Initial Comments:
A focused fundamental survey visit was completed on April 14 through 17, 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 70, and the sample consisted of 10 individuals.
Plan of Correction:
483.430(a) STANDARD
QIDP
Name - Component - 00
Each client's active treatment program must be integrated, coordinated and monitored by a qualified intellectual disability professional who-
Observations:
Based on observations, record review and interview with the Qualified Intellectual Disabilities Professional (QIDP), the QIDP failed to integrate, coordinate and monitor each individual's active treatment program for one of one sample Individual, residing in the yellow building, who utilizes augmentative communicate system. This practice is specific to Individual #4.
Findings include:
The facility failed to provide each employee with initial and continuing training that enables the employee to perform his or her duties effectively, efficiently and competently for one of two sample Individuals with augmentative communication systems. Refer to W 189.
Plan of Correction:
Reference Tag 189
483.430(e)(1) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
The facility must provide each employee with initial and continuing training that enables the employee to perform his or her duties effectively, efficiently, and competently.
Observations:
Based on observation, a review of facility records and interview with the qualified intellectual disabilities professional (QIDP), the facility failed to provide each employee with initial and continuing training that enables the employee to perform his or her duties effectively, efficiently and competently for one of two sample Individuals with augmentative communication systems. This practice is specific to Individuals #4.
Findings include:
1. Observation of the morning routine in the yellow building on 04/14/2025 from approximately 7:25 AM until 8:20 AM revealed that Individual #4 was seated at the dining room table on the left side of the building. Individual #4 greeted this surveyor by smiling and pointing to something in an attempt to communicate to the surveyor. There was no communication device or system available to Individual #4 during this observation.
Observation of the evening routine on 04/15/2025 from approximately 4:30 PM until
5:20 PM revealed that Individual #4 was seated at the dining room table on the left side of the building. During this observation Individual #4 greeted this surveyor with a grimace in an attempt to communicate something, however this surveyor was unable to determine what she was attempting to communicate. There was no augmentative communication system or device available to Individual #4 during the entire observation.
2. A review of the record of Individual #4 was completed on 04/16/2025 between 9:30 AM until 11:00 AM. This review revealed a funtional assessment dated 04/29/2024. Under the communication section of this assessment it notes the following;
-Individual #4 uses the PECS (Picture Exchange Communication System) to communicate.
-Individual #4 has a PECS binder to communicate her wants and needs.
Continued review of Individual #4's record revealed an Individual Program Plan (IPP), dated 05/23/2024. This IPP noted, under the Communication section of this plan, that
"[Individual #4] has a PECS book to help her express her feelings, gestural mood, and activities she would like to do, She has a formal goal to increase her communication skills using her PECS."
Interview with the QIDP on 04/16/2025 at approximately 10:40 AM confirmed that Individual #4 uses a PECS binder to communicate. When this surveyor ask to see this binder the QIDP went to the yellow building and brought Individual #4's PECS binder to this surveyor. When asked if this binder should be with Individual #4 at day program, the QIDP stated that Individual #4's binder should have gone to the day program with Individual #4. This interviewee could not explain why staff are not utilizing the communication binder with Individual #4 or why the communication binder was not sent to day program with
Individual #4 on that date.
Subsequent observation completed on 04/17/2025, between 8:30 AM until 11:00 AM noted that the PECS binder for Individual #4 remained on the table in the administration conference room where it had been brought for the survey team to review on 04/16/2025.
Plan of Correction:1
The Qualified Intellectual Disability Professional will initiate training for all managers and Direct support Professionals in all internal and external programs the Individuals participate in on the augmentative communication system for Individual #4.
5/15/2025
2
The Qualified Intellectual Disability Professional's will initiate training for all managers and Direct Support Professionals in all internal and external programs the Individuals participates on their case load whose Individualized Program plan includes the use of augmentative communication system
5/18/2025
The Qualified Intellectual Disability Professional will complete monthly programing observation and skills assessment in all internal and external programs the Individuals participate in to ensure proper implementation of the use of all augmentative communication systems. All Observations will be documented in each individual's electronic health record. Any noncompliance noted on observations will be immediately retrained by the Qualified Intellectual Disability Professional. All retraining that occurs will be forwarded to the Program Director for review within 72 hours
June 15 and ongoing
The new employee orientation will be updated to include in person training by the Qualified Intellectual Disability Professional for all managers and Direct Support Professionals for each resident on their caseload whose Individualized Program Plan includes the use of augmentative communication system.
