)
7-31-2026
9. DRUM will create a dining audit tool to include monitoring appropriate use of dining supports ensuring all prescribed diet orders are completed as written. The DRUM will submit the tool to the Program Services Director (PSD) for review and approval.
DRUM (I)
PSD (M)
6-12-2026
10. The DRUM will train all RSUMs, RSS and RSWs on the dining audit tool and submit completed rosters to the PSD. The PSD will ensure that all the staff mentioned are trained.
DRUM (I)
PSD (M)
6-15-2026
11. Each RSS and RSW will conduct a weekly dining audit for their assigned living area. If there are any concerns, discrepancies or errors noted during the review, they will be corrected immediately, reported immediately as well as adhering to all policies and procedures. Completed dining audits are to be submitted to their community RSUM weekly.
RSS/ RSW (I)
RSUM (M)
6-16-2026 and ongoing
12. The RSUM will submit a weekly report to the DRUM of their review of the weekly dining audits to ensure that they are completed as directed and any deficiencies noted are corrected.
RSUM (I)
DRUM (M)
6-23-2026 and ongoing
13. For individuals # 23 and 24 the Registered Nurse Instructor (RNI) will retrain target staff in the Enteral Feeding Tubes: Care and Handling Policy, specifically on the following providers' orders for position the head of the bed for individuals feeding tubes. Completed training rosters will be submitted to DRUM.
RNI (I)
DRUM (M)
6-5-2026
14. The Staff Development Specialist 2 (SDS2) will ensure that all Direct care staff in Health and Program services are trained on the Enteral Feeding Tubes: Care and Handling Policy. SDS2 will track the training to ensure that all the above-mentioned staff are trained and submit the completed training rosters to the QARMD. The QARMD will ensure that all nursing and program services staff are trained.
SDS2 (I)
QARMD (M)
7-31-2026
15. DRUM will revise the Residential Unit Managers (RSUM) daily round sheet to include living area audits for head of bed elevations for individuals with enteral feeding tubes. The revised round sheet will be submitted to the Program Servies Director for review and approval.
DRUM (I)
PSD (M)
6-12-2026
16. The DRUM will ensure that all Residential Services Unit Mangers (RSUM) are trained on the monitor. Completed training rosters will be submitted to the PSD.
DRUM (I)
PSD (M)
6-26-2026
17. RSUM will complete a monitoring form in their living areas each shift. If there are any concerns noted during the review they will be corrected immediately, reported immediately as well as adhering to all policies and procedures. Completed monitors will be submitted to the DRUM for review.
RSUM (I)
DRUM (M)
6-27-2026 and ongoing
18. For individual #29 the NM will retrain the target staff to ensure that updated appointment calendars are checked prior to administering sedative medications for appointments. Complete training roster will be submitted to QARMD.
NM (I)
QARMD (M)
6-5-2026
19. The NM will review and update the procedure for appointments Policy to include the checking of appointment calendars prior to administering sedative medications for appointments. Updated policy will be submitted to CSD for review and approval.
NM (I)
CSD (M)
6-12-2026
20. The CSD will submit the revised policy to the FD for final approval
CSD (I)
FD (M)
6-15-2026
21. Staff Development Specialist 2 (SDS2) will ensure that all Direct care staff in Health and Program services are trained in the updated Procedure Appointments Policy. SDS2 will track the training to ensure that all the above-mentioned staff are trained and submit the completed training rosters to the QARMD. The QARMD will ensure that all nursing and program services staff are trained.
SDS2 (I)
QARMD (M)
7-31-2026
22. The NM and DRUM will develop and procedure for effective communication between Nursing Services and Program Services staff to identify next day's appointments and support needed. Procedure will be submitted to CSD for review and approval.
NM (I)
CSD (M)
6-5-2026
23. The NM And DRUM will ensure Register Nurse Supervisor (RNS), RSUM, RSS Residential Services Aide Supervisors (RSAS) and Residential Services Aide Night Supervisors (RSANS) are trained in the communication procedure to include a review of next day appointments. Completed training rosters will be submitted to QARMD.
NM (I)
QARMD (M)
6-12-2026
24. The RNS will report out nightly on communication in the SOD report. The NM will review the SOD Reports daily to ensure communication occurs.
