Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 01G011 (X3) Date Survey Completed 10/04/2025
Name of Provider or Supplier Rainbow Omega, Inc, Street Address, City, State 202 Hope Drive, Eastaboga, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
W0000 A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Alabama Department of Public Health, Bureau of Health Provider Standards.

An unannounced on-site Focused Fundamental Recertification Survey (HSRU11) conducted a the above-named ICF/IID facility from 09/30/25 to 10/04/25 resulted in noncompliance with the Conditions of Participation 483.410 Governing Body & Management, 483.420 Client Protections, 483.430 Facility Staffing, 483.440 Active Treatment Services, and 483.450 Client Behavior & Facility Practices respective to applicable CoP under 42 CFR 483, Subpart 1 and the following standard-level deficiencies listed below.

On 10/02/24 Immediate Jeopardies were identified and the survey team moved to Full Survey.

On 10/02/24 at 8:15 PM, the Facility Director was notified that Immediate Jeopardies were identified at: 483.410 Governing Body & Management (W102), 483.420 Client Protections (W122), 483.430 Facility Staffing (W158), 483.440 Active Treatment Services (W195), and 483.450 Client Behavior & Facility Practices (W266).

On 10/04/25 at 2:35 PM, the facility presented acceptable plans of removal for the Immediate Jeopardies. On 10/04/25 at 6:15 PM, the Facility Director was notified that the Immediacies had been removed.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Alabama Department of Public Health, Bureau of Health Provider Standards.

An unannounced on-site Focused Fundamental Recertification Survey (HSRU11) conducted a the above-named ICF/IID facility from 09/30/25 to 10/04/25 resulted in non-compliance with the Conditions of Participation 483.410 Governing Body & Management, 483.420 Client Protections, 483.430 Facility Staffing, 483.440 Active Treatment Services, and 483.450 Client Behavior & Facility Practices respective to applicable CoP under 42 CFR 483, Subpart 1 and the following standard-level deficiencies listed below.

On 10/02/24 Immediate Jeopardies (IJ) were identified and the survey team moved to Full Survey.

On 10/02/24 at 8:15 PM, the Facility Director was notified that Immediate Jeopardies were identified at: 483.410 Governing Body & Management (W102), 483.420 Client Protections (W122), 483.430 Facility Staffing (W158), 483.440 Active Treatment Services (W195), and 483.450 Client Behavior & Facility Practices (W266).

Th IJ began on 03/18/25 and was removed on 10/04/25.

On 10/04/25 at 2:35 PM, the facility presented acceptable plans of removal for the Immediate Jeopardies. On 10/04/25 at 6:15 PM, the Facility Director was notified that the Immediacies had been removed.
W0102 GOVERNING BODY AND MANAGEMENT
CFR(s): 483.410

The facility must ensure that specific governing body and management requirements are met.


This CONDITION is not met as evidenced by:
Based on observation, interview, record review, and review of facility policies, the Governing Body failed to provide operating direction and management to ensure regulatory compliance was met for Conditions of Participation (CoPs) in Medicare and Medicaid. Immediate Jeopardy was identified at five CoPs. The facility's failures impacted all 15 clients who resided at the facility.

On 10/02/25 at 8:15 PM, the Facility Director was notified the failures constituted Immediate Jeopardy at 483.410 Governing Body and Management.

On 10/04/25 at 2:35 PM, the facility presented an acceptable plan of removal.

The facility's removal plan included:

1. The facility revised their abuse policy to include peer to peer aggression as abuse. The facility immediately started educating their staff on the policy and all staff will be trained prior to the start of their next shift.

2. The facility developed the required written policy and procedure governing the management of inappropriate client behavior. The facility immediately started educating their staff on the policy and all staff will be trained prior to the start of their next shift.

3. The facility identified that the Facility Director and a part-time Qualified Intellectual and Disability Professional (QIDP) would share the QIDP functions until a qualified candidate was hired.

4. The facility started planning for their development of a day training program to ensure clients receive continuous and aggressive active treatment.

5. The facility began educating staff that by not intervening when a client was engaging in self-injurious behavior (SIB) can constitute neglect.

6. The facility consulted with a Board-Certified Behavior Analys (BCBA) who will complete a comprehensive behavior assessment on Client (C) 2 and develop the appropriate behavior plan based on the assessment. The BCBA will educate staff on the developed plan.

7. The facility developed a policy and procedure regarding appropriate notification during incidents of abuse and clients engaging in SIB. The facility immediately started educating their staff on the policy and all staff will be trained prior to the start of their next shift.

Through interview and record review, the survey team was able to validate the facility had begun implementation of the plan of removal, and the Immediate Jeopardy was lifted on 10/04/25 at 6:15 PM.

Findings include:

Based on interview, record review, review of the employee job description, and review of the facility's policy, the Governing Body failed to provide operating direction and management to ensure clients were protected from abuse and neglect, that a Qualified Intellectual Disability Professional (QIDP) was employed, that the facility had the required day training program that provided continuous and aggressive active treatment, that families were notified of client abuse, and that a policy for the management of client behavior was developed and implemented. These failures negatively impacted or had the potential to negatively impact eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8; and placed all clients of the facility (15 total clients) at risk for negative outcomes. Cross Reference: W104.

Based on observation, interview, record review, and review of facility policies, the Governing Body failed to provide operating direction and management to ensure regulatory compliance was met for Conditions of Participation (CoPs) in Medicare and Medicaid. Immediate Jeopardy was identified at five CoPs. The facility's failures impacted all 15 clients who resided at the facility.

On 10/02/25 at 8:15 PM, the Facility Director was notified the failures constituted Immediate Jeopardy at 483.410 Governing Body and Management.

Findings include:

Based on interview, record review, review of the employee job description, and review of the facility's policy, the Governing Body failed to provide operating direction and management to ensure clients were protected from abuse and neglect, that a Qualified Intellectual Disability Professional (QIDP) was employed, that the facility had the required day training program that provided continuous and aggressive active treatment, that families were notified of client abuse, and that a policy for the management of client behavior was developed and implemented. These failures negatively impacted or had the potential to negatively impact eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8; and placed all clients of the facility (15 total clients) at risk for negative outcomes. Cross Reference: W104.

**********************************

On 10/04/25 at 2:35 PM, the facility presented an acceptable plan of removal.

The facility's removal plan included:

1. The facility revised their abuse policy to include peer to peer aggression as abuse. The facility immediately started educating their staff on the policy and all staff will be trained prior to the start of their next shift.

2. The facility developed the required written policy and procedure governing the management of inappropriate client behavior. The facility immediately started educating their staff on the policy and all staff will be trained prior to the start of their next shift.

3. The facility identified that the Facility Director and a part-time Qualified Intellectual and Disability Professional (QIDP) would share the QIDP functions until a qualified candidate was hired.

4. The facility started planning for their development of a day training program to ensure clients receive continuous and aggressive active treatment.

5. The facility began educating staff that by not intervening when a client was engaging in self-injurious behavior (SIB) can constitute neglect.

6. The facility consulted with a Board-Certified Behavior Analys (BCBA) who will complete a comprehensive behavior assessment on Client (C) 2 and develop the appropriate behavior plan based on the assessment. The BCBA will educate staff on the developed plan.

7. The facility developed a policy and procedure regarding appropriate notification during incidents of abuse and clients engaging in SIB. The facility immediately started educating their staff on the policy and all staff will be trained prior to the start of their next shift.

Through interview and record review, the survey team was able to validate the facility had begun implementation of the plan of removal, and the Immediate Jeopardy was lifted on 10/04/25.
W0104 GOVERNING BODY
CFR(s): 483.410(a)(1)

The governing body must exercise general policy, budget, and operating direction over the facility.


This STANDARD is not met as evidenced by:
Based on interview, record review, review of the employee job description, and review of the facility's policy, the Governing Body failed to provide operating direction and management to ensure clients were protected from abuse and neglect, that a Qualified Intellectual Disability Professional (QIDP) was employed, that the facility had the required day training program that provided continuous and aggressive active treatment, that families were notified of client abuse, and that a policy for the management of client behavior was developed and implemented. These failures negatively impacted or had the potential to negatively impact eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8) and placed all 15 clients of the facility at risk for negative outcomes.

Findings include:

1. Review of the facility's policy titled "Continuous Quality Improvement," revised in 2020 revealed, ". . . The entity has a current Continuous Quality Improvement (CQI) Plan approved by the board of directors. ROI will develop a plan of accountability that will improve its success in carrying out the goal of meeting the needs of developmentally handicapped adults through a measurable increase in staff productivity in designated areas over a specified period of time . . . ROI will develop and implement a Continuous Quality Improvement Plan for the purpose of improving the quality of life for those served. 1. The CQI Plan of ROI will be initiated by approval of the board of directors and will be available for review by designated DMR staff.

2. The CQI Plan of ROI will include mechanisms for: a. Problem identification/opportunity for improvement. B. Assessment/analysis of identified performance problems. c. Documentation of problem resolution/improvements. d. Follow-up assessment to evaluate corrective action . . ."

Cross Reference: W122, W149, W158, W160, W195, W196, and W274

2. Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment," revised 03/28/22, revealed the policy failed to identify that aggression from one peer to another peer was abuse. Cross Reference: W149

3. Review of the facility's QIDP's employee file revealed the QIDP lacked the regulatory required one year experience working directly with persons with intellectual disability or other developmental disabilities in setting that served persons with intellectual disabilities. Cross Reference: W160.

4. Review of the facility's undated policy titled, "Individual Programming Plan," revealed, ". . . II. Vocational Program. Individual and vocational day trainees are provided prevocational job training and work experience in [facility' name] vocational workshop, which opened in 1995 . . . Day Habilitation. Day-Hab Program provides services to adults with developmental disabilities which results in substantial functioning limitations in 3 or more major areas: self-care, language, learning, mobility, self-direction, and the capacity for independent living and economic self-sufficiency. Our main goal is to incorporate social, recreational, and community activity skills. Our training program emphasizes on maximizing a person ' s independence in areas of: Daily living skills, Safety Mobility, Money management, Human Rights, Spirituality Growth, Interpersonal relationships, Volunteerism, Self-Advocacy, Recreational & Community activities.

