Initial Comments:
A monitoring survey was conducted on May 6, 7, and 8, 2025, to determine compliance with the requirements of 42 CFR Part 483, Subpart I Requirements for Intermediate Care Facilities. The census during the survey was 40. Two deficiencies were identified as a result of the survey.
Plan of Correction:
483.420(d)(2) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures.
Observations:
Based on staff interview and investigation report review, it was determined facility staff failed to report an allegation of a verbal abuse in a timely manner to facility administration involving one individual residing at the facility. (Individual #2)Findings included:A) Individual #2
1) Review of a facility investigation review, incident report review, and staff interview revealed an incident of potential verbal abuse had occurred on April 7, 2025, at 7:00 PM. The allegation was not reported to facility administration until April 8, 2025, at 7:30 AM, one day after the alleged incident had occurred. Review of the administrative follow-up revealed the alleged verbal abuse was not confirmed.
B) The Assistant Vice President (AVP) was interviewed on May 7, 2025, at 2:30 pm. During the interview, the AVP confirmed the above-mentioned findings.
Plan of Correction:W153 STAFF TREATMENT OF CLIENTS
This incident involves a late report for Individual #2. An allegation of alleged verbal abuse was reported on April 8, 2025 at 7:30am, over (12) hours late from when the actual incident allegedly occurred.
The facility failed to report an allegation of alleged abuse, in a timely manner, to administration. Due to failing to report the allegation in a timely manner, the alleged perpetrator continued to work with Individual #2, and all other residents, who could have been adversely affected due to the late report.
To address the deficient area identified in W153, the facility will implement the following corrective action and systematic change:
All residential staff will receive in-service on the Incident Management Bulletin related to the reporting of abuse and the protocols that all staff should adhere to for an effective and timely investigation. This will address the deficient area identified for Individual #2, and all others who could be adversely affected by the deficient practice.
Staff will be provided with a multiple choice "Reporting of Alleged Abuse" test, which will include timely reporting and consequences for failure to report an allegation in a timely manner.
Progress on the Plan of Correction will be documented within the Monthly Incident Management Meeting Minutes.
The Assistant Vice President, in conjunction with the program director and WWSR Unit Manager, will ultimately be responsible for completion of the Plan of Correction, and to ensure the deficient practice does not reoccur.
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 review of facility incident reports, a facility investigation report, record review and staff interview, it was determined that the facility failed to ensure that staff demonstrated the necessary skills and competencies directed towards the health needs for two individuals in the sample. (Individuals #1 and #3)
Findings included:A) Individual #11) The record of Individual #1 was reviewed on May 7, 2025. This individual's diagnoses included: Severe Intellectual Disability, Cerebral Palsy, and Hydrocephalus. 2) A facility investigation report dated February 23, 2025, regarding an allegation of neglect was reviewed on May 7, 2025. The facility investigation report revealed that on February 23, 2025, while under one-to-one enhanced supervision Individual #1 dislodged her J- tube. Individual #1 was then transported to the Emergency Room where the J- tube was reinserted. The facility investigation determined that facility staff failed to implement the one to one enhanced supervision protocols for Individual #1 at that time resulting in the displacement of the J-tube. Further review of the investigation report revealed that the target staff received disciplinary action because of the incident.
B) Individual #3
1) The record of Individual #3 was reviewed on May 7, 2025. This individual's diagnoses included: Profound Intellectual Disability, Cerebral Palsy, and spastic quadraplegia.
2) A facility variance report revealed that on March 17, 2025, during the evening meal, staff fed Individual #3 her meal with a plastic spoon. Individual #3 bit the spoon causing it to break apart.
3) A review of facility nurses notes dated March 17, 2025 at 6:00 p.m. revealed that Individual #3 bit a piece of the plastic spoon off and appeared to not have swallowed any portions. A small piece was found.