June and ongoing
4.
The Quality Management Coordinator will complete Quarterly Audits for all Individuals who use augmentative communication devices. Audits will include confirmation that monthly goal observation and review related to augmentative communication devices are being completed as scheduled and include documentation related to confirmation of their proper use and implementation across all internal and external programs. All audits will be forwarded to the Program Director within 72 hours of completion.
June/Sept/Dec/March
The program Director will follow up with corrective action related to any non-compliance noted on the quarterly audits and forward to the Administrator within 72 hours.
Person Responsible Administrator
483.480(a)(1) STANDARD
FOOD AND NUTRITION SERVICES
Name - Component - 00
Each client must receive a nourishing, well-balanced diet including modified and specially-prescribed diets.
Observations:
Based on observation, record review and interviews with the administrative staff administrative staff, the facility failed to provide each individual with a nourishing, well-balanced diet including modified and specially-prescribed diets for three of ten sample individuals who have specialized prescribed diets. This practice is specific to Individuals #1, #4, and #8.
Findings include:
Individual #1
Observation of the morning routine, in the blue building, on 04/14/2025 between 7:05 AM until 8:45 AM revealed that the breakfast was served at 7:55 AM. In a bowl placed next to Individual #1's placemat was pre-cut pancakes and Canadian bacon in various sizes from approximately the size of a nickel to quarter size pieces. A review of Individual #1's placemat indicated she is to be served a soft to chew diet with thin liquids. Staff placed the contents of the small bowl into Individual #1's high-sided bowl and she began to eat. Individual #1 scooped one piece of pancake onto her spoon at a time, placed the pancake in her mouth, and swallowed it. When attempting to place one piece of Canadian bacon on her spoon, Individual #1 appeared to struggle, stopping and starting again when more than one piece of Canadian bacon was on her spoon. At one point during her meal, Individual #1 was observed removing pieces of Canadian bacon from her mouth. The staff person who had been sitting at the table next to Individual #1 during the meal, took the spoon from Individual #1, and with the spoon, cut some of the pieces of Canadian bacon into smaller sizes. Individual #1 ate one more piece of Canadian bacon before telling the staff person she was done. Individual #1 left approximately three quarters of Canadian bacon on her plate that the staff had placed there at the beginning of the meal.
A review of Individual #1's record on 04/15/2025 from 2:00 PM to 3:30 PM, revealed an Physician's Order dated 03/26/2025. This physician's order notes Individual #1's diet as gluten free, soft to chew texture, thin/regular (fluid) consistency, scoop dish, 8 ounce insulated mug, no added salt. Further review of Individual #1's record revealed an annual nutrition assessment dated 02/12/2025. This document revealed Individual #1 is on a soft to chew diet due to edentulous (having no teeth). A review of a speech pathology evaluation dated 06/24/2023 revealed diet consistency of easy to chew, thin liquids, mild oral dysphagia characterized by reduced mastication (chewing) formation influenced by absence of teeth.
Interview with the Qualified Intellectual Disability Professional on 04/14/2025 at 8:10 AM revealed that Individual #1 is on a soft to chew diet. This interviewee confirmed that Individual #1 should not have been served Canadian bacon as it is not in compliance with her specialized prescribed diet.
Individual #4
Observation of the evening routine, in the yellow building, on 04/15/2025 between 4:30 PM until 5:20 PM revealed that the dinner was served at 5:00 PM. Individual #4 served herself two large pieces of the vegetable lasagna (each piece was approximately 2 X 5 inches), which covered her entire dinner plate. After Individual #4 ate the entire meal of the lasagna, Staff served her a plastic 4 oz container of orange sherbet. Individual #4 ate her entire meal. There were no measuring cups/handled scoops on the table.