RNS (I)
NM (M)
6-13-2026 and ongoing
25. For individual #30 and #31 the RSS will retrain the target staff to ensure they review the daily appointments and 24hr report for individuals who are NPO. Complete training roster will be submitted to DRUM.
RSS (I)
DRUM (M)
6-5-2026
26. The NM will review and update the procedure for appointments policy to include staff to ensure they review the daily appointments and 24hr report for individuals who are NPO. Updated policy will be submitted to CSD for review and approval.
NM (I)
CSD (M)
6-12-2026
27. The CSD will submit the revised policy to the FD for final approval.
CSD (I)
FD (M)
6-15-2026
28. Staff Development Specialist 2 (SDS2) will ensure that all Direct care staff in Health and Program services are trained in the updates Procedure for Appointments Policy. SDS2 will track the training to ensure that all the above-mentioned staff are trained and submit the completed training rosters to the QARMD. The QARMD will ensure that all nursing and program services staff are trained.
SDS2 (I)
QARMD (M)
7-31-2026
29. For individual #31 the RSS will retrain the target staff to ensure they review the daily appointments and confirm location of the appointment prior to departure. Complete training roster will be submitted to DRUM.
RSS (I)
DRUM (M)
6-5-2026
30. Staff Development Specialist 2 (SDS2) will ensure that all Direct care staff are trained to ensure they review the daily appointments and confirm location of the appointment prior to departure. The QARMD will ensure that all nursing staff are trained.
SDS2 (I)
QARMD (M)
7-31-2026
31. The NM will review and update the procedure for appointments Policy to include staff to ensure they review the daily appointments and confirm location of the appointment prior to departure. Updated policy will be submitted to CSD for review and approval.
NM (I)
CSD (M)
6-12-2026
32. The CSD will submit the revised policy to the FD for final approval.
CSD (I)
FD (M)
6-15-2026
33. Staff Development Specialist 2 (SDS2) will ensure that all Direct care staff in Health and Program services are trained in the updated Procedure for Appointments Policy. SDS2 will track the training to ensure that all the above-mentioned staff are trained and submit the completed training rosters to the QARMD. The QARMD will ensure that all nursing and program services staff are trained.
SDS2 (I)
QARMD (M)
7-31-2026
34. For individual #32, the CSD will train the target provider to ensure they review and sign the consultation notes, writing the appropriate medical orders required to implement the recommendations of the consult. Completed training rosters will be submitted to QARMD.
CSD (I)
QARMD (M)
6-5-2026
35. The CSD will ensure that all medical doctors (MD) and physicians assistants'(PA-C) clinicians are trained to ensure they review and sign the consultation notes, writing the appropriate medical orders required to implement the recommendations of the consult. Completed training rosters will be submitted to QARMD.
CSD (I)
QARMD (M)
6-12-2026
36. The MD will complete one random chart audit weekly to review consultations and appropriate follow-up recommendations for the involved provider. If no errors are identified within thirty days, the MD will reduce the audit frequency to two random chart audits per month to review consultations and follow-up recommendations for the involved provider. If no errors are identified within thirty days, the MD will reduce the audit frequency to one random chart audit per month to review consultations and follow-up recommendations for the involved provider. If at any time an error is noted, then the monitoring will start over and return to the highest frequency and follow the progression. If there are any concerns, discrepancies or errors noted during the review, they will be corrected immediately, reported to the CSD immediately as well as adhering to all policies and procedures.
A report will be submitted weekly to the CSD for review to ensure that they are being completed as directed and any deficiencies noted are corrected.
MD (I)
CSD (M)
6-13-2026 and ongoing
483.430(e)(3) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
Staff must be able to demonstrate the skills and techniques necessary to administer interventions to manage the inappropriate behavior of clients.
Observations:
1. Based on staff interviews and reviews of three facility investigation reports, it was determined that facility staff failed to demonstrate consistent implementation of behavioral intervention techniques that were specified in three individual's Mental Health Support Action plans (MHSA) (Individual #17, #18, and #19).