4) A review of facility dietary notes revealed that a silicone tip spoon was recommended due to Individual #3 clammping teeth against the spoon. A physician's order dated January 10, 2025 was obtained.
5) The Qualified Intellectual Disabilities Professiional (Q.I.D.P) was interviewed on May 7, 2025 at 11:30 a.m. and stated that staff did not follow instructions on Individual #3's dietary card.
C) The Assistant Vice President (AVP) was interviewed on May 7, 2025, at 2:30 pm. During the interview, the AVP confirmed the above-mentioned findings.
Plan of Correction:W192 STAFF TRAINING PROGRAM
This deficient area focuses "skills and competencies" of residential staff in the delivery of services in healthcare needs for Individual #1 and #3.
The facility failed to demonstrate the necessary "skills and competencies" for Individual #1 and #3, in two separate instances. Individual #1 receives nutrition via J-tube, and was under enhanced supervision, 1:1, due to picking at her J-tube. Individual #1, evidently dislodged the J-tube, on 2/23/25, and had to the hospital emergency room for re-insertion of the tube.
In the second incident, Individual #3 bit into a "plastic spoon", breaking off a portion of the spoon. Staff were able to recover the broken part. However, the dietary orders recommended utilization of a "silicone spoon". Individual #3 needs to be fed by staff, and dietary orders identify use of the "silicone spoon" because Individual #3, tends to bite down when a spoon is introduced for feeding. Individual #3 has a diagnosis of cerebral palsy, spasms, contractures and needs to be fed.
In-services were completed for the incidents for both Individual #1 and #3, as part of the facility action.
For the Plan of Correction, additional in-service training will be completed for all staff related to Individual #1's, 1:1 enhanced supervision and Individual #3's, special adaptive feeding utensils, due to oral response of biting down on spoons when fed.
To address Individual #1, Individual #3, and all others who could be adversely affected by deficient practices in the delivery of services to the health care needs of all residents, the facility will implement the following corrective action and systematic changes:
- The Interdisciplinary Team, led by the Unit Managers and QIDP, will review, modify and update all resident "Special Needs Forms". The WWSR resident population is a very diverse group of individuals with "diverse capabilities and behaviors".
- The "Special Needs Form" has been a staple item in the ICF/ID Program that provides a "cheat-sheet" or "specifics" for an individual that varies from the general population. For example, "Enhanced Supervision" such as 1:1, "Line of Vision", "Contact Guard", "2-Person Assist", "Adaptive Equipment during Meals", Wedges for Bed, etc.
- Once updated, all staff will be in-serviced on the Special Needs Form with a written test, that staff will complete, and reviewed by WWSR Supervisors, Unit Manager, QIDP, etc.
- In addition, the facility uses a Dietary Census Book and Menu Cards for each resident that highlights details related to the individuals' meals. Dietary Orders would include "texture" such as Regular-Mechanical Soft-Puree-PEG, adaptive equipment such as "Scoop Dish", "Munchkin Spoon", Monitor of Rate and Volume of Food Intake, "Silicone Spoons, etc. Again, the Interdisciplinary Team led by the Dietician, Unit Manager, QIDP and Supervisors will review, and update as needed, the Dietary Census and Dietary Cards.
- Once updated, all staff will be in-serviced on the Dietary Census/Menu Cards with a written test, that staff will complete, and reviewed by WWSR Supervisors, Unit Manager, QIDP, etc.
These two documents have been utilized for many years with success to keep staff competencies and skills at a high level in the delivery of services for the WWSR residents. These in-services will help to eliminate the deficient practices that were identified in the W192 deficient areas for individual #1 and #3, and all others who may be adversely affected by the deficient practice.
Progress on the Plan of Correction will be documented within the Monthly Incident Management Meeting Minutes.
The Assistant Vice President, in conjunction with the Program Director and WWSR Unit Manager, will ultimately be responsible for completion of the Plan of Correction, and to ensure the deficient practice does not reoccur.
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