A review of Individual #4's record on 04/17/2025 between 9:00 AM until 11:00 AM, revealed an Physician's Order dated 04/17/2025. This physician's order notes Individual #4's diet as small portions, soft to chew texture, thin/regular fluid consistency, and close supervision at meals. Continued review of the record revealed a Nutritional assessment dated 05/16/2024. This assessment notes that Individual #4 is to receive small portions, thin liquids, soft to chew textures and close supervision at meals. The Nutritionist notes that Individual #4 estimated ideal body weight should be in the range of 124 - 162 lbs. Her weight at the time of this assessment was 255 lbs. Under the comment section of this assessment it notes that Individual #4 is not losing weight despite small portion diet, which provides about 1500 calories.
A review of the Yellow building diet book revealed that small portions is defined as;
-3 oz of meat/protein - use white scoop.
-3 oz starch - use white scoop.
-4 oz vegetable - use green scoop.
Interview with the nursing staff on 04/17/2024 at approximately 9:30 AM confirmed that residential staff should utilize the building diet books to ensure that diets are followed.
Individual #8
Observation of the morning routine in the orange building on 04/14/2025 between 7:30 AM until 8:00 AM revealed that breakfast was served at 7:30 AM. Individual #8 was observed
placing 4 to 5 large (50 cent size) pieces of Canadian bacon onto her fork, and placing them in her mouth. There was no re-direction observed from any the four residential staff who were in the dining area, to instruct this Individual to reduce the portion size on her fork to a smaller amount
A review of the record of Individual #8 was completed on 04/16/2025 between 9:00 AM and 11:00 AM. This review noted a Physician's Order dated 04/17/2025 which indicates
Individual #4's diet as small portions, regular texture, thin/regular fluid consistency, and distant supervision at meals. Subsequent review of a Nutrition assessment dated 11/27/2024 also notes that Individual #8 is to receive small portions, thin liquids, regular textures and distant supervision at meals to monitor amount of intake and speed of intake.
in review of a document titled "My DPV Passport", under the section named Eating and Drinking, the following is written; "Staff need to monitor the amount and speed of food intake."
Interview with the residential nurse on 04/17/2024 at approximately 9:30 AM confirmed that staff are monitor and intervene to ensure the diets are being followed to inlcude amount and speed of intake of food items.
Plan of Correction:
Training will be initiated by the Registered Dietitian and Director of Operations for all Direct Support Professionals, Managers, Residential Coordinators, Qualified Intellectual Support Professionals and Nurses on the prescribed modified diets for Individual #1, #4 and #8
5/7/2025
2
Training will be initiated by the Registered Dietitian and Director of Operations for all Direct Support Professionals, Mangers Residential Coordinators, Qualified Intellectual Support Professionals and Nurses on the prescribed modified diets for all other residents on campus.
5/14/2025
3
The Registered Dietician will create a detailed Meal Service, Process and Point of service safety guidelines binder. The Registered Dietician and Director of Operations will initiate training for all Direct Support Professionals, Mangers, Residential Coordinators, Qualified Intellectual Support Professionals and Nurses for all residential buildings on the use of this binder throughout meal preparation, mealtimes and as needed as a reference to confirm proper implementation of prescribed modified diets
The new employee orientation will be updated to include in-person training with the Registered Dietitian related to all prescribed modified diets and the meal Service Process and Point of Service safety guidelines binder.
June and ongoing
4
Campus Managers and Residential Coordinators will conduct weekly observations and skills assessments related to proper implementation of prescribed modified diets. with 2 Direct Support Professionals per shift/per week /per cottage for 3 months and then continue quarterly ongoing. The Managers will immediately retrain any non-compliance noted during the skills assessment. The Managers will document each skills assessment on the updated mealtime observation form and submit the form to the Director of Operations within 72 hours
The Director of Operations will follow up with corrective action related to noncompliance within 72 hours of review and then forward all corrective action related to non-compliance to the Administrator within 72 hours.
9/30/25 and ongoing quarterly
Responsible Person Administrator
483.480(b)(2)(ii) STANDARD
MEAL SERVICES
Name - Component - 00
Food must be served at appropriate temperature.
Observations:
Based on observations and interview with facility staff, the facility failed to ensure that food is served at an appropriate temperature during the breakfast meal in the Blue Building .
This practice is specific to two of two sample Individuals that reside in Blue Building, specifically Individual #1 and #7.