The findings included in the following:
A. Individual #17
1. The record of Individual #17 was reviewed on May 18,2026, at 11:30 AM. This Individual's diagnoses include Mild Intellectual Disability, Schizoaffective Disorder, Borderline Personality Disorder, Psychotic Disorder, Impulse Control Disorder, and Pica.
2. Individual #17 has a Mental Health Support Action plan (MHSA) addressing the inappropriate behaviors of Pica attempts and actual ingestion of non-edible objects. Individual #17's plan includes the following intervention: one-to-one supervision always and in all locations. The plan also requires staff to be in close proximity to Individual #17 when around other individuals or when handling items that may put her or others at risk. Immediate staff intervention is expected to prevent target behaviors and prevent injury to Individual #17 and others.
3. An investigation report review and staff interview with the Quality Assurance Coordinator (QAC) on May 19, 2026, at 3:15 PM revealed that on February 6, 2026, at approximately 11:45 AM, Individual #17 was outside with staff when she swallowed a pebble approximately 8.22 mm in diameter. An x-ray was obtained on which revealed a foreign body in the ascending colon. Follow-up x-rays were completed on February 13, 2026, which revealed no foreign body present. It was determined at that time that Individual #17 had passed the object with no additional complications. The investigation determined that Individual #17 was being supervised by a one-to-one staff at the time of the incident; however, the target staff was unable to intervene and prevent the ingestion of the pebble. Staff were retrained and counseled regarding the incident.
B. Individual #18 1. The record of Individual #18 was reviewed on May 19, 2026, at 1:00 PM. This individual's diagnoses included the following: Mild Intellectual Disabilities, Major Depressive Disorder, Borderline Personality Disorder, Autism Spectrum Disorder, and Pica behavior.
2. Individual #18 had an MHSA plan addressing the inappropriate behavior of attempting to ingest non-edible and harmful objects. Individual #18's plan included the following intervention: three-to-one direct care staff supervision always and in all locations. The plan also requires that staff have all personal items secured and kept in a locked area so that Individual #18 does not have access to them as she may attempt to ingest the item.
3. Investigation report review and staff interview with the QAC on May 19, 2026, at 3:30 PM revealed that on December 31, 2025, at 4:45 PM, Individual #18 was in the game room with her assigned staff, who had been assisting her with writing a letter. The staff took the cap off the marker being used and set the cap down on the table. Individual #18 grabbed the cap from the table and subsequently ingested it. The nurse assessed Individual #18 and contacted the on-call physician. The on-call physician directed staff to monitor Individual #18's stools to see when the item passed. Review of the report revealed that the item did not pass, and the physician ordered the individual to be evaluated at the emergency room. At the hospital, the presence of the marker cap was confirmed with imaging, and the item was subsequently removed via upper endoscopy. No complications were noted.
4. The investigation determined that Individual #18 was being supervised by her assigned one-to-one staff at the time of the incident, but staff had failed to follow the MHSA plan environmental precautions for Pica. Staff were retrained and counseled regarding the incident.
C. Individual #191. The record of Individual #19 was reviewed on May 19, 2026, at 2:00 PM. This individual's diagnoses included the following: Profound Intellectual Disabilities, Obsessive Compulsive Disorder, Anxiety Disorder, Autism Spectrum Disorder, and Pica behavior.
2. Individual #19 had an MHSA plan addressing the inappropriate behavior of attempting to ingest non-edible and harmful objects. Individual #19's plan included the following intervention: one-to-one direct care staff supervision at arm's length always and in all locations. The plan also requires that staff complete environmental sweeps in all her areas due to Pica behavior.
3. Investigation report review and staff interview with the QAC on May 19, 2026, at 3:50 PM revealed that on March 3, 2026, direct care staff assisted Individual #19 into the bathroom area to change her ileostomy bag. At that time, the staff discovered a self-tapping screw in the ileostomy bag. The staff immediately reported the finding, and the physician ordered x-rays. The x-rays were completed with no other foreign objects being found. The facility initiated an investigation at that time due to the finding of the foreign object in the ileostomy bag, as well as confirming why it was unknown as this had occurred when Individual #19 was under one-on-one supervision during those hours.
4. The facility investigation could not definitively determine where Individual #19 had obtained the self-tapping screw; however, they did determine neglect had occurred as the event had occurred while the individual was under one-to-one supervision.
