Initial Comments:
A focused fundamental survey was conducted February 3 - 6, 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 six and the sample consisted of three individuals. Five deficiencies were identified as a result of the survey.
Plan of Correction:
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 observation, record review and staff interview, it was determined that the facility failed to ensure a continuous active treatment program was implemented according to the individuals' program plans (IPP). This was noted for all six individuals in the home (Individuals #1, #2, #3, #4, #5, #6). The findings included:
A. A physical plant inspection was conducted on February 3, between 9:00 AM and 11:00 AM. The inspection revealed that the cabinet in the laundry room had Lysol spray and other cleaning supplies in it. The cabinet was not locked. Individual #3 is the only individual that is ambulatory and has access to this room. On February 4, 2026, the Qualified Intellectual Disabilities Professional (QIDP) was taken to the area of concern. The QIDP confirmed that the cleaning supplies should be locked.
Further observations revealed on February 5, 2026, at approximately 10:00 AM the staff nurse accompanied the surveyor to the shower room. Among the individuals' personal items was a bottle of disinfectant. Individuals #1, #2, #3, #4, #5, and #6 were not present at the time of the inspection.
B. Review of Individual #1, #2, #3, #4, #5, and #6's records revealed informed consent and human rights committee approval to lock cleaning supplies in the facility. A review of all the individual's functional assessments stated that all individuals residing in the facilty have no understanding of the danger of poisonous materials.
C. The Administrator of Residential Services (ARS) was interviewed on February 5, 2026, at 1:00 PM. The ARS confirmed that cleaning supplies must be locked in cabinets in the facility for the safety of all Individuals residing in the facility.
Plan of Correction: St. Joseph's Center is committed to meeting the needs of the individual based on an assessment and review of their skill needs and abilities.
With regards to Individual #1, #2, #3, #4 #5 and #6, it has been determined that none of the individuals in the Hughestown Community ICF/ID have the ability to understand the danger of poisonous materials.
As a result, all materials which are poisonous or can create harm to an individual are locked with a key kept in the nurses' office.
All poisonous materials will remain in their original manufacturer containers with intact labels to ensure that the materials are clearly identified, there are proper hazard warnings and there are also correct usage instructions.
The Nurse on Duty will ensure that all poisonous materials are locked and that if there are any issues with the locks, they will be replaced as soon as possible.
The QIDP will ensure that the annual assessments clearly reflect the skills and abilities of each resident. The QIDP will also address any safety issues regarding poisonous materials immediately when doing routine rounds at the Community ICF home.
The Infection Control Manual will be reviewed to ensure that the issue of storage of poisonous materials is adequately addressed.
Staff in the Community ICF home will be trained regarding the proper storage of poisonous materials as well as the understanding of the individuals in the home regarding same. This training will be conducted through either and or the Health Services Coordinator of the home of the QIDP.
The Administrator of Residential Services will ensure that the Plan of Corrections is implemented as outlined above.
483.460(c) STANDARD
NURSING SERVICES
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The facility must provide clients with nursing services in accordance with their needs.
Observations:
Based on record review, incident report review and staff interview, it was determined that the facility failed to provide nursing services in accordance with one individual's needs. (Individual #3)
Findings included:
A. Record review and staff interview for Individual #3 was conducted on February 3, 2026. This review revealed Individual #3 had a telemedicine psychiatric medication evaluation with his Medical Doctor (MD) on August 28, 2025. The MD recommended that his Lexapro be increased from ten milligrams to 20 milligrams. Review of Individual #3's informed consent for psychotropic medication was obtained and signed by his guardian on September 4, 2025, his primary MD on September 9, 2025 and the facility's Human Rights Committee on September 16, 2025. Review of Individual #3's physician orders and medication administration record revealed that the facility did not increase the Lexapro dose to 20 milligrams until October 31, 2025.
Interview with facility nurse February 3, 2026 at 11:00AM confirmed the Lexapro dose was not increased after consents were obtained September 16, 2025 until October 31, 2025, a time frame of six weeks and two days.
B. Review of incident report and medication administration record for Individual #3 was conducted on February 3, 2026. Incident report review and record review revealed on September 12, 2025, Individual #3 developed a cold sore to his left lower lip. The facility called his Medical Doctor (MD) on September 12, 2025 and received a verbal order for "Valacyclovir HCL 1 GRAM tabs, take two tabs by mouth in the morning and before bedtime X 1 day". Further review of incident report revealed that on September 15, 2025, the nurses at facility discovered "there was no active physician order documented in the chart and no medication administration record entry for this medication".
Interview with facility nurse on February 5, 2026 at 10:00 AM confirmed that there was no active physician order documented in the chart or medication administration record (MAR) completed when the verbal physician order was received on September 12, 2025 at 3:00PM.
