Initial Comments:
A focused fundamental survey was conducted May 11-14, 2026, to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I Regulations for Intermediate Care Facilities. The census during the survey was 22 and the sample consisted of four 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 observations and interviews, it was determined that the facility failed to ensure that all staff were trained in accordance with the individuals' health needs. This applied to all three cottages at the facility. Findings included:
Observations were completed in all three cottages during the morning and breakfast routine on May 12, 2026, from 6:50 AM to 8:15 AM. During this time, all the staff in cottage 2 were observed to prepare two cold cereal options and toast for breakfast. There was one individual in cottage 2 that received eggs for breakfast. At 7:30 AM, a kitchen staff in cottage 2 was interviewed and stated that the one individual does receive eggs for breakfast due to a health condition. The staff was asked for the menu and when it was presented it was noted that the breakfast meal for that morning was to be "french toast and bacon, assorted fruit, milk and juice." At this same time the staff was asked about the discrepancy of the menu and the observed breakfast items. The staff stated, "This is a new menu and we follow the old one, and we are not given anything to prepare these menu items." Interview completed with the staff in cottages 1 and 3 confirmed that the menus stated french toast and bacon, fruit, milk and juice; however, they were observed to offer cold and hot cereal choices. The staff stated that it was due to not having the correct items.
Interview with the executive director (ED) on May 13, 2026, at 2:00 PM, confirmed that it is the expectation that the staff in the cottages follow the menu and if there is an issue with the food not being available that they should call immediately. The ED further stated that the staff should be retrained to follow the menu.
Plan of Correction:On 5/12/26, the staff working in cottages 1, 2, and 3 did not provide the breakfast that was stipulated on the menu for that day; instead served cold cereal and toast.
On 6/1/26, the Executive Director spoke with the Dietary Manager about the deficiency associated with tag 0192. The Executive Director explained to the Dietary Manager that in the event that food items are not available for preparation of the items listed on the menu for the morning, to contact the Executive Director or the QIDP with the alternative breakfast to be prepared. This information will be immediately relayed to the cottage staff. Otherwise, the menu is to be followed as outlined in the menu book.
Additionally, all of the staff will be retrained in the meal preparation process and following established menu guidelines. This training will include the expectations of following the established menus unconditionally and the steps to follow should this process be interrupted due to necessary food items not be available, etc. The staff will be told that providing meals/breakfast that are not part of the established menus for their own conveniences will not be tolerated. This training for all staff will be completed by 6/17/26.
To assure that the above listed corrective action is followed as stipulated, either the Dietary Manager, Executive Director, QIDP, or other Ramsbottom administrative/supervisory staff as delegated will make regular, unannounced visits to the cottages during mealtimes to assure the menu is being followed as written. There will be a tracking sheet developed to document these unannounced encounters and the results of the check. These unannounced checks will begin on 7/1/26.
The Executive Director and QIDP will be responsible for monitoring this area for compliance. Discussion of menus and dietary issues will be added to the weekly Wednesday manager's meeting agenda effective immediately. Additionally, the results of the unannounced visits will be detailed and results provided at the meeting. Minutes of these meetings are maintained in the Executive Director's office.
483.440(d)(1) STANDARD
PROGRAM IMPLEMENTATION
Name - Component - 00
As soon as the interdisciplinary team has formulated a client's individual program plan, each client must receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan.
Observations:
Based on record reviews and interview, it was determined that the facility failed to ensure that all individual program plans (IPPs) developed by the interdisciplinary team (IDT) were implemented in all relevant settings in order to provide training opportunities needed by each individual. This applied to four (#1, #2, #3, and #4) of four individuals in the survey sample. Findings included:
1. A record review was completed for Individual #1 on May 13, 2026. This review revealed an IPP developed by the IDT for Individual #1 on April 1, 2026. The IPP identified that Individual #1 would continue to work on a goal in the cognitive domain in the area of "develop coin recognition", but indicated that the training program is to be implemented only at "ADS", a separately licensed adult day program. Goal data documentation review was completed for Individual #4 on May 14, 2026. This review failed to reveal that Individual #1's training program in the area of coin recognition was implemented within Individual #4's residential setting.
2. A record review was completed for Individual #2 on May 13, 2026. This review revealed an IPP developed by the IDT for Individual #2 on November 5, 2025. The IPP identified that Individual #2 would continue to work on the goal "develop quarter recognition (ADS)." Further review revealed that the IDT identified the goal domain for this goal as a "cognitive" training program, but indicated that this program be implemented only at "ADS", a separately licensed adult day program. Goal data documentation review was completed for Individual #2 on May 14, 2026. This review failed to reveal that Individual #2's training program in the area of quarter recognition was implemented within Individual #2's residential setting.