Goals are developed based on deficits in skill sets that can be worked on throughout the year in an array of settings. Goals are typically worked on in classroom settings, community settings, and social settings . . ." Through observation, interview, and record review, it was determined the facility failed to have a vocational program. Cross Reference: W195 and W196

5. Review of the facility's undated policy titled, "Emergencies (Section from the facility's Emergency Preparedness Plan)," revealed, ". . . EMERGENCY PROCEDURES FOR SEVERE BEHAVIORAL PROBLEMS IN ALL ROI PROGRAMS - (i.e., residential and workplace violence involving residents and staff or between residents). Policy: [Facility Name] is committed to the safety and well being of all residents, staff, and visitors. Crisis Prevention Intervention (CPI) procedures are to be practiced at all times . . ." The facility's policy did not address the use of a functional behavior assessment, a hierarchy of least to most intrusive measures, or the incorporation of behavior management programs in clients' IPPs. Cross Reference: W266 and W274.

Based on interview, record review, review of the employee job description, and review of the facility's policy, the Governing Body failed to provide operating direction and management to ensure clients were protected from abuse and neglect, that a Qualified Intellectual Disability Professional (QIDP) was employed, that the facility had the required day training program that provided continuous and aggressive active treatment, that families were notified of client abuse, and that a policy for the management of client behavior was developed and implemented. These failures negatively impacted or had the potential to negatively impact eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8) and placed all 15 clients of the facility at risk for negative outcomes.

Findings include:

1. Review of the facility's policy titled "Continuous Quality Improvement," revised in 2020 revealed, ". . . The entity has a current Continuous Quality Improvement (CQI) Plan approved by the board of directors. ROI will develop a plan of accountability that will improve its success in carrying out the goal of meeting the needs of developmentally handicapped adults through a measurable increase in staff productivity in designated areas over a specified period of time . . . ROI will develop and implement a Continuous Quality Improvement Plan for the purpose of improving the quality of life for those served.

1. The CQI Plan of ROI will be initiated by approval of the board of directors and will be available for review by designated DMR staff.

2. The CQI Plan of ROI will include mechanisms for: a. Problem identification/opportunity for improvement. B. Assessment/analysis of identified performance problems. c. Documentation of problem resolution/improvements. d. Follow-up assessment to evaluate corrective action . . ."

Cross Reference: W122, W149, W158, W160, W195, W196, and W274

2. Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment," revised 03/28/22, revealed the policy failed to identify that aggression from one peer to another peer was abuse. Cross Reference: W149

3. Review of the facility's QIDP's employee file revealed the QIDP lacked the regulatory required one year experience working directly with persons with intellectual disability or other developmental disabilities in setting that served persons with intellectual disabilities. Cross Reference: W160.

4. Review of the facility's undated policy titled, "Individual Programming Plan," revealed, ". . . II. Vocational Program. Individual and vocational day trainees are provided prevocational job training and work experience in [facility' name] vocational workshop, which opened in 1995 . . . Day Habilitation. Day-Hab Program provides services to adults with developmental disabilities which results in substantial functioning limitations in 3 or more major areas: self-care, language, learning, mobility, self-direction, and the capacity for independent living and economic self-sufficiency. Our main goal is to incorporate social, recreational, and community activity skills. Our training program emphasizes on maximizing a person ' s independence in areas of: Daily living skills, Safety Mobility, Money management, Human Rights, Spirituality Growth, Interpersonal relationships, Volunteerism, Self-Advocacy, Recreational & Community activities.

Goals are developed based on deficits in skill sets that can be worked on throughout the year in an array of settings. Goals are typically worked on in classroom settings, community settings, and social settings . . ." Through observation, interview, and record review, it was determined the facility failed to have a vocational program. Cross Reference: W195 and W196

5. Review of the facility's undated policy titled, "Emergencies (Section from the facility's Emergency Preparedness Plan)," revealed, ". . . EMERGENCY PROCEDURES FOR SEVERE BEHAVIORAL PROBLEMS IN ALL ROI PROGRAMS - (i.e., residential and workplace violence involving residents and staff or between residents). Policy: [Facility Name] is committed to the safety and well being of all residents, staff, and visitors. Crisis Prevention Intervention (CPI) procedures are to be practiced at all times . . ." The facility's policy did not address the use of a functional behavior assessment, a hierarchy of least to most intrusive measures, or the incorporation of behavior management programs in clients' IPPs. Cross Reference: W266 and W274.
W0122 CLIENT PROTECTIONS
CFR(s): 483.420(a)

The facility must ensure the rights of all clients. Therefore the facility must


This CONDITION is not met as evidenced by:
Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the protection of client rights for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8.) The violation of client rights placed all 15 clients of the facility at risk of living in a restrictive and unsafe environment. All clients who resided in the home were restricted from their kitchen and access to their front doors (freedom of movement) without due process. C2 was neglected by staff and by the interdisciplinary team who were aware of the incidents that constituted neglect. C3 and C4 were victims of a peer to peer abuse. The families of the clients who were victims of abuse were not notified of the abuse; and the State Survey Agency was not notified.

On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures related to the protection of client rights constituted Immediate Jeopardy. It was determined the Immediate Jeopardy existed on 07/14/23.

The facility presented an acceptable plan of removal on 10/04/25 at 2:35 PM.

The facility's removal plan included:

1. The facility revised their policy to include peer to peer aggression constituted abuse. The facility began training staff on the revised policy and stated all staff would be training prior to working their next shift.

2. The facility educated all staff on intervening during episodes of client self-injurious behavior (SIB) and failure to intervene was neglect.

Through interview and record review, the survey team was able to validate all components of the plan of removal were implemented, and the Immediate Jeopardy was removed on 10/02/25 at 6:15 PM.

Findings include:

1. The Qualified Intellectual Disability Professional (QIDP), who was not qualified for the position, failed to ensure clients' Individual Program Plans (IPPs) were monitored quarterly with data to support progression or regression including documented observation of clients during program implementation for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). Additionally, the QIDP failed to promote competent interactions of residential staff when he/she received notification of C2 engaging in high frequency episodes of self-injurious behavior (SIB) and did not ensure the client had the needed behavior supports. C2 sustained harm for SIBs. These failures placed all 15 clients of the home at risk for not receiving the services needed for their active treatment program. Cross Reference: W125.

2. The facility failed to ensure three of eight clients (Client (C) 2, C3, and C 4) were free from abuse and neglect. C2 engaged in frequent and repetitive Self-Injurious Behavior (SIB) and staff neglected to intervene to protect the resident. Additionally, C3 and C4 were not protected from peer to peer abuse that facility identified as peer to peer aggressive behavior. These failures place the client at risk of living in an unsafe environment. Cross Reference: W127.

3. The facility failed to ensure video/audio live feed monitoring and/or recording was not used in place of staff supervision for one of eight sampled clients (Client (C) 5). C5 had a live feed video monitor in his/her bedroom which violated the client's right to privacy. Cross Reference: W129.

4. The facility failed to ensure staff encouraged and trained clients to use age-appropriate materials and not reinforce childlike socialization for one of eight sampled clients (Client (C) 8). C8 commonly had with him/her a babydoll; however, staff engaged in social interaction with the adult client in a childlike manner. This failure placed the client at risk for stigmatization and diminished opportunity for growth. Cross Reference: W137.

5. The facility failed to ensure parents and/or guardians were notified of abuse or allegations of abuse for two of eight sampled clients (Client (C) 3 and C4). Both C3 and C4 were victims of abuse from their peers; however, notifications of the abuse were not made to the family/guardian. Cross Reference: W148.

6. The facility failed to ensure their abuse policy identified instances of peer to peer aggression as abuse to prohibit client abuse. This failure had the potential to affect all 15 clients who resided at the facility. Cross Reference: W149.

7. The facility failed to ensure allegations and/or instances of abuse were immediately reported to the facility's Director and to the State Survey Agency (SSA) for two of eight sampled clients (Client (C) 3 and C4). Both C3 and C4 were victims of abuse from their peers; the facility's Director was not immediately notified nor was the SSA notified within 24 hours of the allegation/abuse. These failures place all 15 clients of the facility at risk for action not to be taken to prevent further abuse. Cross Reference: W153.

8. The facility failed to ensure allegations and/or instances of abuse were investigated for two of eight sampled clients (Client (C) 3 and C4). It was witnessed that C3 was abused by his/her peer; and C4 made an allegation that a peer hit him/her; however, neither of these instances were investigated as abuse. These failures place all 15 clients of being victims of abuse with no corrective action due to the facility not completing the investigations. Cross Reference: W154.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the protection of client rights for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8.) The violation of client rights placed all 15 clients of the facility at risk of living in a restrictive and unsafe environment. All clients who resided in the home were restricted from their kitchen and access to their front doors (freedom of movement) without due process. C2 was neglected by staff and by the interdisciplinary team who were aware of the incidents that constituted neglect. C3 and C4 were victims of a peer to peer abuse. The families of the clients who were victims of abuse were not notified of the abuse; and the State Survey Agency was not notified.

On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures related to the protection of client rights constituted Immediate Jeopardy. It was determined the Immediate Jeopardy existed on 07/14/23.

Findings include:

1. The Qualified Intellectual Disability Professional (QIDP), who was not qualified for the position, failed to ensure clients' Individual Program Plans (IPPs) were monitored quarterly with data to support progression or regression including documented observation of clients during program implementation for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). Additionally, the QIDP failed to promote competent interactions of residential staff when he/she received notification of C2 engaging in high frequency episodes of self-injurious behavior (SIB) and did not ensure the client had the needed behavior supports. C2 sustained harm for SIBs. These failures placed all 15 clients of the home at risk for not receiving the services needed for their active treatment program. Cross Reference: W125.

2. The facility failed to ensure three of eight clients (Client (C) 2, C3, and C 4) were free from abuse and neglect. C2 engaged in frequent and repetitive Self-Injurious Behavior (SIB) and staff neglected to intervene to protect the resident. Additionally, C3 and C4 were not protected from peer to peer abuse that facility identified as peer to peer aggressive behavior. These failures place the client at risk of living in an unsafe environment. Cross Reference: W127.

3. The facility failed to ensure video/audio live feed monitoring and/or recording was not used in place of staff supervision for one of eight sampled clients (Client (C) 5). C5 had a live feed video monitor in his/her bedroom which violated the client's right to privacy. Cross Reference: W129.

4. The facility failed to ensure staff encouraged and trained clients to use age-appropriate materials and not reinforce childlike socialization for one of eight sampled clients (Client (C) 8). C8 commonly had with him/her a babydoll; however, staff engaged in social interaction with the adult client in a childlike manner. This failure placed the client at risk for stigmatization and diminished opportunity for growth. Cross Reference: W137.

5. The facility failed to ensure parents and/or guardians were notified of abuse or allegations of abuse for two of eight sampled clients (Client (C) 3 and C4). Both C3 and C4 were victims of abuse from their peers; however, notifications of the abuse were not made to the family/guardian. Cross Reference: W148.

6. The facility failed to ensure their abuse policy identified instances of peer to peer aggression as abuse to prohibit client abuse. This failure had the potential to affect all 15 clients who resided at the facility. Cross Reference: W149.