C. Administrator of Residential Services (ARS) was interviewed on February 5, 2026 at 1:10 PM. ARS verified that the facility failed to provide nursing services in accordance with one individual's needs.
Plan of Correction: With regards to Individual#3, when reviewing the reason for the delay, the problem was the time in which the order was brought to the Hughestown Community ICF home. The process has been revised so that once the order from the psychiatrist is received, it will be delivered to the home via an email from behavioral services. This will occur for all individuals receiving orders for psychotropic medications in all 3 ICF programs of St. Joseph's Center.
The QIDP and the Director of Behavioral services will monitor this process to ensure that the orders are received by the home, within a day, but no later than 48 hours.
The Administrator of Residential Services will ensure that this process is implemented as outlined.
With regards to the order for Valacyclovir, the problem was a transcription error which resulted in the order not being carried over and subsequently the MAR not being accurate.
This error was corrected by a new order for this medication which has been a longstanding order for Individual #3. The Health Services Coordinator and all nurses taking orders in the Hughestown home will follow the Order Tracking sheet which has been developed. In addition, the monthly orders will be reviewed by another nurse in the home to ensure accuracy in the transcribing of orders.
The Health Services Coordinator, who is the house supervisor, will assume primary responsibility to ensure that this process is implemented and followed. The Administrator of Residential Services will assume overall responsibility for the implementation of this plan as outlined above.
The a
483.460(c)(3)(iii) STANDARD
NURSING SERVICES
Name - Component - 00
Nursing services must include, for those clients certified as not needing a medical care plan, a review of their health status which must be on a quarterly or more frequent basis depending on client need.
Observations:
Based on record review and staff interview, it was determined that the facility failed to ensure nursing physical examinations were conducted on at least a quarterly basis. This was noted for three individuals in the facility (Individual #1, Individual #3, Individual #6).
Findings included:
A. Individual #1's record was reviewed on February 4, 2026. This review revealed that Individual #1 had a physical examination completed by a nurse on February 22, 2025 and August 22, 2025. Individual #1 also had an annual physical completed by the primary care physician on April 19, 2025. There was no documentation to support that a nursing physical examination was conducted on a quarterly basis, a gap of 4 months.
B. Individual #3 's record was reviewed on February 3, 2026. This review revealed that Individual #3 had a physical examination completed by a nurse on February 22, 2025 and August 22, 2025. Individual #3 also had an annual physical completed by the primary care physician on April 19, 2025. There was no documentation to support that a nursing physical examination was conducted on a quarterly basis, a gap of four months.
C. Individual #6's record was reviewed on February 4, 2026. This review revealed that Individual #6 had a physical examination completed by a nurse on August 3, 2025. Individual #6 also had an annual physical completed by the primary care physician on February 11, 2025. There was no other documentation in Individual #6's record to support that nursing physical examinations were conducted on a quarterly basis.
D. The facility nurse was interviewed on February 5, 2026 at 9:15 AM. Facility nurse confirmed that nursing physical examinations for Individual's #1, #3, and #6 were not conducted by a nurse, at least quarterly.
E. Administrator of Residential Services (ARS) was interviewed on February 5, 2026 at 11:10 AM. The ARS confirmed that nursing physical examinations for Individual #1, Individual #3, Individual #6 were not conducted on a quarterly basis.
Plan of Correction: With regards to Individuals #1, #3 and #6, the nursing staff was counseled to follow the quarterly schedule as organized for the home. The staff were encouraged to ask for assistance, if necessary, in order to complete the quarterly in a timely manner.
All nurses will review the quarterly schedule for the year, and staff will be assigned to complete the physical as scheduled.
The Health Services Coordinator will ensure that the physicals are completed as assigned. Retraining or remediation will be conducted as necessary.
The QIDP will also do audits of the nursing quarterlies to ensure that they are completed as scheduled.
The Administrator of Residential Services will ensure that this plan of correction is implemented as outlined above.
483.460(k)(1) STANDARD
DRUG ADMINISTRATION
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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, Medication Administration Record review, documentation review and staff interviews, it was determined the facility failed to ensure that one individual's medications were administered without error. (Individual #3)
The findings included:
Facility incident report and investigation from September 18, 2025 were reviewed on February 3 and 4, 2026. This review revealed the following:
A. Review of incident report and medication administration record for Individual #3 on February 3 and 4, 2026, revealed on September 12, 2025 Individual #3 developed a cold sore to his left lower lip. The facility called his Medical Doctor (MD) on September 12, 2025 and received a verbal order for "Valacyclovir HCL 1 GRAM tabs, take two tabs by mouth in the morning and before bedtime X 1 day". Incident report dated September 18, 2025 revealed that Individual #3 did not receive the second dose of Valacyclovir HCL. Further review of incident report revealed on September 15, 2025, the evening shift nurse at facility discovered left over Valacyclovir and questioned its presence in the medication cart. The nurse contacted the physicians office on September 15, 2025 with no response. The physician was contacted again on September 17, 2025, with no response regarding the missed dose. On September 18, 2025, MD office was again contacted, at which time the physician instructed staff to administer the missed dose of medication. Individual #3 did not receive the second dose of Valacyclovir as prescribed by his MD resulting in one medication error.