3. A record review was completed for Individual #3 on May 13, 2026. This review revealed an IPP developed by the IDT for Individual #3 on November 19, 2025. The IPP identified that Individual #3 would continue to work on the goal "develop counting change (ADS)." Further review revealed that the IDT identified the goal domain for this goal as a "cognitive" training program, but indicated that this training program be implemented only at "ADS", a separately licensed adult day program. Goal data documentation review was completed for Individual #3 on May 14, 2026. This review failed to reveal that Individual #3's training program in the area of counting change was implemented within Individual #3's residential setting.
4. A record review was completed for Individual #4 on May 13, 2026. This review revealed an IPP developed by the IDT for Individual #4 on October 1, 2025. The IPP identified that Individual #4 would continue to work on goals in the following areas: "improve time telling (ADS), develop coin recognition (ADS)". Further review revealed that the IDT identified the goal domains for Individual #4's training programs in the areas of "develop coin recognition" and "improving telling time" as "cognitive" training programs, but indicated that these training programs be implemented only at "ADS", a separately licensed adult day program. Goal data documentation review was completed for Individual #4 on May 14, 2026. This review failed to reveal that Individual #4's training programs in the areas of coin recognition and telling time were implemented within Individual #4's residential setting.
An interview with the executive director (ED) was conducted on May 14, 2026, at 9:00 AM. The ED confirmed that Individuals #1, #2, #3, and #4, had goals developed within their IPPs that were not implemented within the residential setting.
Plan of Correction:Regarding Individual #1, The QIDP will be developing a program plan in the area of "developing coin recognition" for the residential setting. Regarding Individual #2, the QIDP will be developing a training program plan in the area of "quarter recognition" for the residential setting. Regard Individual #3, the QIDP will be developing a training program plan in the area of "counting change" for the residential setting. Regard Individual #4, the QIDP will be developing a training program plan in the area of "coin recognition and telling time" for the residential setting. These plans will be carried over into the residential setting by 6/17/26. Additionally, all other individuals in the ICF program that attend the Adult Day Services program will be evaluated to see if their ADS program plans can be also worked on in the residential setting. This process will also be completed by 6/17/26.
Inasmuch as goal development and implementation begins in the residential program, the QIDP will initiate a meeting with the Adult Day Services Supervisor and review all program plans being implemented. The QIDP will evaluate whether any of the program plans can be worked on in the residential setting for continuity of learning purposes. This meeting will occur by 6/17/26. Additionally, during the quarterly review process the QIDP will determine the progress or lack thereof with each plan and alter or discontinue altogether the plan and re-develop into another objective within the plan.
To monitor this area and to ensure that all of the program plans currently being implemented in the day program also cross over and are implemented within the residential setting as appropriate, this area will be monitored / reviewed during weekly supervisors meeting by the treatment team to assure implementation is occurring. These monitoring checks will be noted in the minutes of the supervisor meeting. This monitoring process will begin on 7/1/26.
Additionally, during the individual's annual IPP process the QIDP along with the IDT team will review the priority needs list and determine the most appropriate plans to have moving forward as the various domains priority areas are assessed.
The Executive Director is responsible for monitoring this area for compliance and to assure that all program plans are appropriate and derived from the individual's priority needs list. The Executive Director will coordinate with the QIDP and ADS Director monthly to assure there is continuity with regards to the plans between programs (when appropriate). Notes of these coordination meetings will be kept in the Executive Director's office. These meeting will begin in July 2026.
483.440(f)(3)(i) STANDARD
PROGRAM MONITORING & CHANGE
Name - Component - 00
The committee should review, approve, and monitor individual programs designed to manage inappropriate behavior and other programs that, in the opinion of the committee, involve risks to client protection and rights.
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that the human rights committee (HRC) reviewed and approved all restrictive programs before they were implemented. This applied to one (#6) of one individual newly admitted to the facility. Findings included:
Record review in selected areas was completed on May 13, 2026, for Individual #6, who was admitted to the facility on April 20, 2026. This review revealed that the guardian consented to Individual #6's psychotropic medications utilized for behavior management on April 20, 2026. This review further revealed that the HRC gave consent for this restriction on April 21, 2026.
Interview with the executive director (ED) on May 13, 2026, at 10:30 AM, confirmed that the facility failed to obtain the HRC consent for Individual #6's restrictive program until April 21, 2026. The ED further confirmed that Individual #6 did receive the medications the evening of April 20, 2026, at the facility prior to when HRC consent was obtained.
Plan of Correction:Human Rights Committee (HRC) consent for individual #6's psychotropic medications was obtained on 4/21/26; one day late as she was admitted on 4/20/26 and did receive her medications that day of admission. This was an error in the already established process for assuring parental and HRC consents are received prior to administering psychotropic medications.