Findings included:
1. Observations completed in Blue Building on 04/14/2025 from 7:05 AM to 8:45 AM, revealed that upon entering the dayroom, this surveyor observed glass doors into the right side dining room area. This surveyor noted that there was one large bowl and several smaller bowls that were covered with foil on the two dining room tables . At each chair was a placemat with an Individual's first name and last initial,which listed the type of diet, adaptive equipment if prescribed, plate or bowl, napkin and spoon.
This surveyor entered this dining room area, and upon peeling back the foil of the large bowl placed in the center of the table nearest to the kitchen counter, it contained a pureed substance that was later identified as pancakes by residential staff. In the smaller bowl placed at Individual #1's seat, there were pancakes and Canadian bacon cut into various size pieces. The sides of both bowls were lukewarm, and no steam was visible coming from the food.
Upon entering the dining room to the left of the dayroom, large and small bowls covered with foil were located on the kitchen counter to the right of the sink The bottom of the bowls were lukewarm, and upon pulling back the foil, there was no visible steam was coming from the food in these bowls. The tables were set with a placemat with an Individual's first name and last initial, type of diet, adaptive equipment if prescribed, plate/bowl, napkin and spoon.
2. At 7:50 AM, staff began bringing the Individuals into their respective dining rooms - either the left or right- assisting them to their assigned seat at the table. At 7:55 AM, staff in the left dining room brought the serving bowls to the dining room tables and prepared to assist the Individuals in serving their food items. This surveyor asked the staff what the procedure was when food is not served at the time the delivery is made and hot food gets cold.
Staff touched the side of the bowl and responded "well we can heat it I guess."
This surveyor encountered the same in the dining room to the right of the dayroom. Staff did not reheat the food that had sat on the table for over 50 minutes prior to serving it to the Individuals. Once questioned about serving food that should be served hot without reheating, the staff in this dining room area stopped the Individuals from scooping their food from the bowls to their plates, and informed this surveyor that the food would be reheated in the microwave before serving it to the Individuals.
Prior to questioning by the survey staff, there was no evidence that staff were aware or completed the action of reheating food items designed to be served hot when they had not been on/in a temperature controlled device for a protracted time period before serving
3. Interview with administrative staff on 04/17/2025 at approximately 8:45 AM confirmed that in the event hot food becomes cold, staff should be reheating the food to ensure it is served at the correct temperature.
Plan of Correction:
1
The Registered Dietitian and Director of Operations will initiate Training in The Blue Building for all Direct Support Professionals, Managers, Residential Coordinators, Qualified Intellectual Disability Professionals and Nurses on food preparation and point of service temperature safety guidelines
5/7/2025
2
The Registered Dietitian and Director of Operations will initiate Training in The Blue Building for all Direct Support Professionals, Managers, Residential Coordinator, Qualified Intellectual Disability Professionals and Nurses on food preparation and point of service temperature safety guidelines.
5/14/2025
3
The Registered Dietitian will create a detailed Meal Service Process and Point of Service safety guidelines binder. The Registered Dietitian and Director of Operations will initiate training for all Direct Support Professionals, Mangers Residential Coordinators, Qualified Intellectual Support Professionals and Nurses for all residential buildings on the use of this binder throughout meal preparation, mealtimes and as needed as a reference to confirm proper implementation of food preparation and point of service temperature safety guidelines
The new employee orientation will be updated to include in-person training with the Registered Dietitian related to food preparation and point of service temperature safety guidelines
June and ongoing monthly
4
Campus Managers and Residential Coordinators will conduct weekly observations and skills assessments related to proper implementation of safety guidelines when preparing and serving meals, with 2 Direct Support Professionals per shift/per week /per cottage for 3 months and then continue quarterly ongoing.
The Managers will immediately retrain any non-compliance noted during the skills assessment. The Managers will document each skills assessment and retraining completed on the updated mealtime observation form and submit the form to the Director of Operations within 72 hours
The Director of Operations will follow up with corrective action related to noncompliance within 72 hours of review and then forward all corrective action related to non-compliance to the Administrator within 72 hours.
9/30/25 and ongoing quarterly
Person Responsible Administrator
483.480(d)(4) STANDARD
DINING AREAS AND SERVICE
Name - Component - 00
The facility must assure that each client eats in a manner consistent with his or her developmental level.