D. The Facility Director (FD) was interviewed at 2:30 PM on May 21, 2026. During the interview, the FD confirmed facility staff failed to implement MHSA plan interventions as required, and this resulted in three incidents of successful Pica.
2. Based on staff interviews and facility investigation report review, it was determined that facility staff utilized blue blocking pads in an unapproved and unauthorized manner for two individuals (Individuals #17 and #25).
The findings included the following:
A. Individual #17
1. An investigation report, dated February 3, 2026, was reviewed. This review revealed that on January 7, 2026, during the early morning hours, a registered nurse supervisor (RNS) observed Individual #17 attacking staff. During this incident, the RNS reported observing the staff use a blue blocking pad to forcefully push Individual #17 against a wall and hold her there. Based on witness testimony, the investigation concluded that abuse/unauthorized restraint was confirmed. Staff were retrained and counseled regarding the incident.
B. Individual #25
1. The record of Individual #25 was reviewed on May 18, 2026. This individual's diagnoses included the following: Unspecified Impulse Control Disorder, Intermittent Explosive Disorder, Reactive Airway Disease and Pulmonary Edema secondary to congestive heart failure. Individual #25 has utilized a tracheostomy since 2008, with a Passey Muir Valve on the trach to aid with speech and safe swallowing.
2. Individual #25 had an MHSA plan addressing the inappropriate behavior of aggression towards peers and staff. Individual #25's plan included the following intervention: one-to-one direct care staff supervision on all three shifts. The plan also instructed staff that crisis techniques should be handled with the use of blue protective pads when necessary. It indicates the blue pads should be used to block aggression only.
3. Investigation report review revealed that on January 16, 2026, at 11:30 AM, the psychological support service (PSS) staff entered the living area and observed Individual #25 seated on a couch attempting to kick at direct care staff. The PSS observed Individual #25 attempting to get up from the couch. At this time, the direct care staff also stood from the couch and pushed her body weight into the blue pad and into Individual #25's face and neck area. Based on witness testimony, the investigation concluded that abuse/unauthorized restraint was confirmed.
C. The facility director (FD) was interviewed at 2:45 PM on May 21, 2026. During the interview, the FD confirmed facility staff utilized blue blocking pads in an unapproved and unauthorized manner for Individuals #17 and #25.
Plan of Correction:1. For Individuals #17 and #19, the Residential Services Supervisor (RSS) will train the target staff on the specific supervision parameters outlined in the Enhanced Supervision Plan and Mental Health Support Action (MHSA), including required staff positioning and observation requirements such as conducting required pica sweeps, and adhering to any other individualized supervision and support expectations identified in the plans. The RSS will submit completed training rosters to the Director of Residential Unit Management (DRUM).
RSS (I),
DRUM (M)
6-5-2026
2. The Staff Development Specialist 2 (SDS2) will train all program services staff to follow specific supervision parameters outline in the Enhanced Supervision Plan and MHSA, including following all required staff parameters and observation requirements as written. The SDS2 will submit completed training rosters to the Quality Assurance Risk Management Director (QARMD).
SDS2 (I)
QARMD (M)
7-31-2026
3. For Individual #18, the Residential Services Supervisor will train target staff on the specific requirements outlined in the MHSA, including conducting pica sweeps at the prescribed frequency, securing all identified items when not in use, and adhering to all other individualized supports and safety measures identified in the MHSA. The RSS will submit the completed training roster to the DRUM.
RSS (I)
DRUM (M)
6-5-2026
4. The DRUM will review the Personal Possessions Policy to determine whether revisions are necessary. Any recommended changes will be submitted to the Facility Director (FD) for review and approval.
DRUM (I)
FD (M)
6-15-2026
5. The SDS2 will train all program services staff on the Personal Possessions Policy. The SDS2 will submit completed training rosters to the QARMD.
SDS2 (I)
QARMD (M)
7-31-2026
6. The SDS2 will provide in-person training to all Program Services staff on pica-related risks and interventions, including conducting pica sweeps, identifying potential pica hazards, recognizing environmental concerns, and implementing individualized supports and safety measures in accordance with applicable assessments and plans. The SDS2 will submit completed training rosters to QARMD.
