Initial Comments:
A focused fundamental survey visit was completed on December 3 and 4, 2025. The purpose of this visit was to evaluate compliance with the requirements of 42 CFR, Part 483,
Subpart I regulations for Intermediate Care Facilities for Individuals with intellectual disabilities. The census at the time of the visit was four, and the sample consisted of two Individuals.
Plan of Correction:
483.410(a)(1) STANDARD
GOVERNING BODY
Name - Component - 00
The governing body must exercise general policy, budget, and operating direction over the facility.
Observations:
Based on observations and interviews with facility and administrative staff to include the Qualified Intellectual Disabilities Professional (QIDP), the governing body failed to exercise general operating direction over the facility to ensure the necessary environment to provide for the health and safety of Individuals at this residence during evacuation drills. This practice is specific to Individuals #1, #2, #3 and #4.
Findings included:
1. A review of the facility's evacuation drills for the period from 10/2024 through 09/2025 revealed the evacuation drill reports listed the following information:
-Names of the individuals who participated in the evacuation drill
-The hypothetical location of the fire:
- exit used during the fire
In further review of these reports, there was no indication regarding the location of each Individual within the facility prior to the start of the fire drill, in order to assess if the evacuation route utilized was the best route based on the designated location of the fire during this drill.
Exemplary of this practice is as follows:
- On 03/28/2025 at 9:30 PM the evacuation alarm was pulled. The report identified the hypothetical fire as being located in Bedroom #3. All bedrooms are located in a common hallway on one end of the residence that is connected to a family room area. The kitchen area of this residence is located on the opposite end of the bedroom area, and is not adjacent to the family room area of the residence.
The exit utilized during this fire drill was listed as the kitchen exit. There is a front door exit located in the family room area which is between the kitchen exit and the location of the fire. There was no indication in the report to indicate where the individuals were located at the time of the alarm to determine if the kitchen door was the appropriate exit to be utilized during this evacuation drill.
2. Interview with the Director of Quality Improvement on 12/03/2025 at approximately
9:45 AM, revealed that the people responsible for reviewing the evacuation reports after the completion of the evacuation drill are as follows:
-Supervisor of the facility
-Operation Manager
-Director of Operations
-Quality Improvement department
Interview with the QIDP on 12/03/2025 at 9:00 AM, and subsequent interview with the Operational Manager on 12/03/2025 at approximately 9:10 AM, noted that both interviewees noted that they do not evaluate these drills regarding the exit utilized versus the designated location of the fire.
Plan of Correction:CE1 Past fire drills cannot be corrected. A new fire drill form to include the location of each individual was created by the Sr. Director by 12/16/2025. This new form will be shared with the Operations leadership and all employees by 12/31/2025.
CE2 The building leadership will be instructed to discard any older fire drill forms and begin using the new form by 1/1/2026.
CE3 The new Fire drill form which includes the location of each individual at the time of the drill and exit used will be trained to all employees, the Supervisor, the Operations Manager, the Director of Operations and the Qualified Intellectual Disability Professional by 1/1/2026 to be implemented starting 1/1/2026. The training is to include leadership review of the completed form the Supervisor, Operations Manager and Director of Operations to accurately document the path of exit including the exit used, the safety of individuals and thorough completion of the form. The Supervisor and Operations Manager will sign that they reviewed the form within 2 business days of the drill. If the new form is not completed accurately or depicts an unsafe condition, the Supervisor and/or Operations Manager will re-train the employee leading the drill using an in-service sheet. The drill will be redone within 48 hours of error being noted.
CE4 The completed and corrected, if applicable, form will be submitted to the Quality Improvement Department within 2 business days of completion. The Quality Improvement Coordinator will check the form for accuracy and safety of individuals. If any errors or unsafe conditions are noted or sections are not thoroughly completed the Quality Improvement Coordinator will return the drill to the Operations Manager and Director of Operations for correction, coping the Sr. Director. If a redrill is needed, the redrill is to be completed within 2 business days from the notification from the Quality Improvement Coordinator. The redrill will follow this same process.
CE5 If there are repeated failure to follow this plan of correction, the Director of Quality Improvement will notify the Sr. Director, who will take action to address any personnel who fail to meet this corrective action with re-training, counseling or disciplinary action starting 1/1/2026 and ongoing.
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
and under varied conditions to-
Observations:
Based on record review and interview with administrative staff, the facility failed to hold evacuation drills under varied conditions of time. This practice is specific to the first and third shift of personnel.
Findings include:
A review of the facility's evacuation drills for the period from 10/2024 through 09/2025 was completed on 12/03/2025 from approximately 9:15 AM to 9:45 AM. This review revealed evacuation drills were not varied throughout the extent of the first and third shift of personnel as follows :
First Shift of Personnel Evacuation Drills defined as 7:00 AM to 3:00 PM:
11/16/2024 9:41 AM
02/15/2025 2:00 PM
05/10/202510:36 AM
08/09/2025 9:25 AM
Third Shift of Personnel Evacuation Drills defined as 11:00 PM to 7:00 AM:
11/02/2024 2:10 AM
01/20/2025 3:15 AM
04/22/202512:09 AM
07/20/2025 2:30 AM
Interview with the Director of Quality Improvement on 12/03/2025 at approximately
9:45 AM confirmed the times of the evacuation drills were not varied as noted above for the first and third shift of personnel.
Plan of Correction:CE1 Past fire drills cannot be corrected. A new fire drill schedule will be developed by the Quality Improvement Director by 12/31/2025. This new schedule will be shared with the Operations leadership and all employees by 12/31/2025.
CE2 By 12/16/2025, the Quality Improvement Director will review the December 2025 fire drill schedule to identify that the drill will occur at a varied time slot. The Quality Improvement Director will inform via email the Director of Operations if they can proceed with the time slot or identify a new time slot for the December 2025 fire drill.
CE3 The Quality Improvement Director will complete the 2026 fire drill schedule including the last quarter of 2025. The schedule will include varied dates and times to hold the drills. The 2026 fire drill schedule will be sent to the Director of Operations and Operations Manager by 12/31/2025. The Supervisor and Operations Manager will be counseled and trained by the Director of Operations to follow the fire drill schedule as written by 1/1/2026. If the schedule is not followed, the Director of Operations will provide re-training and counseling as needed.
CE4 If the published fire drill schedule is not followed, the drill will need to be completed again in accordance with the schedule or a varied time as identified by the Quality Improvement Department. Each month, the Quality Improvement Coordinator will check that the schedule was followed. If the drill did not occur per the schedule, the Quality Improvement Coordinator will inform the Director of Operations copying the Director of Quality Improvement to repeat the drill with an identified time and date that is varied. The Quality Improvement Coordinator will track the fire drills to document that the drills occur at varying days and times. The Director of Quality Improvement will train the Quality Improvement Coordinator to use a tracker for this purpose.
CE5 If the fire drill schedule is not followed, the Director of Quality Improvement will notify the Sr. Director, who will take action to address any personnel who fail to meet this corrective action with re-training, counseling or disciplinary action starting 1/1/2026 and ongoing.
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