To assure compliance in this area moving forward, a tracking sheet has been developed which will itemize all required and necessary information, including client name, medication(s), guardian verbal consent date, guardian signed consent date, HRC verbal consent date, HRC signed consent date, medication range correct on medication reduction plan and correct medication range on HRC form. This form is already in existence and being utilized. Each time there is a medication change, a medication range change or a new admission into the program, the tracking sheet will be updated and the Executive Director and Nurse Manager will sign off on as authentication that the form is accurate and all necessary consents are obtained prior to medication administration.
Additionally, each morning at the 9:15am update meeting, any medication changes or range alternations will be discussed and subsequently documented on the tracking sheet so that the changes are documented in "real time." Minutes of each 9:15am update meeting are maintained in the BLARS Administrative Assistant's office.
The QIDP, Lead Nurse and the Executive Director will review the tracking sheet for accuracy each month and sign off on the sheet as evidence of the review.
The BLARS Executive Director will be responsible for monitoring this area for compliance. Additionally, the Executive Director will share any updates, reviews and changes to the tracking sheet with the Vice President for Compliance.
This process has already been initiated.
483.460(a)(3) STANDARD
PHYSICIAN SERVICES
Name - Component - 00
The facility must provide or obtain preventive and general medical care.
Observations:
Based on record review and interviews, it was determined that the facility failed to ensure that all individuals were provided with preventative medical care. This applied to one (#4) of four individuals in the survey sample. Findings included:
A record review for Individual #4 was completed on May 13, 2026. This review revealed that Individual #4's last vision screening was completed on April 26, 2024. Further review revealed that Individual #4's last dental examination was completed on May 21, 2024.
An interview was conducted with the executive director (ED) on May 13, 2026, at 10:30 AM. The ED stated that Individual #4 is resistant to attending medical appointments, often resulting in behavioral events. The ED further stated that the facility has attempted to provide preventative medical care for Individual #4, but with no success. The ED further stated that none of the attempted interventions by the facility were documented and there was no written education plan for Individual #4 on the importance of preventative medical care.
An interview was conducted with the nurse manager (NM) on May 13, 2026, at 1:50 PM. The NM confirmed that Individual #4 did not receive preventative medical care in the areas of vision or dental services on an annual basis.
Plan of Correction:Individual #4's next vision appointment is scheduled for 6/11/26. The next dental appointment is scheduled for 6/15/26.
To assist with the likelihood of successful, completed appointments, a desensitization / education plan will be developed for individual #4. This plan will include education on the importance of attending scheduled appointments and also steps to make individual #4 more comfortable and amendable to attending appointments. All efforts to complete scheduled appointments will be itemized on this plan as well as detailed updates as to the outcome of the appointments. This desensitization / education plan will be a running document whereas new efforts and ideas will be documented as appointments are completed as well as what didn't work. This plan will be developed prior to his next appointment on 6/11/26.
This plan will be developed by the treatment team and will be monitored by the QIDP and Executive Director for its effectiveness. A copy of this plan will be shared with all of the staff as it is developed and they will all sign off on the plan as authentication of their review and understanding. This plan will be a part of the medical record.
Additionally, all individuals in the ICF program will be reviewed and their ability to successfully complete the required medical appointments will be assessed. Should an individual be identified as having a need for an education / desensitization plan, one will be developed using the above criteria and review process. This review process will be completed by 7/1/26.
The Executive Director and/or QIDP will be responsible for monitoring this area for compliance. Each weekday morning at the "9:15 Update Meeting" all appointments from the previous day are reviewed; this agenda topic will now include the productiveness, or lack thereof, of the education / desensitization plan. At this meeting, additions, deletions, or alternative ideas can be added to the plan to be used at the next scheduled appointment for that individual. This process will begin on 6/17/26.
The Nurse Manager is responsible for keeping the "appointment grid" up to date and will allow for notice of upcoming appointment to assure there is time to implement all aspects of the desensitization / education plan.
483.460(c) STANDARD
NURSING SERVICES
Name - Component - 00
The facility must provide clients with nursing services in accordance with their needs.
Observations:
Based on review of facility provided incident reports and interviews, it was determined that the facility failed to ensure that nursing services were provided to the individuals in accordance with their healthcare needs. This applied to one (#5) of 22 individuals residing at the facility. Findings included:
A review of facility provided incident reports was completed on May 12, 2026. This review revealed an incident from April 12, 2026, involving Individual #5, in which a restrictive procedure was implemented. This review further revealed that Individual #5 fell during the course of the implementation of the restrictive procedure, resulting in Individual #5 hitting their head on a wooden bench in the residence. This review revealed a debriefing that occurred between the individual and the staff following the restrictive procedure on April 12, 2026. During that time, Individual #5 complained of arm pain and staff noted an abrasion on the left shoulder. This review further revealed a nursing assessment, completed on April 15, 2026, noting, "lump on lateral head aprox. 3 cm diameter and 1.5 - 2 cm high." This review failed to reveal a nursing assessment at time that the incident occurred. This review also failed to reveal that Individual #5's arm pain and shoulder abrasion were assessed by a nurse.