7. The facility failed to ensure allegations and/or instances of abuse were immediately reported to the facility's Director and to the State Survey Agency (SSA) for two of eight sampled clients (Client (C) 3 and C4). Both C3 and C4 were victims of abuse from their peers; the facility's Director was not immediately notified nor was the SSA notified within 24 hours of the allegation/abuse. These failures place all 15 clients of the facility at risk for action not to be taken to prevent further abuse. Cross Reference: W153.

8. The facility failed to ensure allegations and/or instances of abuse were investigated for two of eight sampled clients (Client (C) 3 and C4). It was witnessed that C3 was abused by his/her peer; and C4 made an allegation that a peer hit him/her; however, neither of these instances were investigated as abuse. These failures place all 15 clients of being victims of abuse with no corrective action due to the facility not completing the investigations. Cross Reference: W154.

**********************

The facility presented an acceptable plan of removal on 10/04/25 at 2:35 PM.

The facility's removal plan included:

1. The facility revised their policy to include peer to peer aggression constituted abuse. The facility began training staff on the revised policy and stated all staff would be training prior to working their next shift.

2. The facility educated all staff on intervening during episodes of client self-injurious behavior (SIB) and failure to intervene was neglect.

Through interview and record review, the survey team was able to validate all components of the plan of removal were implemented, and the Immediate Jeopardy was removed on 10/04/25.
W0125 PROTECTION OF CLIENTS RIGHTS
CFR(s): 483.420(a)(3)

The facility must ensure the rights of all clients. Therefore, the facility must allow and encourage individual clients to exercise their rights as clients of the facility, and as citizens of the United States, including the right to file complaints, and the right to due process.


This STANDARD is not met as evidenced by:
Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8) had freedom of movement throughout their home, that restrictions were not imposed without due process including the approval of the Human Rights Committee (HRC) with a behavior plan to restore each client's right. This violated all 15 clients' rights who resided in the home and limited each client's autonomy and independence.

(Refer to W122, W129, and W262)

Findings include:

Review of the facility's policy titled, "Individual Rights and Grievance Procedure," revised 08/2022, revealed, ". . . It is the policy of [Facility Name] to provide age appropriate assistance to individuals who are admitted to [Facility Name] and to responsible others acting on their behalf, to exercise the same human and legal rights guaranteed all persons by the U.S. Constitution unless the individual has been specifically determined to be incompetent by judicial proceedings or otherwise legally restricted. Without regard to competency or legal restrictions, [Name of Facility] recipients have the right to provision of services within an environment that is safe, humane, and abuse free . . . In addition . . . residents have the right to appropriate quality treatment, services, and habilitation specifically designed to maximize their developmental potential within the least restrictive setting . . . HUMAN TREATMENT AND CIVIL RIGHTS. A home-like atmosphere shall be provided. A written policy concerning resident's rights shall be posted in a conspicuous location, and residents on admission shall be informed of their rights orally and in writing in plain and simple language . . . Each resident shall have the right to participate in or abstain from religious observances as he chooses. However, a Christian environment shall be fostered as the philosophy and mission of [Name of Facility] and all residents will have the opportunity to attend religious services within the community . . ."

Review of the facility's "Individual Rights Handbook," revised 08/2022, revealed, ". . . This handbook tells you about the rights, privileges and responsibilities you have while you are receiving services in programs . . . you, your family and friends can be certain that every . . . employee wants to protect your rights. While you are residing and/or receiving services . . . the Human Rights Committee and the [Facility Name] Employees will guard your rights. All of these people want to assist you and to preserve your rights . . . As a recipient of services available from [Facility Name] you have all the rights listed in this handbook the following: 1. You have the right to be treated as an adult and exercise your rights without being punished for doing it . . . 4. You have all the rights as an U.S. citizen and of the state of Alabama, unless your rights have been limited by a judge. This is only done for very good reasons. This includes the right to be considered competent until a court orders otherwise . . . 11. You should be told of your Person Centered Plan (PCP) or Individual Program Plan (IPP) and any restrictions to your rights. Sometimes, some of your rights might be restricted. You may ask your Program Director for a review of this decision if you do not agree with it ...25. You have the right not to be unnecessarily restrained, (physically or chemically), or isolated unless for your safety or the safety of others . . ."

Review of the facility's policy titled, "Personal Care and House Rules," dated 08/2008, revealed, ". . . to establish a home that enables the residents to progress or be maintained in the least restrictive environment. The effectiveness in providing adequate support services is to provide as much independence as possible and not provide personal care elements that are not needed . . . staff shall provide observation and precautionary measures to provide safety and protection from residents ' falling, wandering, and harm . . ."

During an interview on 09/30/25 at 4:23 PM, when asked how clients accessed their kitchen, Cook (CK) 1 stated the clients were not allowed in the kitchen here.

Observation on 09/30/25 at 4:25 PM of the dining room revealed signage on the wall by the door to the kitchen of "Only dietary staff permitted in the kitchen . . . Kitchen door to be locked and shut at all times . . ."

During an interview on 09/30/25 at 4:47 PM, when asked if clients of the home were able to access their kitchen, the Food Service Director (FSD) stated staff would assist the clients if they needed or wanted anything that was in the kitchen. The FSD stated normally, the kitchen door was only unlocked during normal business hours.

Observation on 09/30/25 at 4:50 PM of the front door of the home (main entrance) revealed the door was equipped with delayed egress hardware and had a sign which stated if the bar was pushed for 15 seconds (consistently) the door would open. The door required a code to get out the door without a 15 second delay.

Observation on 09/30/25 at 5:06 PM revealed when this writer attempted to exit the home by pushing on the exit bar, an audible alarm sounded until the bar was released. The door did not open and a key code was required to exit the home.

During an interview on 10/01/25 at 7:53 AM, Resident Aide (RA) 1 stated he had worked at the facility for almost three years. When asked if the clients had access to their home's kitchen, RA1 stated, "No, but the clients would ask staff if they wanted a snack or a drink." RA1 also stated clients were not "allowed" to go into the kitchen.

During an interview on 10/01/25 at 8:06 AM, RA3 stated she had been employed at the facility for five years. RA3 stated clients were not allowed to go into the kitchen and had not been able to go into the kitchen since she had been employed due to safety reasons.

During an interview on 10/01/25 at 8:17 AM, the Program Coordinator (PC) who was also a Licensed Practical Nurse (LPN) stated she was responsible for overseeing everything in the home. The PC stated clients who lived in the home could not go into the kitchen because of safety reasons.

During an interview on 10/01/25 at 9:47 AM, when asked about the clients not having access to their own kitchen, the Qualified Intellectual Disability Professional (QIDP) stated the clients should have been able to have access to the kitchen of their home; however, the direct care staff did not allow the clients to have access because of safety reasons.

1. Review of C1's "Comprehensive Functional Assessment (CFA)," dated 05/011/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post traumatic stress disorder (PTSD). Continued review of the CFA revealed it was identified that C1 understood all of his/her rights and how to advocate, as well as the grievance process, but would feel afraid or uncomfortable doing so.

Review of C1's "Individual Program Plan (IPP)," dated 05/2025 and provided by the facility, revealed, ". . . QIDP reviewed C1's Rights Restrictions and [C1's family names] were in agreement with [his/her] restrictions. As the QIDP began talking about the goals that were formulated for [C1's Name] [he/she] went into detail about [his/her] goals and stated that [he/she] agreed with [his/her] plan . . . [C1's Name] looks forward to being challenged and especially focusing on [his/her] bracelet business and having the freedom to travel throughout the [Facility Name] community . . . [C1's Name] family is very interested in creating 'lanes' for [C1's Name] to drive [his/her] wheelchair throughout the community [facility campus] . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, individual program planning, and alternate placement . . . Why is this limitation being recommended? [C1's name] is included in the decisions concerning [him/her]. [He/She] is able to make most decisions for [himself/herself]. [He/She] may receive some guidance from [his/her] parents . . . 7. The right to freedom from the use of unnecessary medications and mechanical, chemical, or physical restraints. Why is this limitation being recommended? [C1's Name] uses bedrails on [his/her] bed and seat belts in [his/her] wheelchair and shower chair . . ." Continued review revealed the IPP identified that C1's right to freedom of movement in the home, campus grounds, and off campus grounds were not restricted. C1's IPP did not include any type of behavior plan or a plan to restore the client's rights that had been restricted. There was no documented evidence HRC had reviewed the identified restrictions.

During an interview on 10/01/25 at 12:25 PM, C1 stated living an independent life was very important to him/her. C1 stated he/she was 26 years old and wanted to visit his/her friends who lived on campus at the other houses. C1 stated he/she can independently use his/her wheelchair and has a cell phone he/she could independently use; however, at this time he/she is not allowed to make that choice. C1 stated he/she could not even independently go sit on the front porch of the home because the door stays locked by a keypad. C1 further stated he/she nor other clients were allowed to access the home's kitchen.

2. Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder.

Review of C2's "IPP," dated 11/21/24 and provided by the facility, revealed, ". . . Rights Assessment: It has been assessed that [he/she] does not understand them and didn't really want to hear them at this time. [He/She] was unable to state who [he/she] would tell if [he/she] felt [his/her] rights were violated . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of restrictive behavior and/or medical procedures . . . 9. The right to have access to, to keep, and to spend personal money. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds, and off [facility name] grounds . . . A reduction in the rights restraints will occur when [C2's name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] is no longer a resident . . . [His/Her] rights will be reviewed annually . . ." There was no documented evidence of a behavior plan addressing these restrictions nor a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

3. Review of C3's "IPP," dated 05/09/25 and provided by the facility, revealed the client was a 71 year old client who was admitted to the facility 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities. The IPP also revealed, ". . . Rights Assessment: [C3's Name] does understand some of [his/her] rights but needs assistance with others. [His/Her] rights will be reviewed with [his/her] annual. The QIDP asked whom [he/she] would feel comfortable talking to if [he/she] felt [he/she] was being mistreated and [he/she] [identified persons] . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds . . ." There was no documented evidence the restrictions were documented in a behavior plan nor a plan to restore the restricted rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

4. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C4's "IPP," dated 12/12/24 and provided by the facility, revealed, ". . . Rights Assessment: [C4's Name] had [his/her] rights reviewed with [him/her] and it has been assessed that [he/she] does have limited understanding of [his/her] rights and how to report concerns . . . Any recommendations for goals retaining to rights: None at this time . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . ." The IPP indicated C4's right to freedom of movement in the home, vocational center, and on the facility's campus was not restricted and documented "[C4's] name has freedom of movement at the health and wellness center and in the ICF. [He/She] has supervision when outdoors . . . as a safety precaution . . ." There was no documented evidence the restrictions documented in a behavior plan nor a plan to restore the restricted rights. Additionally, the IPP failed to identify C4's freedom of movement was restricted in his/her home as he/she could not access his/her home's kitchen and the front door of his/her home was equipped with a delayed egress locking system.