SDS2 (I)
QARMD (M)
7-31-2026
7. The RSS will train Residential Services Aid Supervisors (RSAS) and Residential Services Aid Night Supervisors (RSANS) on the use of pica sweep documentation for individuals residing in their assigned community, including expectations for completion, review and follow-up on identified concerns. The RSS will submit completed training rosters to the DRUM.
RSS (I)
DRUM (M)
7-3-2026
8.Each RSAS and RSANS will conduct and document a weekly pica sweep for all individuals with a history of pica in their assigned community. Identified hazards or concerns will be corrected immediately and documented on the Pica sweep form. The RSAS and RSANS will submit completed Pica sweep documentation to the RSUM weekly.
RSAS/RSANS (I),
RSUM (M)
7-3-2026 and ongoing
9.The RSUM will review all submitted pica sweep documentation on a weekly basis to ensure completion, identify trends or concerns, and verify that appropriate follow-up actions have been taken. The RSUM will provide a weekly summary report of findings, concerns, and corrective actions to the DRUM.
RSUM (I)
DRUM (M)
7-3-2026 and ongoing
10. The RSS will conduct team meetings for individuals with a history of Pica to review the individual's support plan, identified risks, supervision requirements, environmental controls, and intervention strategies. Meeting notes and attendance rosters will be submitted to the DRUM.
RSS (I)
DRUM (M)
7-3-2026
11.The DRUM will establish a multidisciplinary Pica committee. The DRUM will report identified members and committee guidelines to the Facility Director (FD) for approval.
DRUM (I)
FD (M)
6-30-2026
12.The DRUM will set up monthly meetings for the Pica Committee to review incidents, trends, environmental concerns, interventions, and recommendations related to Pica. The DRUM will submit monthly meetings to the PSD.
DRUM (I)
PSD (M)
7-31-2026 and ongoing
13.The DRUM will submit monthly meeting minutes to the FD. The FD will review monthly meeting minutes
DRUM (I)
FD(M)
7-31-2026 and ongoing
14.For individuals #17 and #25, the SDS2 will provide in-person retraining to target staff on the appropriate use of blocking pads, including expectations, limitations, and prohibited use, utilizing scenario-based training to reinforce proper application. SDS2 will submit completed training rosters to the DRUM.
SDS2 (I)
DRUM (M)
6-13-2026
15.The SDS2 will provide in-person retraining to all Program Services staff on the appropriate use of blocking pads, including expectations, limitations, and prohibited use, utilizing scenario-based training to reinforce proper application. The SDS2 will submit completed training rosters to the QARMD for documentation and compliance monitoring.
SDS2 (I)
QARMD (M)
7-31-2026
16.The DRUM will develop a "Rapid Response Debriefing Form" to document key details of each rapid response event, including a summary of the incident, actions taken, what went well, and identified opportunities for improvement. The completed form will be submitted to the Facility Director (FD) for review and approval.
DRUM (I)
FD (M)
6-30-2026
17.The DRUM will provide training to Division Directors (DD), RSUM, and Registered Nurse Supervisors (RNS) on the completion and proper use of the Rapid Response Debriefing Form, including accurate documentation of incident details, identified strengths, and opportunities for improvement. The DRUM will submit completed training rosters to the QARMD.
DRUM (I)
QARMD (M)
7-3-2026
18. A Division Director (DD), Residential Services Unit Manager (RSUM), or Registered Nurse Supervisor (RNS) will attend all rapid response calls and complete the Rapid Response Debriefing Form following each event, ensuring accurate and timely documentation of the incident, staff response, individuals involved, and outcomes. The debriefing will include personnel who participated in the rapid response. Any immediate issues identified during the response will be addressed and corrected in real time, with follow-up actions initiated as necessary to ensure ongoing safety and compliance. The DD, RSUM, or RNS completing the form will submit the completed Rapid Response Debriefing Form to the Facility Director (FD) for review.
DD/RSUM/RNS (I),
FD (M)
7-3-2026
483.430(e)(4) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
Staff must be able to demonstrate the skills and techniques necessary to implement the individual program plans for each client for whom they are responsible.