An interview was conducted with the nurse manager (NM) on May 12, 2026, at 8:50 AM. The NM was questioned regarding Individual #5 receiving a timely assessment after the incident that occurred on April 12, 2026. The NM stated that staff are trained by the facility and directed to complete the assessment and call the nurse at the time of the incident. At this time, the NM confirmed that Individual #5 was not assessed by a nurse until April 15, 2026. The NM further confirmed that there was no documentation that Individual #5's arm pain and shoulder abrasion were assessed by a nurse.
An interview was conducted with the executive director (ED) on May 13, 2026, at 2:00 PM. At this time, the ED confirmed that Individual #5 did not receive nursing services in accordance with their healthcare needs following the incident that occurred on April 12, 2026. The ED further confirmed that the expectation should have been that Individual #5 be assessed by nursing, not by staff, in a timely manner.
Plan of Correction:Regarding Individual #5, the Ramsbottom Center RN reassessed the left arm / shoulder and the lump on the head on 6/1/26. This assessment showed everything to be normal.
The Executive Director will conduct a training with all of the staff (direct support professionals) which will clearly detail that they are not credentialed to assess injuries or any health related incidents beyond basic first aid. This training will direct the staff to notify a member of the nursing staff (or nursing on-call) for any injury beyond basic first aid. Only the nurse contacted will assess the individual and recommend treatment options. If a member of the nursing staff or on-call nursing is unavailable to respond and assess the injury in person, the staff will be directed to take the individual to the Urgent Care or nearby hospital emergency room. This training will occur by 6/17/26 and all staff will sign off on an on-campus training record as evidence of their attendance.
For continued monitoring purposes, each day (Monday through Friday) all injuries will be reviewed at the daily 9:15am update meeting. This meeting includes the Ramsbottom administrative staff and nursing staff. All injuries and the aforementioned notification protocols will be reviewed for compliance. It should be noted that on weekends, the Executive Director and/or QIDP are also notified of injuries beyond first aid. This process will begin on 6/17/26.
Additionally, the Executive Director has spoken directly to the Ramsbottom Nurse Manager and Director of Nursing to reiterate the stipulation that only health care professionals (nurses, doctors, PA's, Etc.) can assess injuries beyond basic first aid to the ICF individuals. This conversation to place on 5/14/26 with the Ramsbottom Nurse Manager and 6/15/26 with the Director of Nursing.
The Executive Director is responsible for monitoring this area for compliance.
483.460(j)(1) STANDARD
DRUG REGIMEN REVIEW
Name - Component - 00
A pharmacist with input from the interdisciplinary team must review the drug regimen of each client at least quarterly.
Observations:
Based on record reviews and interview, it was determined that the facility failed to ensure that each individual's drug regimen was reviewed by the pharmacist on a quarterly basis. This applied to all individuals residing at the facility. Findings included:
Record reviews were completed for Individuals #1, #2, #3, and #4 on May 12, 2026. These reviews revealed drug regimen reviews completed on June 25, 2025, for Individuals #1, #2, #3, and #4. This review failed to reveal any drug regimen reviews completed since June 25, 2025.
An interview was conducted with the nurse manager (NM) on May 12, 2026, at 9:45 AM. The NM confirmed that a drug regimen review had not been completed for Individuals #1, #2, #3, and #4 since June 25, 2025. The NM stated that this occured due to the facility switching to a different pharmacy. The NM further confirmed that quarterly drug regimen reviews were not completed for all the individuals at the facility since June 2025.
Plan of Correction:The Ramsbottom Center Director of Nursing has been in touch with the new pharmacy (Care-Fill LTC) and schedule the drug regimen reviews for Individuals #1, #2, #3, and #4 along with all other individuals in the ICF program. This review will occur on 6/16/26.
Moving forward the Director of Nursing and Ramsbottom Center Nurse Manager will be responsible for scheduling these quarterly reviews with Care-Fill within the regulatory time frames and will report these dates to the Executive Director who will log the future dates on the daily 9:15am meeting minutes form for regular review and oversight.
The Executive Director will, as part of his monthly quality checks, assure that review are completed as scheduled. A tracking spreadsheet has been developed for assurance of completed, timely pharmacy reviews. The Executive Director will sign off on this form as assurance of completion and compliance. This process will begin on 7/1/26.
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