5. Review of C5's "IPP," dated 08/20/25 and provided by the facility, revealed the client was a 44 year old client who was admitted to the facility on 08/06/14 with diagnoses which included Wolf-Hirschhorn Syndrome, profound intellectual disabilities, and epilepsy. The IPP also revealed, ". . . Right Assessment: It has been assessed that [C5's Name] does not understand [his/her] rights and would not be able to advocate for [himself/herself] in the event [his/her] rights were violated in some way . . . Any recommendations for goals relating to rights: none at this time . . . Limitations of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is the limitation being recommended? [C5's Name] uses a specialized bed with high bedrails on all four sides. [He/She] has a seatbelt, a chest strap, and thigh/trunk guides on [his/her] wheelchair . . . 8. The right to wear, to keep, to use own clothing, personal hygiene items, and personal possessions. Why is this limitation being recommended? [C5's Name] hygiene items are kept in a safe place where staff can access them. [He/She] is not able to read or understand about the hazards of various substances and may ingest harmful ones. [He/She] is physically unable to use [his/her] hygiene products on [his/her] own . . . 11. The right to privacy. Why is this limitation being recommended? [C5's Name] has a live time monitor in [his/her] room to monitor for safety due to brittle bones-to help staff be aware of [his/her] safety needs . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C5's Name] has no safety awareness and requires supervision on an off [Facility Name] grounds . . ." There was no documented evidence of a behavior plan to address the right restrictions nor any evidence of a restoration plan to restore these rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

6. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder.

Review of C6's "IPP," dated 02/06/25 and provided by the facility, revealed, ". . . Rights Assessment: . . . it was assessed that [C6's] name does not understand [his/her] rights . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [C6's Name] uses bedrails on [his/her] bed and seatbelts on [his/her] wheelchair and shower chair to prevent falls and a gait belt when walking. There are wheelchair and bed alarms to alert staff if [he/she] is in need of assistance . . . 11. The right to privacy. Why is this limitation being recommended? [C6's Name] requires standby assistance with all areas of hygiene due to seizure precautions, and therefore [his/her] right to privacy is limited for medical reasons. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C6's Name] has supervision when [he/she] is on or off [Facility Name] property. [He/She] requires help with transportation and ambulation . . . The reduction in [C6's Name] rights is congruent with [his/her] care needs. If at anytime it is shown that [C6's Name] is able to exercise these rights safely without restrictions or when [he/she] is no longer a resident, these restrictions will be removed . . ." There was no documented evidence of a behavior plan nor a restoration plan to restore the client's rights restrictions. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

7. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities.

Review of C7's "IPP," dated 07/10/25 and provided by the facility, revealed, ". . . Rights Assessment: . . . It has been assessed that [R7's Name] does not understand the rights and responsibilities due to [his/her] speech and disability . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement. Why is the limitation recommended? [C7's Name] does not understand some aspects of [his/her] care, finances, and/or legal issues. [He/She] has legal guardians to help [him/her] with decisions . . . 5. The right to make and to receive confidential phone calls. Why is the limitation recommended? [C7's Name] still has the right to make and receive phone calls in private. [His/Her] sisters who are [his/her] guardians have asked that [he/she] not have [his/her] cell phone until after the evening meal . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [He/She] [C7] uses bedrails and bed alarms due to a seizure disorder. [He/She] has a restricted wheelchair seatbelt and shower chair belt due to [his/her] seizure disorder. 8. The right to wear, to keep, and to use own clothing, personal hygiene items, and personal possessions. Why is this limitation being recommended? [C7's Name] is kept at the nurse's station to prevent [him/her] from calling people in the middle of the night. [He/She] has agreed with [his/her] sisters on this issue . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? To protect [him/her] from exploitation and to ensure safety, [he/she] is accompanied by a staff if [he/she] is outside or off the property ...A reduction in the rights restrictions will occur when [C7's Name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] is no longer is a resident of the facility . . ." There was no documented evidence the restrictions were identified in a behavior plan nor was there a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

8. Review of C8's "CFA," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities.

Review of C8's "IPP," dated 02/20/25 and provided by the facility, revealed, ". . . Rights Assessment: [C8's Name] were reviewed with [him/her]. It has been assessed that [he/she] does not understand some of [his/her] rights, but is limited to being able to advocate for [himself/herself] if [his/her] rights were violated . . . Limitation of Rights: 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [C8's Name] uses bedrails on [his/her] bed and a seatbelts in wheelchair and shower chair and a chest harness . . . 11. The right to privacy. Why is this limitation being recommended? [C8's Name] has a call bell in [his/her] bathroom in order to alert staff if [he/she] needs/wants assistance. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C8's Name] does not always pay attention around traffic and is open to exploitation. [He/She] should be supervised when outside the ICF building in the event [he/she] has a need. [He/She] needs seatbelts on wheelchair and shower and chest harness on wheelchair . . . A reduction in the rights restrictions will occur when [C8's Name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] is no longer a resident of the facility . . ." There was no documented evidence that the restrictions were identified in a behavior plan nor was there a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed that the clients not having access to their kitchen and not being able to freely go out the front door due to a delayed egress locking system that required a code to exit was not taken to HRC for approval. The director stated with the design of the home, he/she did not realize the clients were supposed to be able to access the kitchen. The facility Director confirmed all of the restrictions above did not have the required components including restoration plans for their rights.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8) had freedom of movement throughout their home, that restrictions were not imposed without due process including the approval of the Human Rights Committee (HRC) with a behavior plan to restore each client's right. This violated all 15 clients' rights who resided in the home and limited each client's autonomy and independence.

(Refer to W122, W129, and W262)

Findings include:

Review of the facility's policy titled, "Individual Rights and Grievance Procedure," revised 08/2022, revealed, ". . . It is the policy of [Facility Name] to provide age appropriate assistance to individuals who are admitted to [Facility Name] and to responsible others acting on their behalf, to exercise the same human and legal rights guaranteed all persons by the U.S. Constitution unless the individual has been specifically determined to be incompetent by judicial proceedings or otherwise legally restricted. Without regard to competency or legal restrictions, [Name of Facility] recipients have the right to provision of services within an environment that is safe, humane, and abuse free . . . In addition . . . residents have the right to appropriate quality treatment, services, and habilitation specifically designed to maximize their developmental potential within the least restrictive setting . . . HUMAN TREATMENT AND CIVIL RIGHTS. A home-like atmosphere shall be provided. A written policy concerning resident's rights shall be posted in a conspicuous location, and residents on admission shall be informed of their rights orally and in writing in plain and simple language . . . Each resident shall have the right to participate in or abstain from religious observances as he chooses. However, a Christian environment shall be fostered as the philosophy and mission of [Name of Facility] and all residents will have the opportunity to attend religious services within the community . . ."

Review of the facility's "Individual Rights Handbook," revised 08/2022, revealed, ". . . This handbook tells you about the rights, privileges and responsibilities you have while you are receiving services in programs . . . you, your family and friends can be certain that every . . . employee wants to protect your rights. While you are residing and/or receiving services . . . the Human Rights Committee and the [Facility Name] Employees will guard your rights. All of these people want to assist you and to preserve your rights . . . As a recipient of services available from [Facility Name] you have all the rights listed in this handbook the following: 1. You have the right to be treated as an adult and exercise your rights without being punished for doing it . . . 4. You have all the rights as an U.S. citizen and of the state of Alabama, unless your rights have been limited by a judge. This is only done for very good reasons. This includes the right to be considered competent until a court orders otherwise . . . 11. You should be told of your Person Centered Plan (PCP) or Individual Program Plan (IPP) and any restrictions to your rights. Sometimes, some of your rights might be restricted. You may ask your Program Director for a review of this decision if you do not agree with it ...25. You have the right not to be unnecessarily restrained, (physically or chemically), or isolated unless for your safety or the safety of others . . ."

Review of the facility's policy titled, "Personal Care and House Rules," dated 08/2008, revealed, ". . . to establish a home that enables the residents to progress or be maintained in the least restrictive environment. The effectiveness in providing adequate support services is to provide as much independence as possible and not provide personal care elements that are not needed . . . staff shall provide observation and precautionary measures to provide safety and protection from residents ' falling, wandering, and harm . . ."

During an interview on 09/30/25 at 4:23 PM, when asked how clients accessed their kitchen, Cook (CK) 1 stated the clients were not allowed in the kitchen here.

Observation on 09/30/25 at 4:25 PM of the dining room revealed signage on the wall by the door to the kitchen of "Only dietary staff permitted in the kitchen . . . Kitchen door to be locked and shut at all times . . ."

During an interview on 09/30/25 at 4:47 PM, when asked if clients of the home were able to access their kitchen, the Food Service Director (FSD) stated staff would assist the clients if they needed or wanted anything that was in the kitchen. The FSD stated normally, the kitchen door was only unlocked during normal business hours.

Observation on 09/30/25 at 4:50 PM of the front door of the home (main entrance) revealed the door was equipped with delayed egress hardware and had a sign which stated if the bar was pushed for 15 seconds (consistently) the door would open. The door required a code to get out the door without a 15 second delay.

Observation on 09/30/25 at 5:06 PM revealed when this writer attempted to exit the home by pushing on the exit bar, an audible alarm sounded until the bar was released. The door did not open and a key code was required to exit the home.

During an interview on 10/01/25 at 7:53 AM, Resident Aide (RA) 1 stated he had worked at the facility for almost three years. When asked if the clients had access to their home's kitchen, RA1 stated, "No, but the clients would ask staff if they wanted a snack or a drink." RA1 also stated clients were not "allowed" to go into the kitchen.

During an interview on 10/01/25 at 8:06 AM, RA3 stated she had been employed at the facility for five years. RA3 stated clients were not allowed to go into the kitchen and had not been able to go into the kitchen since she had been employed due to safety reasons.

During an interview on 10/01/25 at 8:17 AM, the Program Coordinator (PC) who was also a Licensed Practical Nurse (LPN) stated she was responsible for overseeing everything in the home. The PC stated clients who lived in the home could not go into the kitchen because of safety reasons.

During an interview on 10/01/25 at 9:47 AM, when asked about the clients not having access to their own kitchen, the Qualified Intellectual Disability Professional (QIDP) stated the clients should have been able to have access to the kitchen of their home; however, the direct care staff did not allow the clients to have access because of safety reasons.