Observations:
Based on observations, record review and interview with facility and administrative staff, the facility failed to assure that each client eats in a manner consistent with his or her developmental level to ensure Individuals feed themselves in accordance with assessed abilities in the use of utensils during the meal. This practice is specific to 4 of 10 sample Individuals who were observed during the morning and evening meals periods. Specifically, Individual #1, #4, #6, and #7.
Findings include:
Yellow Building
Individual #4
Observations of the morning routine on 04/14/2025 from approximately 7:25 AM until
8:20 AM revealed that Individual #4 was seated at the dining room table in the dining room on the left side of the building. Individual #4 had a plate, fork, spoon and knife at her place setting. Individual #4 served herself two whole pancakes and two patties of Canadian bacon. She put syrup on the pancakes. Individual #4 then proceed to use her spoon to cut her pancakes and independently spooned the pancakes into her mouth. After she ate her pancakes, she attempted to cut the Canadian bacon with her spoon. She had difficulty cutting the Canadian bacon in this manner then proceeding to place the spoon directly on the Canadian bacon, and use her other hand's fingers to rip the Canadian bacon into large pieces. This process occurred until she was finished eating her meal. At no time did the staff prompt Individual #4 to use her knife to cut the Canadian bacon.
Observations of the evening routine on 04/15/2025 from approximately 4:30 PM until
5:20 PM revealed that the dinner meal was served at approximately 5:00 PM. Individual #4 was seated in the dining room, on the left side of the building. She had a plate, spoon, knife and fork at her place setting. She served herself two large pieces (each piece was approximately 2 X 5 inches), of vegetable lasagna onto her plate. Individual #4 proceed to attempt to cut her lasagna with her spoon by holding the lasagna with her spoon, and using her other hand's fingers to rip the noodles apart and continue to eat the pieces with her spoon. This process occurred throughout the entire meal. There was no prompting from staff to Individual #4 to utilize her knife to cut her meal.
A review of the record for Individual #4 was completed on 04/16/2025 from approximately 9:30 AM until 11:00 AM. This review revealed a comprehensive funtional assessment dated, 04/29/2025. Under the section of eating/drinking it notes that Individual #4 is able to use a knife with two verbal prompts.
Individual #6
Observation of the dining room, on the right side of the building, on 04/14/2025 from approximately 7:25 AM until 8:20 AM, revealed Individual #6 had a plate, knife, spoon and fork at her place setting. She then proceed to serve herself two whole pancakes and two whole pieces of Canadian bacon. She put syrup on the pancakes with staff assistance. Individual #6 proceed to use her fork to cut her pancakes and eat the pancakes utilizing the fork independently. After she ate her pancakes she attempted to cut the Canadian bacon with her fork. After she had difficulty with this method, Individual #6 proceed to hold her fork on the Canadian bacon and use her other hand's fingers to rip the Canadian bacon into large pieces. This process occurred until she was finished eating. At no time did the staff prompt Individual #6 to use her knife to cut the Canadian bacon.
A review of the record for Individual #6 was completed on 04/16/2025 from approximately 10:00 AM until 11:30 AM. This review revealed a comprehensive funtional assessment dated, 09/17/2025. Under the section of eating/drinking it notes that Individual #6 is able to use a knife with hand over hand prompts.
Interview with the Qualified Intellectual Disabilities Professional (QIDP) on 04/16/2025 at approximately 10:45 AM confirmed that staff should have prompted both Individuals to utilize their knives to cut their food.
Blue Building
Observations of the morning routine in blue building were completed on 04/14/2025 from approximately 7:05 AM to 8:30 AM revealed the following:
Individual #1
Individual #1 was seated at the dining room table within the right side dining room of the building. Individual #1 had a high sided plate and spoon at her place setting. there were no other utensils at this place setting during this observation period.
Individual #1 was served pre-cut pancakes and pieces of Canadian bacon of various sizes ranging form a nickel to quarter-sized pieces. Individual #1 scooped a piece of pancake one at a time onto her spoon and placed the spoon in her mouth. Individual #1 appeared to have difficulty scooping just one piece of Canadian bacon at a time onto her spoon, removing the pieces and starting again when successfully getting one piece onto her spoon. At one point, the staff sitting with the Individuals at the table took Individual #1's spoon from her hand and cut several pieces of Canadian bacon into smaller pieces and returned the spoon to her hand. Individual #1 ate all of the pieces of pancake but left approximately three quarters of uneaten Canadian bacon on her plate.