B. Medication administration record review on February 4, 2026 revealed Individual #3 received his missed dose of medication on September 18, 2025 at 8:00PM, five days after it was missed. Review of Nurses notes dated September 19, 2025 at 8:00AM stated the "cold sore to left lower lip was healed".
C. On February 5, 2026 at 10:45 AM Administrator of Residential Services was interviewed and verified Individual# 3 did not experience any ill effects as a result of this medication error.
Plan of Correction: St. Joseph's Center is committed to providing medical care in a timely manner. The physician, following this incident with Individual #3 was contacted to review the situation and to ensure that future issues would be addressed in a timelier manner.
St. Joseph's Center will develop a policy for physicians in the Hughestown Community ICF as well as all ICF programs which specifies Practical Timeliness expectations which will address the following:
Immediate/Urgent Situations
Time-Sensitive Clinical Needs
Routine/ Non-Urgent Orders
A draft policy will be presented at the Quarterly Medical Staff meeting in March 2026. Recommendations and other considerations will be incorporated into a final draft which will be implemented following final review by the Medical Director.
The Administrator of Residential Services will ensure that his plan is implemented as outlined above.
483.470(l)(1) STANDARD
INFECTION CONTROL
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The facility must provide a sanitary environment to avoid sources and transmission of infections.
Observations:
Based on observations and staff interviews, it was determined the facility failed to follow appropriate infection control practices. This applied to six individuals residing in the the facility. (Individual #1, #2, #3, #4 ,5 and #6)Findings included:A. Individuals #1, #2, #3, #4 ,#5 and #6
An environmental tour of the facility was conducted on February 3, 4, and 5, 2026 at various times. During the observations of the bathroom areas (tub room and shower room) there were several personal care items that were used and unlabeled, such as deodorant, hairbrushes, toothpaste, shampoo and body wash, uncovered toothbrush, unlabeled razors. On February 5, 2026 the nurse confirmed that personal care items should be in the individuals personal care kits.
B. Individual #2
Individual #2 has a Behavioral Support Plan that addresses mouthing inappropriate items. He is provided chew toys for this behavior. On February 5, 2026, during a physical plant inspection, the chew toys were noted to be placed in a dish above the kitchen sink along with a bag of avocados. On February 4, 2026 at 2:00PM the nurse confirmed the chew toys and avocados should not be placed near one another.
C. Individuals #4 and #6
Individuals #4 and #6 have gastrostomy tubes (G tubes). On February 4, 2026, during morning observations, the syringes to flush the tubes were placed in plastic labeled cups on the food prep area. On February 4, 2026 at 7:30AM the nurse confirmed the syringes to flush the G tubes should not be left near a food prep area.D. An interview with the Administrator of Residential Services (ARS) was conducted on February 5, 2026 at 1:00 PM. During the interview, the ARS confirmed that the hygiene products that were found in the bathrooms may have been used by the individuals since the items were not labeled and, in the individuals personal care kits.
Plan of Correction: St. Joseph's Center is committed to providing a sanitary and safe environment which adheres to best practice with regards to infection control.
With regards to the care and management of personal hygiene items used by individuals in the Hughestown Community ICF/ID they will be stored, handled and maintained in a manner that prevents contamination and reduces the risk of infection transmission.
With regards to personal care items for all individuals (Individual#1, #2, #3, #4, #5, and #6) that are used, they will be labeled, toothbrushes will be covered and labeled and in individual's personal care kit. Single use items are disposed of, and razors will be stored in a closed container and replaced per manufacturer guidelines.
With regards to Individual #2, the chew toys will be stored in plastic bags and placed on Individual #2s dresser. The bag which contains the chew toys is labeled. This will be done for any individual who has similar items.
With regards to Individual #4 and #6, their syringes used to flush feedings, were labeled, and placed in individual baskets, which are also labeled and placed in the med closed in the nursing office. This practice will be done with all individuals who have gastrostomy tubes.
The Infection Control Manual will be revised to include more specifically how to address the personal care items listed below. Once revised, the staff will be in- serviced on the guidelines. The training will be conducted by the house supervisor.
In addition, the facility will conduct a quarterly audit on the storage of personal care items and make corrections immediately as well as provide re-training and education as necessary.
The Administrator of Residential Services will ensure that this plan of correction is implemented as outlined above.
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