1. Review of C1's "Comprehensive Functional Assessment (CFA)," dated 05/011/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post traumatic stress disorder (PTSD). Continued review of the CFA revealed it was identified that C1 understood all of his/her rights and how to advocate, as well as the grievance process, but would feel afraid or uncomfortable doing so.

Review of C1's "Individual Program Plan (IPP)," dated 05/2025 and provided by the facility, revealed, ". . . QIDP reviewed C1's Rights Restrictions and [C1's family names] were in agreement with [his/her] restrictions. As the QIDP began talking about the goals that were formulated for [C1's Name] [he/she] went into detail about [his/her] goals and stated that [he/she] agreed with [his/her] plan . . . [C1's Name] looks forward to being challenged and especially focusing on [his/her] bracelet business and having the freedom to travel throughout the [Facility Name] community . . . [C1's Name] family is very interested in creating 'lanes' for [C1's Name] to drive [his/her] wheelchair throughout the community [facility campus] . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, individual program planning, and alternate placement . . . Why is this limitation being recommended? [C1's name] is included in the decisions concerning [him/her]. [He/She] is able to make most decisions for [himself/herself]. [He/She] may receive some guidance from [his/her] parents . . . 7. The right to freedom from the use of unnecessary medications and mechanical, chemical, or physical restraints. Why is this limitation being recommended? [C1's Name] uses bedrails on [his/her] bed and seat belts in [his/her] wheelchair and shower chair . . ." Continued review revealed the IPP identified that C1's right to freedom of movement in the home, campus grounds, and off campus grounds were not restricted. C1's IPP did not include any type of behavior plan or a plan to restore the client's rights that had been restricted. There was no documented evidence HRC had reviewed the identified restrictions.

During an interview on 10/01/25 at 12:25 PM, C1 stated living an independent life was very important to him/her. C1 stated he/she was 26 years old and wanted to visit his/her friends who lived on campus at the other houses. C1 stated he/she can independently use his/her wheelchair and has a cell phone he/she could independently use; however, at this time he/she is not allowed to make that choice. C1 stated he/she could not even independently go sit on the front porch of the home because the door stays locked by a keypad. C1 further stated he/she nor other clients were allowed to access the home's kitchen.

2. Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder.

Review of C2's "IPP," dated 11/21/24 and provided by the facility, revealed, ". . . Rights Assessment: It has been assessed that [he/she] does not understand them and didn't really want to hear them at this time. [He/She] was unable to state who [he/she] would tell if [he/she] felt [his/her] rights were violated . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of restrictive behavior and/or medical procedures . . . 9. The right to have access to, to keep, and to spend personal money. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds, and off [facility name] grounds . . . A reduction in the rights restraints will occur when [C2's name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] is no longer a resident . . . [His/Her] rights will be reviewed annually . . ." There was no documented evidence of a behavior plan addressing these restrictions nor a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

3. Review of C3's "IPP," dated 05/09/25 and provided by the facility, revealed the client was a 71 year old client who was admitted to the facility 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities. The IPP also revealed, ". . . Rights Assessment: [C3's Name] does understand some of [his/her] rights but needs assistance with others. [His/Her] rights will be reviewed with [his/her] annual. The QIDP asked whom [he/she] would feel comfortable talking to if [he/she] felt [he/she] was being mistreated and [he/she] [identified persons] . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds . . ." There was no documented evidence the restrictions were documented in a behavior plan nor a plan to restore the restricted rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

4. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C4's "IPP," dated 12/12/24 and provided by the facility, revealed, ". . . Rights Assessment: [C4's Name] had [his/her] rights reviewed with [him/her] and it has been assessed that [he/she] does have limited understanding of [his/her] rights and how to report concerns . . . Any recommendations for goals retaining to rights: None at this time . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . ." The IPP indicated C4's right to freedom of movement in the home, vocational center, and on the facility's campus was not restricted and documented "[C4's] name has freedom of movement at the health and wellness center and in the ICF. [He/She] has supervision when outdoors . . . as a safety precaution . . ." There was no documented evidence the restrictions documented in a behavior plan nor a plan to restore the restricted rights. Additionally, the IPP failed to identify C4's freedom of movement was restricted in his/her home as he/she could not access his/her home's kitchen and the front door of his/her home was equipped with a delayed egress locking system.

5. Review of C5's "IPP," dated 08/20/25 and provided by the facility, revealed the client was a 44 year old client who was admitted to the facility on 08/06/14 with diagnoses which included Wolf-Hirschhorn Syndrome, profound intellectual disabilities, and epilepsy. The IPP also revealed, ". . . Right Assessment: It has been assessed that [C5's Name] does not understand [his/her] rights and would not be able to advocate for [himself/herself] in the event [his/her] rights were violated in some way . . . Any recommendations for goals relating to rights: none at this time . . . Limitations of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is the limitation being recommended? [C5's Name] uses a specialized bed with high bedrails on all four sides. [He/She] has a seatbelt, a chest strap, and thigh/trunk guides on [his/her] wheelchair . . . 8. The right to wear, to keep, to use own clothing, personal hygiene items, and personal possessions. Why is this limitation being recommended? [C5's Name] hygiene items are kept in a safe place where staff can access them. [He/She] is not able to read or understand about the hazards of various substances and may ingest harmful ones. [He/She] is physically unable to use [his/her] hygiene products on [his/her] own . . . 11. The right to privacy. Why is this limitation being recommended? [C5's Name] has a live time monitor in [his/her] room to monitor for safety due to brittle bones-to help staff be aware of [his/her] safety needs . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C5's Name] has no safety awareness and requires supervision on an off [Facility Name] grounds . . ." There was no documented evidence of a behavior plan to address the right restrictions nor any evidence of a restoration plan to restore these rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

6. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder.

Review of C6's "IPP," dated 02/06/25 and provided by the facility, revealed, ". . . Rights Assessment: . . . it was assessed that [C6's] name does not understand [his/her] rights . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [C6's Name] uses bedrails on [his/her] bed and seatbelts on [his/her] wheelchair and shower chair to prevent falls and a gait belt when walking. There are wheelchair and bed alarms to alert staff if [he/she] is in need of assistance . . . 11. The right to privacy. Why is this limitation being recommended? [C6's Name] requires standby assistance with all areas of hygiene due to seizure precautions, and therefore [his/her] right to privacy is limited for medical reasons. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C6's Name] has supervision when [he/she] is on or off [Facility Name] property. [He/She] requires help with transportation and ambulation . . . The reduction in [C6's Name] rights is congruent with [his/her] care needs. If at anytime it is shown that [C6's Name] is able to exercise these rights safely without restrictions or when [he/she] is no longer a resident, these restrictions will be removed . . ." There was no documented evidence of a behavior plan nor a restoration plan to restore the client's rights restrictions. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

7. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities.

Review of C7's "IPP," dated 07/10/25 and provided by the facility, revealed, ". . . Rights Assessment: . . . It has been assessed that [R7's Name] does not understand the rights and responsibilities due to [his/her] speech and disability . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement. Why is the limitation recommended? [C7's Name] does not understand some aspects of [his/her] care, finances, and/or legal issues. [He/She] has legal guardians to help [him/her] with decisions . . . 5. The right to make and to receive confidential phone calls. Why is the limitation recommended? [C7's Name] still has the right to make and receive phone calls in private. [His/Her] sisters who are [his/her] guardians have asked that [he/she] not have [his/her] cell phone until after the evening meal . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [He/She] [C7] uses bedrails and bed alarms due to a seizure disorder. [He/She] has a restricted wheelchair seatbelt and shower chair belt due to [his/her] seizure disorder. 8. The right to wear, to keep, and to use own clothing, personal hygiene items, and personal possessions. Why is this limitation being recommended? [C7's Name] is kept at the nurse's station to prevent [him/her] from calling people in the middle of the night. [He/She] has agreed with [his/her] sisters on this issue . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? To protect [him/her] from exploitation and to ensure safety, [he/she] is accompanied by a staff if [he/she] is outside or off the property ...A reduction in the rights restrictions will occur when [C7's Name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] is no longer is a resident of the facility . . ." There was no documented evidence the restrictions were identified in a behavior plan nor was there a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

8. Review of C8's "CFA," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities.

Review of C8's "IPP," dated 02/20/25 and provided by the facility, revealed, ". . . Rights Assessment: [C8's Name] were reviewed with [him/her]. It has been assessed that [he/she] does not understand some of [his/her] rights, but is limited to being able to advocate for [himself/herself] if [his/her] rights were violated . . . Limitation of Rights: 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [C8's Name] uses bedrails on [his/her] bed and a seatbelts in wheelchair and shower chair and a chest harness . . . 11. The right to privacy. Why is this limitation being recommended? [C8's Name] has a call bell in [his/her] bathroom in order to alert staff if [he/she] needs/wants assistance. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C8's Name] does not always pay attention around traffic and is open to exploitation. [He/She] should be supervised when outside the ICF building in the event [he/she] has a need. [He/She] needs seatbelts on wheelchair and shower and chest harness on wheelchair . . . A reduction in the rights restrictions will occur when [C8's Name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] is no longer a resident of the facility . . ." There was no documented evidence that the restrictions were identified in a behavior plan nor was there a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed that the clients not having access to their kitchen and not being able to freely go out the front door due to a delayed egress locking system that required a code to exit was not taken to HRC for approval. The director stated with the design of the home, he/she did not realize the clients were supposed to be able to access the kitchen. The facility Director confirmed all of the restrictions above did not have the required components including restoration plans for their rights.
W0127 PROTECTION OF CLIENTS RIGHTS
CFR(s): 483.420(a)(5)

The facility must ensure the rights of all clients. Therefore, the facility must ensure that clients are not subjected to physical, verbal, sexual or psychological abuse or punishment.


This STANDARD is not met as evidenced by:
Based on record review, interview, and review of the facility's policy, the facility failed to ensure three of eight clients (Client (C) 2, C3, and C 4) were free from abuse and neglect. C2 engaged in frequent and repetitive Self-Injurious Behavior (SIB) and staff neglected to intervene to protect the resident. Additionally, C3 and C4 were not protected from peer to peer abuse that the facility only identified as peer to peer aggressive behavior. These failures place the client at risk of living in an unsafe environment.