Observations:
Based on staff interview and investigation report review, it was determined the facility failed to ensure staff demonstrated the skills and techniques needed to implement the individual program plan for five individuals residing at the facility. (Individuals #20, #21, #26, #27, and #28)
The findings included the following:
A. Individual #20
1. A review of a facility investigation revealed that on December 10, 2025, at approximately 8:50 AM, Individual #20 fell out of his wheelchair trying to reach for his toy bats and sustained a reddened area on his face.
2. Review of facility investigation also revealed that the target of the investigation was responsible for putting Individual #20 in his wheelchair and admitted in the incident report that he was not properly secured. An allegation of neglect was confirmed by the facility.
B. Individual #21
1. A review of a facility investigation revealed that on December 28, 2025, Individual #21 was walking in the hallway pulling his clothing hamper when he fell. The individual is known for having an unsteady gait with a history of increased falls and requires enhanced supervision for safety. The target of the investigation was not utilizing the gait belt per Individual #21's plan. No injuries were noted from the fall.
2. A review of an Occupational/Physical Therapy (OT/PT) consult dated February 6, 2026, revealed that anytime Individual #21 is transferring or ambulating, the gait belt should be utilized.
3. Further review of the facility investigation revealed through witness statements and video footage that the target did not apply or utilize a gait belt on the morning of the fall. An allegation of neglect was confirmed by the facility. Staff was counseled, and retraining was provided.
C. Individual #26
1. An investigation report, dated May 7, 2026, was reviewed on May 19, 2026. This review revealed that on April 30, 2026, at approximately 7:00 AM, Residential Services Aide (RSA) staff reported that he assisted Individual #26 to the toilet and then left to give another individual a shower. Sometime between five and fifteen minutes later, the RSA returned to find Individual #26 had fallen on his left side on the floor. The facility nurse was called to assess this individual. No injuries were noted at the time.
2. Further review of the investigation revealed that Individual #26's information card and one-page summary state that Individual #26 should not be left alone in the bathroom. Facility investigation determined that neglect did occur when staff failed to follow needed supports. Target staff was retrained to follow supports as written.
D. Individual #27
1. An investigation report, dated April 13, 2026, was reviewed on May 19, 2026. This review revealed that on March 31, 2026, at approximately 1:30 PM, Individual #27 fell out of her wheelchair after being transferred into it from a mechanical lift using two staff.
2. Further review of the investigation revealed that after the two staff placed Individual #27 into the wheelchair, one RSA attempted to remove a green pad from underneath Individual #27 prior to buckling her seatbelt. Individual #27 fell forward out of her chair, causing a small red area on her forehead. Head Injury Protocol was initiated and resolved the following day. Facility investigation determined neglect had occurred when staff failed to utilize the wheelchair seatbelt immediately after placing individual into the wheelchair.
E. Individual #28
1. A review of a facility investigation report revealed that on January 29, 2026, at approximately 11:10 AM, staff secured Individual #28 into a toilet chair utilizing a seatbelt restraint while the individual was in the bathroom. Review of the physician's orders at the time of the incident revealed there was no physician's order or documented consent authorizing use of the seatbelt restraint prior to implementation. The investigation further revealed that staff left the individual unattended while restrained, at which time the individual experienced a fall. No injuries were reported as a result of the incident.
2. A review of the individual's prior support documentation dated December 12, 2025, revealed staff were instructed to assist the individual to the toilet; however, the individual was otherwise noted to be independent. Further review revealed there was no authorization in place for use of a seatbelt restraint prior to the incident on January 29, 2026.
3. A review of facility records revealed that corrective actions were initiated following the incident. Further review revealed the physician's orders were updated on January 29, 2026, at approximately 3:00 PM following the incident to include the use of a seatbelt while on the toilet.
F. The Facility Director (FD) was interviewed at 3:00 PM on May 21, 2026. During the interview, the FD confirmed the staff failed to implement the individual program treatment plan for five individuals residing at the facility.
Plan of Correction:1.For individuals #20, #21 and #26 target staff will be trained on the information cards and safety supports of the individual specifically ensuring that seat belts are properly secured and gait belts are in use by the Residential Services Supervisor (RSS). RSS will complete and track the training to ensure that target staff have been trained and submit the completed training rosters to the Director of Residential Unit Management (DRUM). The DRUM will verify that all identified staff are trained.