A review of the record for Individual #1 was completed on 04/15/2025 from approximately 2:00 PM until 3:30 PM. This review revealed a comprehensive funtional assessment dated, 12/16/2025. Under the section of eating/drinking it notes that Individual #1 is able to independently use a fork and knife.
Interview with residential staff on 04/14/2025 at approximately 8:20 AM revealed that this staff was unable to explain why the tables were not set with a full compliment of utensils for each Indivdual to utilize during the meal. This interviewee confirmed that each place setting should include a full set of utensils.
Individual #7
During this same observation period, Individual #7 was observed seated at the dining room table within the left side dining room of the building. Individual #7 had a plate, a weighted adaptive spoon and napkin on her placemat. Individual #7 was served pre-cut pancakes and Canadian bacon of various sizes ranging form a nickel to quarter-sized pieces. Individual #7 used her fingers to pick up the pieces of pancake and Canadian bacon and put the food in her mouth. Individual #7 continued to eat with her fingers until all her food was consumed. Staff sitting next to Individual #7 at the table did not prompt her to use her spoon to eat her breakfast. When questioned regarding why this Individual was no encouraged to utilize the spoon, this staff stated "she doesn't like to use a spoon."
A review of the record for Individual #7 was completed on 04/17/2025 from approximately 8:34 AM until 10:00 AM. This review revealed a comprehensive funtional assessment dated, 08/27/2024. This document noted that Individual #7 is able to feed herself and use her mealtime adaptive equipment. This assesment also noted that staff should encourage Individual #7 to use her spoon.
Interview with administrative staff on 04/14/2025 at approximately 8:40 AM confirmed that staff should have prompted Individual #7 to use her adaptive spoon throughout the meal.
Plan of Correction:
1
The Registered Dietitian and Director of Operations will initiate Training on providing the appropriate level of support related to the Individualized abilities and functioning level throughout mealtimes for Individuals # 1, #4, #6 and #7 for all Direct Support Professionals, Managers, Residential Coordinator, Qualified Intellectual Disability Professionals and Nurses
May 7, 2025
2
The Registered Dietitian and Director of Operations will initiate Training on providing the appropriate level of support related to their Individualized abilities and functioning level throughout mealtimes for all other residents throughout campus for all Direct Support Professionals, Managers, Residential Coordinator, Qualified Intellectual Disability Professionals and Nurses
May 14, 2025
3
The Registered Dietician will attend 2 Residential Building Interdisciplinary team meetings per month for 3 months with the Qualified Intellectual Disability Professional, Health Care Coordinator and Manager to review the Individualized Assessment for the residents of their case load. Any recommendations or changes related to the level of support needed at mealtimes will be documented, and the residents individualized placemats will be updated by the Registered Dietitian and forward it to the Qualified Intellectual Disability Professional within 24 hours.
Within 24 hours of receiving the updated placemat, The Qualified Intellectual Support Professional will initiate training on any changes made for all Direct Support Professionals, Managers, Residential Coordinator and Nurses.
August 30th 2025
The new employee orientation will be updated to include in-person training with the Registered Dietitian related to the Individualized placemats utilized throughout campus as a tool that contains the most updated and appropriate information related to the level of support an Individual requires throughout mealtimes.
June and ongoing monthly
4
Campus Managers and Residential Coordinators will conduct weekly skills observations and assessments related to the appropriate levels of support provided throughout mealtimes. with 2 Direct Support Professionals per shift/per week /per cottage for 3 months and then continue quarterly ongoing.
The Managers will immediately retrain any non-compliance noted during the skills assessment. The Managers will document each skills assessment, and any retraining completed on the updated mealtime observation form and submit the form to the Director of Operations within 72 hours
The Director of Operations will follow up with any needed corrective action related to noncompliance within 72 hours of review and then forward all corrective action related to non-compliance to the Administrator within 72 hours.
9/30/25 and ongoing quarterly
5
Person Responsible Administrator
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