Findings include:

Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment, revised 03/08/22, revealed ". . . Abuse" Physical: Any assault by an employee upon an individual served and includes, but not limited to: hitting, kicking, pinching, slapping, or otherwise striking an individual or using excessive force regardless of whether an injury results. Assault used in this definition implies intent. Physical injury, as used herein, is defined as impairment of physical condition or substantial pain . . . Neglect: Failure to carry out a duty through reckless conduct, carelessness, inattention, or disregard of duty whereby the individual served is exposed to harm or risk of harm, and includes, but is not limited to: failing to appropriately supervise individuals or otherwise leaving individuals served unattended, failing to ensure that an individual's basic needs for safety, nutrition, medical care and personal attention are met, failing to provide treatment in accordance with the individual support plan/person directed planning or failing to develop a program plan, and utilizing treatment techniques, restraints (unless authorized with express written consent to promote an individual's safety), seclusion (unless as. part of a behavior support plan and reviewed by the Human Rights

Committee), etc., in violation of standards, whether or not injury results . . ." The policy did not identify one client hitting another as peer to peer abuse.

1. Review of C2's "Comprehensive Functional Assessment (CFA)," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. The CFA identified client had a behavior support plan (BSP) and identified target behaviors of physical aggression, verbal aggression, and self-injurious behavior (SIB); however, through record review and interview, it was confirmed C2 did not have any type of behavior plan.

Review of C2's "Therap (name of electronic medical record system) Communication Log (T-Log)," dated 11/13/24 and located in the client's electronic medical record (EMR) under the "T-Log" tab, revealed, "While assisting resident to bathroom [he/she] was walking towards toilet and went to head-butt padded area on wall, [he/she] missed the pad and head-butted wall hard and resident stated 'ouch.' Nurse notified."

Review of C2's "T-Log," dated 12/20/24 and located in the client's EMR under the "T-Log" tab, revealed, "[C2's Name] came out [his/her] room with [his/her] breakfast plate and [Resident Aide (RA) 1's name] told [him/her] to go back in [his/her] room and [he/she] did not then [he/she] saw me and I told [him/her] to go back into [his/her] room and walked past [him/her] to go help [RA1's name] and then [he/she] throws [his/her] breakfast plate towards my back and it fell into the floor."

Review of C2's "T-Log," dated 12/22/24 and located in the client's EMR under the "T-Log" tab, revealed, "Approximately around 2:30pm I was telling resident to go back into [his/her] room per quarantine instructions. While trying to re-direct resident to [his/her] room [he/she] managed to throw [himself/herself] on the floor by another residents [sic] room where [his/her] head caught the edge of the metal piece in the corner where [he/she] received a laceration. Charge nurse was notify [sic]."

Review of C2's "T-Log," dated 12/23/24 and located in the client's EMR under the "T-Log" tab, revealed, "Resident returned to facility at 8:10 P.M. from the emergency room, [he/she] was alert and good spirits. Resident received eleven staples to the back of [his/her] head."

Review of C2's "T-Log," dated 03/26/25 and located in the client's EMR under the "T-Log" tab, revealed, "[C2's Name] was being sent to the living/dining area to wait for breakfast, while the aid made [his/her] bed and cleaned [his/her] room. The resident became upset because [he/she] wanted to lay down instead of going to breakfast. [C2's name] proceeded to bang [his/her] head against the wall repeatedly until the nurse and aid intervened. Nurse was notified."

Review of C2's "T-Log," dated 04/04/25 and located in the client's EMR under the "T-Log" tab revealed "Staff reported resident head- banged wall while in bathroom, no evident injury

noted, [Name of C2's Attending Physician] made aware, neuro checks initiated, neuro intact at this time, care ongoing."

Review of C2's "T-Log," dated 04/04/25 and located in the client's EMR under the "T-Log" tab, revealed, "While showering [C2's initials] [he/she] got very agitated and when going to wash [his/her] legs [he/she] started kicking the wall. Then the aid moved so [he/she] would not get hit but when the aid went back to trying to wash the resident [he/she] hit the aid on the side of the head. The aid moved and told [C2's initials] to stop. The aid moved and the resident began hitting [himself/herself] in the face. The aid then washed off [C2's initials] and started to dry [him/her] and the resident kicked the aid in the shin. Next, the aid started to dress [C2's initials] and [he/she] hit the aid in the hand and squeezed the aids [sic] hand. The aid reported it to the nurse."

Review of C2's "T-Log," dated 06/29/25 and located in the client's EMR under the "T-Log" tab, revealed, "I happened to notice [C2's name] became irritated at lunch because [his/her] ice cream was still frozen and [he/she] could not get it out of the cup. I took [his/her] ice cream cup which had [his/her] spoon in it to the kitchen to soften it for [him/her]. When I came back [he/she] was irritated and eating [his/her] cake with [his/her] hands. At some point [he/she] had put [his/her] hands on [his/her] head and got icing in [his/her] hair and on the side of [his/her] face. [He/She] finished a little before 12pm and started to [his/her] room when I saw [his/her] face and hands covered in cake. I stopped [him/her] to wipe [his/her] hands and face and [he/she] showed discontent at first. I tried to keep [his/her] attention but [he/she] screamed and started to hit [himself/herself] in the face and got [sic] made contact a couple of times. I began to redirected [sic] [his/her] hand and [he/she] stopped for a second. Then, [he/she] started hitting [his/her] right side. I began to wipe that hand of the icing to distract [him/her] and [he/she] screamed again. I wiped [his/her] face and [he/she] continued to [his/her] room."

Review of C2's "T-Log," dated 06/29/25 and located in the client's EMR under the "T-Log" tab, revealed, "Resident was in bed and appeared to be sleep during 10pm rounding. By the time staff returned to the desk, [he/she] come out of [his/her] bedroom with a big smile. [He/She] said something to staff and when staff could not understand [him/her] and asked [him/her] to repeat what [he/she] said, [he/she] put [his/her] head as if looking at the floor and hands over [his/her] ears. Staff came closer to try to understand. [He/She] attempted to repeat [himself/herself] then appear frustrated. [He/She] hit [his/her] forehead and nose with the back of [his/her] hand and stomped [his/her] foot. Then [he/she] reached onto the nurses [sic] cart and grabbed a cup with spoons in it off the nursing cart. Resident put the spoons back on the cart and took the cup into [his/her] room. Approx. 10 minutes later [he/she] returned the cup to the cart. Cup which was once dry now had drips of water inside and out. Staff said keep it but [he/she] insisted on putting it back. Then [he/she] returned to [his/her] room."

Review of C2's "T-Log," dated 06/30/25 and located in the client's EMR under the "T-Log" tab, revealed, "This morning when the aids went into [C2's initials] room to get [him/her] up and showered [C2's initials] hit [himself/herself] in the face eleven times, bit [himself/herself] three times, hit [his/her] head on the wall three times, pinched the aid, and screamed four times. All happened while showing and clothing [him/her]. Will continue to monitor behavior."

Review of C2's "T-Log," dated 06/30/25 and located in the client's EMR under the "T-Log" tab, revealed, "Before lunch aide was cleaning [his/her] face, [C2's initials] hit [himself/herself] in the face as well as bit [his/her] arm multiple times. After lunch, [C2's initials] was transported to the bathroom during that duration [he/she] bit [himself/herself] three times and hit [himself/herself] multiple times."

Review of C2's "T-Log," dated 07/09/25 and located in the client's EMR under the "T-Log" tab revealed "While getting [C2's initials] up to take [him/her] to the bathroom and shower [him/her], [he/she] was aggressive with the aide multiple times, would not comply with the aide and then had an incontinent void in the bed, bit [himself/herself] multiple times, hit [his/her] head on the wall multiple times, punched [himself/herself] in the face multiple times, kicked the wall three times, squeezed the aide's hand three times, tried to punch the aide in the face twice, and tried to head-butt the aide twice. The aide and [C2's initials] have no sign of injuries. Will continue to document behavior."

Review of C2's "T-Log," dated 07/14/25 and located in the client's EMR under the "T-Log" tab, revealed, "Resident displayed SIB numerous ways this morning while assisting with getting up, showered, and dressed. Biting wrist approx. [approximately] 10 times. Striking face approx. 20 times. Striking top on head approx. 10 times. Kicking wall in shower approx 10 times.

Review of C2's "T-Log," dated 09/04/25 and located in the client's EMR under the "T-Log" tab, revealed, "While assisting resident with toileting resident was sitting on toilet and leaned backwards and started banging head on bathroom wall, nurse notified."

During an interview on 10/01/25 at 3:50 PM, the Qualified Intellectual Disability Professional (QIDP) stated the client did not have any type of behavior plan at this time. The QIDP stated there should have been a BSP a long time ago. The QIDP also confirmed there had not been any behavior functional assessments completed to his/her knowledge.

During an interview on 10/01/25 at 5:10 PM, Resident Aide (RA) 1 stated it was normal for C2 to engage in multiple and repetitive episodes of SIB each day. RA1 stated when they wake him/her up in the morning, he/she will bite himself/herself, hit himself/herself in the face, and headbang the wall. When asked if there was anything to follow when he/she did engage in SIB or if he/she had received any training on how to prevent or respond to the behaviors such as intervening, the RA stated they were instructed when C2 had SIB to make a note in the client's T-Log. The RA stated he/she had been trained in the facility's Crisis Prevention Intervention (CPI) program where he/she was taught to ignore the behaviors, especially "junk behaviors." When asked what junk behaviors were, the RA stated that was basically attention seeking behaviors. RA1 stated they do not intervene when C2 engages in SIB including headbanging as this was the client's normal behavior. Continued interview with RA1 revealed on 12/22/24, C2 was being redirected back to his/her room due to the home being on quarantine precautions when C2 did not want to go back to his/her room and when the RA attempted to guide the C2, C2 purposely threw himself/herself to the floor where the client had to go to the emergency room and get stitches.

During an interview on 10/01/25 at 6:15 PM, RA2 stated he/she had been employed at the facility for five years. When asked about C2, RA2 stated the client engaged in SIBs of headbanging, hitting himself/herself in the mouth, and biting himself/herself really aggressively. RA2 stated on 12/22/24 the clients were quarantined to their rooms due to COVID protocols. RA2 stated the staff from the prior shift told him/her they had to redirect C2 back to his/her room. RA2 stated C2 was out of his/her room so he/she verbally redirected the client. RA2 stated he/she put his/her arms out like a wall so it would better direct C2 when he/she verbally redirected the client to the room. RA2 stated when he/she verbally redirected C2 back to his/her room, C2 purposefully threw himself/herself to the floor where he/she hit his/her head on the outside corner of the wall. RA2 stated the client had to be transported to the ER to receive stitches.

During an interview on 10/02/25 at 1:07 PM, when asked about the multiple documented incidents of C2 engaging in repetitive SIB of headbanging with no staff intervention and what that could be viewed as, the facility Director stated "neglect." When asked why C2 did not have any behavior supports such as a behavior plan, the facility Director stated it has been over a year but the last time the team consulted with a BCBA, the team was told a plan was not needed. The facility Director stated he/she was not sure a plan would have prevented any injury because if C2 wanted to hurt himself/herself, he/she was going to hurt himself/herself.