Residential Services Supervisor (RSS) (I)
Director of Residential Unit Management (DRUM) (M)
6-5-2026
2.The DRUM will forward the complete training rosters to the Quality Assurance Risk Management Director (QARMD).
DRUM (I)
Quality Assurance Risk Management Director (QARMD)
6-5-2026
3. All Program Services staff will be trained by the Staff Development Specialist 2 (SDS2) on ensuring staff review individual information cards, safety supports prior to their assignment and ensuring all safety supports are utilized as written.
Staff Development Specialist 2 (SDS2) (I)
7-31-2026
4. SDS2 will complete and track the training to ensure that all Program Services staff are trained and submit the completed training rosters to the QARMD. The QARMD will verify all that all identified staff are trained.
SDS2 (I)
QARMD (M)
7-31-2026
5. For individual 27, target staff will be trained to ensure that the green pad is in the proper position before lowering the individual into the chair. RSS will complete and track the training to ensure that target staff have been trained and submit the completed training rosters to the Director of Residential Unit Management (DRUM). The DRUM will verify that all identified staff are trained.
RSS (I)
Director of Residential Unit Management (DRUM) (M)
6-5-2026
6.The DRUM will forward the completed training rosters to the Quality Assurance Risk Management Director (QARMD).
DRUM (I)
Quality Assurance Risk Management Director (QARMD)(M)
6-5-2026
7. All Program Services staff will be trained by the Staff Development Specialist 2 (SDS2) when transferring an individual to ensure all items and safety supports are in place before transferring them.
SDS2 (I)
7-31-2026
8. SDS2 will complete and track the training to ensure that all Program Services staff are trained and submit the completed training rosters to the QARMD. The QARMD will verify all that all identified staff are trained.
SDS2 (I)
QARMD (M)
7-31-2026
9.For individual 28, the target staff will be trained to only use approved restrictive supports for the person they are supporting by the RSS. RSS will complete and track the training to ensure that target staff have been trained and submit the completed training rosters to the Director of Residential Unit Management (DRUM). The DRUM will verify that all identified staff are trained.
RSS (I)
DRUM (M)
6-5-2026
10. All Program Services staff will be trained by the Staff Development Specialist 2 (SDS2) trained to only use approved restrictive supports for the person they are supporting.
Staff Development Specialist 2 (SDS2) (I)
7-13-2026
11. SDS2 will complete and track the training to ensure that all Program Services staff are trained and submit the completed training rosters to the QARMD. The QARMD will verify all that all identified staff are trained.
SDS2 (I)
QARMD (M)
7-13-2026
12. The DRUM will develop a living area meeting minutes form to be utilized for weekly meetings. These weekly living area meetings will be used to review and reinforce all current approved safety supports. This form will be submitted to the Program Servies Director (PSD) for approval.
Drum (I)
Program Servies Director (PSD) (M)
6-12-2026
13. The DRUM will train the RSS and Residential Services Unit Manager (RSUM) on the form. Completed training rosters will be submitted to the PSD. The PSD will verify all identified staff are trained.
Drum (I)
Program Servies Director (PSD) (M)
6-19-2026
14. The RSS will schedule and hold weekly living area meetings with living area staff including aides, RSUM and RSAS/RSANS to communicate changes.
RSS (I)
6-29-2026 and ongoing
15. The RSS will complete meeting minutes for the living area meetings. These will be submitted to the RSUM weekly for review. If there are any concerns or discrepancies, they are to be addressed with the living area RSS.
RSS (I)
RSUM (M)
6-29-2026 and ongoing
16. The RSUM will submit a report to the DRUM summarizing the weekly meetings including any concerns addressed.
RSUM (I)
DRUM (M)
6-29-2026 and ongoing
17. The RSS will place completed meeting minutes in a binder accessible to all staff on the living area for review. The RSUM will ensure that this binder is kept up to date during daily rounds. If there are any concerns or discrepancies, they are to be addressed with the living area RSS and reported to the DRUM
RSS (I)
RSUM (M)
DRUM (M)
6-29-2026 and ongoing
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