During an interview on 10/02/25 at 4:07 PM, the Psychiatrist (Psych) stated he/she knew C2 well. The Psych stated he/she consulted with a provider who had treated C2 prior to him/her treating the client and discovered that the client had engaged in SIB for years. The Psych stated he/she had attempted different antipsychotic medications to assist in improving the client's behavior; however, the risk of the side effects outweighed the benefits, and the medications were considered failed attempts; however, these were additional antipsychotics that C2 was already on for his/her schizoaffective disorder. When asked about his/her expectation as to staff managing C2's behaviors, the Psych stated medications were not going to improve C2's behavior. The Psych stated the BCBA (Board Certified Behavior Analysis) could develop a plan with interventions. The Psych stated with the C2's autism diagnosis, he/she could benefit from a sensory room. The Psych stated when C2 was asked to do a task, and then engages in SIB, he/she believed the function of the behavior would be "escape." The Psych stated C2 worked with a BCBA at one time; however, it may be more beneficial to C2 if they attempted to find a BCBA who works with intellectual disabilities with clients who have dual diagnoses (Intellectual Disability/Developmental Disability and mental illness). The Psych stated it was his/her expectation when C2 engaged in SIB, especially the headbanging, staff would have been trained on keeping the client safe. The Psych also stated staff having the proper training from the appropriate discipline such as a BCBA would make the client more comfortable and give the client more autonomy.

2. a. Review of C3's "Individual Program Plan (IPP)," dated 05/09/25 and provided by the facility revealed the client was a 71 year old client who was admitted to the facility 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities.

Review of C2's "T-Log," note, dated 09/09/25 and located in the client's EMR under the "T-Log" tab, revealed, "This afternoon at approximately 2:45 p.m. during Health and Wellness, [C2's name] exhibited ATO [aggression towards others] behavior and struck a peer on the right arm. The hit was not forceful; however, [C2's name] displayed signs of aggression and agitation."

Revie of C3's "T-Log," note, dated 09/09/25 and located in the client's EMR under the "T-Log" tab revealed "During Health and Wellness, [C3's name] was struck on the right arm by another

peer. [C3's name] did not report or display any signs of pain at the time of the incident. Staff monitored [him/her] and no further concerns were observed."

b. Review C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C3's "T-Log" note, dated 09/18/25 and located in the client's EMR under the "T-Log" tab, revealed, "Overheard RA telling resident to go to room. Upon entering the dining room

resident noted to be agitated and fussing at other resident and staff. Resident was instructed to go to room for cooling off period. Resident attempted to hit me with [his/her] elbow. Resident finally went to [his/her] room. When asked what happened another resident [C4] stated [he/she] [C3] hit me. PD [program director] and PC [program coordinator] notified."

During an interview on 10/01/25 at 3:50 PM, the QIDP stated he/she had not been trained that a client hitting another client was considered abuse. The QIDP stated he/she had not been trained on reporting abuse. When asked if he/she became aware of an allegation of abuse or witnessed abuse, who would he/she report that to, the QIDP stated when he/she had a concern about a client's behavior and/or a concern about staff treatment of the clients, he/she must get the facility Director's approval before reporting or educating the staff.

During an interview on 10/02/25 at 1:07 PM, the facility Director stated he/she was not aware that a client hitting another client would be considered abuse. The Director stated the facility considered and documented that as ATO (aggression towards others). The facility Director confirmed the facility staff had not been educated that a client hitting another client was abuse.

Based on record review, interview, and review of the facility's policy, the facility failed to ensure three of eight clients (Client (C) 2, C3, and C 4) were free from abuse and neglect. C2 engaged in frequent and repetitive Self-Injurious Behavior (SIB) and staff neglected to intervene to protect the resident. Additionally, C3 and C4 were not protected from peer to peer abuse that the facility only identified as peer to peer aggressive behavior. These failures place the client at risk of living in an unsafe environment.

Findings include:

Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment, revised 03/08/22, revealed ". . . Abuse" Physical: Any assault by an employee upon an individual served and includes, but not limited to: hitting, kicking, pinching, slapping, or otherwise striking an individual or using excessive force regardless of whether an injury results. Assault used in this definition implies intent. Physical injury, as used herein, is defined as impairment of physical condition or substantial pain . . . Neglect: Failure to carry out a duty through reckless conduct, carelessness, inattention, or disregard of duty whereby the individual served is exposed to harm or risk of harm, and includes, but is not limited to: failing to appropriately supervise individuals or otherwise leaving individuals served unattended, failing to ensure that an individual's basic needs for safety, nutrition, medical care and personal attention are met, failing to provide treatment in accordance with the individual support plan/person directed planning or failing to develop a program plan, and utilizing treatment techniques, restraints (unless authorized with express written consent to promote an individual's safety), seclusion (unless as. part of a behavior support plan and reviewed by the Human Rights

Committee), etc., in violation of standards, whether or not injury results . . ." The policy did not identify one client hitting another as peer to peer abuse.

1. Review of C2's "Comprehensive Functional Assessment (CFA)," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. The CFA identified client had a behavior support plan (BSP) and identified target behaviors of physical aggression, verbal aggression, and self-injurious behavior (SIB); however, through record review and interview, it was confirmed C2 did not have any type of behavior plan.

Review of C2's "Therap (name of electronic medical record system) Communication Log (T-Log)," dated 11/13/24 and located in the client's electronic medical record (EMR) under the "T-Log" tab, revealed, "While assisting resident to bathroom [he/she] was walking towards toilet and went to head-butt padded area on wall, [he/she] missed the pad and head-butted wall hard and resident stated 'ouch.' Nurse notified."

Review of C2's "T-Log," dated 12/20/24 and located in the client's EMR under the "T-Log" tab, revealed, "[C2's Name] came out [his/her] room with [his/her] breakfast plate and [Resident Aide (RA) 1's name] told [him/her] to go back in [his/her] room and [he/she] did not then [he/she] saw me and I told [him/her] to go back into [his/her] room and walked past [him/her] to go help [RA1's name] and then [he/she] throws [his/her] breakfast plate towards my back and it fell into the floor."

Review of C2's "T-Log," dated 12/22/24 and located in the client's EMR under the "T-Log" tab, revealed, "Approximately around 2:30pm I was telling resident to go back into [his/her] room per quarantine instructions. While trying to re-direct resident to [his/her] room [he/she] managed to throw [himself/herself] on the floor by another residents [sic] room where [his/her] head caught the edge of the metal piece in the corner where [he/she] received a laceration. Charge nurse was notify [sic]."

Review of C2's "T-Log," dated 12/23/24 and located in the client's EMR under the "T-Log" tab, revealed, "Resident returned to facility at 8:10 P.M. from the emergency room, [he/she] was alert and good spirits. Resident received eleven staples to the back of [his/her] head."

Review of C2's "T-Log," dated 03/26/25 and located in the client's EMR under the "T-Log" tab, revealed, "[C2's Name] was being sent to the living/dining area to wait for breakfast, while the aid made [his/her] bed and cleaned [his/her] room. The resident became upset because [he/she] wanted to lay down instead of going to breakfast. [C2's name] proceeded to bang [his/her] head against the wall repeatedly until the nurse and aid intervened. Nurse was notified."

Review of C2's "T-Log," dated 04/04/25 and located in the client's EMR under the "T-Log" tab revealed "Staff reported resident head- banged wall while in bathroom, no evident injury

noted, [Name of C2's Attending Physician] made aware, neuro checks initiated, neuro intact at this time, care ongoing."

Review of C2's "T-Log," dated 04/04/25 and located in the client's EMR under the "T-Log" tab, revealed, "While showering [C2's initials] [he/she] got very agitated and when going to wash [his/her] legs [he/she] started kicking the wall. Then the aid moved so [he/she] would not get hit but when the aid went back to trying to wash the resident [he/she] hit the aid on the side of the head. The aid moved and told [C2's initials] to stop. The aid moved and the resident began hitting [himself/herself] in the face. The aid then washed off [C2's initials] and started to dry [him/her] and the resident kicked the aid in the shin. Next, the aid started to dress [C2's initials] and [he/she] hit the aid in the hand and squeezed the aids [sic] hand. The aid reported it to the nurse."

Review of C2's "T-Log," dated 06/29/25 and located in the client's EMR under the "T-Log" tab, revealed, "I happened to notice [C2's name] became irritated at lunch because [his/her] ice cream was still frozen and [he/she] could not get it out of the cup. I took [his/her] ice cream cup which had [his/her] spoon in it to the kitchen to soften it for [him/her]. When I came back [he/she] was irritated and eating [his/her] cake with [his/her] hands. At some point [he/she] had put [his/her] hands on [his/her] head and got icing in [his/her] hair and on the side of [his/her] face. [He/She] finished a little before 12pm and started to [his/her] room when I saw [his/her] face and hands covered in cake. I stopped [him/her] to wipe [his/her] hands and face and [he/she] showed discontent at first. I tried to keep [his/her] attention but [he/she] screamed and started to hit [himself/herself] in the face and got [sic] made contact a couple of times. I began to redirected [sic] [his/her] hand and [he/she] stopped for a second. Then, [he/she] started hitting [his/her] right side. I began to wipe that hand of the icing to distract [him/her] and [he/she] screamed again. I wiped [his/her] face and [he/she] continued to [his/her] room."

Review of C2's "T-Log," dated 06/29/25 and located in the client's EMR under the "T-Log" tab, revealed, "Resident was in bed and appeared to be sleep during 10pm rounding. By the time staff returned to the desk, [he/she] come out of [his/her] bedroom with a big smile. [He/She] said something to staff and when staff could not understand [him/her] and asked [him/her] to repeat what [he/she] said, [he/she] put [his/her] head as if looking at the floor and hands over [his/her] ears. Staff came closer to try to understand. [He/She] attempted to repeat [himself/herself] then appear frustrated. [He/She] hit [his/her] forehead and nose with the back of [his/her] hand and stomped [his/her] foot. Then [he/she] reached onto the nurses [sic] cart and grabbed a cup with spoons in it off the nursing cart. Resident put the spoons back on the cart and took the cup into [his/her] room. Approx. 10 minutes later [he/she] returned the cup to the cart. Cup which was once dry now had drips of water inside and out. Staff said keep it but [he/she] insisted on putting it back. Then [he/she] returned to [his/her] room."

Review of C2's "T-Log," dated 06/30/25 and located in the client's EMR under the "T-Log" tab, revealed, "This morning when the aids went into [C2's initials] room to get [him/her] up and showered [C2's initials] hit [himself/herself] in the face eleven times, bit [himself/herself] three times, hit [his/her] head on the wall three times, pinched the aid, and screamed four times. All happened while showing and clothing [him/her]. Will continue to monitor behavior."

Review of C2's "T-Log," dated 06/30/25 and located in the client's EMR under the "T-Log" tab, revealed, "Before lunch aide was cleaning [his/her] face, [C2's initials] hit [himself/herself] in the face as well as bit [his/her] arm multiple times. After lunch, [C2's initials] was transported to the bathroom during that duration [he/she] bit [himself/herself] three times and hit [himself/herself] multiple times."

Review of C2's "T-Log," dated 07/09/25 and located in the client's EMR under the "T-Log" tab revealed "While getting [C2's initials] up to take [him/her] to the bathroom and shower [him/her], [he/she] was aggressive with the aide multiple times, would not comply with the aide and then had an incontinent void in the bed, bit [himself/herself] multiple times, hit [his/her] head on the wall multiple times, punched [himself/herself] in the face multiple times, kicked the wall three times, squeezed the aide's hand three times, tried to punch the aide in the face twice, and tried to head-butt the aide twice. The aide and [C2's initials] have no sign of injuries. Will continue to document behavior."

Review of C2's "T-Log," dated 07/14/25 and located in the client's EMR under the "T-Log" tab, revealed, "Resident displayed SIB numerous ways this morning while assisting with getting up, showered, and dressed. Biting wrist approx. [approximately] 10 times. Striking face approx. 20 times. Striking top on head approx. 10 times. Kicking wall in shower approx 10 times.

Review of C2's "T-Log," dated 09/04/25 and located in the client's EMR under the "T-Log" tab, revealed, "While assisting resident with toileting resident was sitting on toilet and leaned backwards and started banging head on bathroom wall, nurse notified."

During an interview on 10/01/25 at 3:50 PM, the Qualified Intellectual Disability Professional (QIDP) stated the client did not have any type of behavior plan at this time. The QIDP stated there should have been a BSP a long time ago. The QIDP also confirmed there had not been any behavior functional assessments completed to his/her knowledge.

During an interview on 10/01/25 at 5:10 PM, Resident Aide (RA) 1 stated it was normal for C2 to engage in multiple and repetitive episodes of SIB each day. RA1 stated when they wake him/her up in the morning, he/she will bite himself/herself, hit himself/herself in the face, and headbang the wall. When asked if there was anything to follow when he/she did engage in SIB or if he/she had received any training on how to prevent or respond to the behaviors such as intervening, the RA stated they were instructed when C2 had SIB to make a note in the client's T-Log. The RA stated he/she had been trained in the facility's Crisis Prevention Intervention (CPI) program where he/she was taught to ignore the behaviors, especially "junk behaviors." When asked what junk behaviors were, the RA stated that was basically attention seeking behaviors. RA1 stated they do not intervene when C2 engages in SIB including headbanging as this was the client's normal behavior. Continued interview with RA1 revealed on 12/22/24, C2 was being redirected back to his/her room due to the home being on quarantine precautions when C2 did not want to go back to his/her room and when the RA attempted to guide the C2, C2 purposely threw himself/herself to the floor where the client had to go to the emergency room and get stitches.

During an interview on 10/01/25 at 6:15 PM, RA2 stated he/she had been employed at the facility for five years. When asked about C2, RA2 stated the client engaged in SIBs of headbanging, hitting himself/herself in the mouth, and biting himself/herself really aggressively. RA2 stated on 12/22/24 the clients were quarantined to their rooms due to COVID protocols. RA2 stated the staff from the prior shift told him/her they had to redirect C2 back to his/her room. RA2 stated C2 was out of his/her room so he/she verbally redirected the client. RA2 stated he/she put his/her arms out like a wall so it would better direct C2 when he/she verbally redirected the client to the room. RA2 stated when he/she verbally redirected C2 back to his/her room, C2 purposefully threw himself/herself to the floor where he/she hit his/her head on the outside corner of the wall. RA2 stated the client had to be transported to the ER to receive stitches.

During an interview on 10/02/25 at 1:07 PM, when asked about the multiple documented incidents of C2 engaging in repetitive SIB of headbanging with no staff intervention and what that could be viewed as, the facility Director stated "neglect." When asked why C2 did not have any behavior supports such as a behavior plan, the facility Director stated it has been over a year but the last time the team consulted with a BCBA, the team was told a plan was not needed. The facility Director stated he/she was not sure a plan would have prevented any injury because if C2 wanted to hurt himself/herself, he/she was going to hurt himself/herself.

During an interview on 10/02/25 at 4:07 PM, the Psychiatrist (Psych) stated he/she knew C2 well. The Psych stated he/she consulted with a provider who had treated C2 prior to him/her treating the client and discovered that the client had engaged in SIB for years. The Psych stated he/she had attempted different antipsychotic medications to assist in improving the client's behavior; however, the risk of the side effects outweighed the benefits, and the medications were considered failed attempts; however, these were additional antipsychotics that C2 was already on for his/her schizoaffective disorder. When asked about his/her expectation as to staff managing C2's behaviors, the Psych stated medications were not going to improve C2's behavior. The Psych stated the BCBA (Board Certified Behavior Analysis) could develop a plan with interventions. The Psych stated with the C2's autism diagnosis, he/she could benefit from a sensory room. The Psych stated when C2 was asked to do a task, and then engages in SIB, he/she believed the function of the behavior would be "escape." The Psych stated C2 worked with a BCBA at one time; however, it may be more beneficial to C2 if they attempted to find a BCBA who works with intellectual disabilities with clients who have dual diagnoses (Intellectual Disability/Developmental Disability and mental illness). The Psych stated it was his/her expectation when C2 engaged in SIB, especially the headbanging, staff would have been trained on keeping the client safe. The Psych also stated staff having the proper training from the appropriate discipline such as a BCBA would make the client more comfortable and give the client more autonomy.

2. a. Review of C3's "Individual Program Plan (IPP)," dated 05/09/25 and provided by the facility revealed the client was a 71 year old client who was admitted to the facility 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities.

Review of C2's "T-Log," note, dated 09/09/25 and located in the client's EMR under the "T-Log" tab, revealed, "This afternoon at approximately 2:45 p.m. during Health and Wellness, [C2's name] exhibited ATO [aggression towards others] behavior and struck a peer on the right arm. The hit was not forceful; however, [C2's name] displayed signs of aggression and agitation."

Revie of C3's "T-Log," note, dated 09/09/25 and located in the client's EMR under the "T-Log" tab revealed "During Health and Wellness, [C3's name] was struck on the right arm by another

peer. [C3's name] did not report or display any signs of pain at the time of the incident. Staff monitored [him/her] and no further concerns were observed."

b. Review C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C3's "T-Log" note, dated 09/18/25 and located in the client's EMR under the "T-Log" tab, revealed, "Overheard RA telling resident to go to room. Upon entering the dining room

resident noted to be agitated and fussing at other resident and staff. Resident was instructed to go to room for cooling off period. Resident attempted to hit me with [his/her] elbow. Resident finally went to [his/her] room. When asked what happened another resident [C4] stated [he/she] [C3] hit me. PD [program director] and PC [program coordinator] notified."

During an interview on 10/01/25 at 3:50 PM, the QIDP stated he/she had not been trained that a client hitting another client was considered abuse. The QIDP stated he/she had not been trained on reporting abuse. When asked if he/she became aware of an allegation of abuse or witnessed abuse, who would he/she report that to, the QIDP stated when he/she had a concern about a client's behavior and/or a concern about staff treatment of the clients, he/she must get the facility Director's approval before reporting or educating the staff.

During an interview on 10/02/25 at 1:07 PM, the facility Director stated he/she was not aware that a client hitting another client would be considered abuse. The Director stated the facility considered and documented that as ATO (aggression towards others). The facility Director confirmed the facility staff had not been educated that a client hitting another client was abuse.
W0129 PROTECTION OF CLIENTS RIGHTS
CFR(s): 483.420(a)(7)

The facility must ensure the rights of all clients. Therefore, the facility must provide each client with the opportunity for personal privacy.


This STANDARD is not met as evidenced by:
Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure video/audio live feed monitoring and/or recording was not used in place of staff supervision for one of eight sampled clients (Client (C) 5). C5 had a live feed video monitor in his/her bedroom which violated the client's right to privacy.

Findings include:

Review of the facility's policy titled, "Board of Directors Policy on Resident Rights," revised 08/2022, revealed, ". . . 6. Each resident shall have the right to privacy, which promotes the quality of life. Limitations to privacy rights shall pertain only to the individual ' s care, treatment, and habilitation as determined by program director in accordance with resident rights policy . . ."

Review of C5's "Individual Program Plan (IPP)," dated 08/20/25 and provided by the facility, revealed the client was a 44 year old client who was admitted to the facility on 08/06/14 with diagnoses which included Wolf-Hirschhorn Syndrome, profound intellectual disabilities and epilepsy. The IPP also revealed, ". . . Right Assessment: It has been assessed that [C5's Name] does not understand [his/her] rights and would not be able to advocate for [himself/herself] in the event [his/her] rights were violated in some way . . . Any recommendations for goals relating to rights: none at this time . . . Limitations of Rights: . . . 11. The right to privacy. Why is this limitation being recommended? [C5's Name] has a live time monitor in [his/her] room to monitor for safety due to brittle bones-to help staff be aware of [his/her] safety needs . . ." There was no documented evidence of a behavior plan to address the right restriction nor any evidence of a restoration plan to restore the right.

Observation on 10/01/25 at 11:50 AM of C5's bedroom revealed a live video monitoring system.

During an interview on 10/04/25 at 9:15 AM, the facility Director confirmed there was no right restoration plan in place for C5's privacy restriction. The Director stated it was suggested by C5's father. The facility Director also confirmed there was no physical support plan in place either.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure video/audio live feed monitoring and/or recording was not used in place of staff supervision for one of eight sampled clients (Client (C) 5). C5 had a live feed video monitor in his/her bedroom which violated the client's right to privacy.

Findings include:

Review of the facility's policy titled, "Board of Directors Policy on Resident Rights," revised 08/2022, revealed, ". . . 6. Each resident shall have the right to privacy, which promotes the quality of life. Limitations to privacy rights shall pertain only to the individual ' s care, treatment, and habilitation as determined by program director in accordance with resident rights policy . . ."

Review of C5's "Individual Program Plan (IPP)," dated 08/20/25 and provided by the facility, revealed the client was a 44 year old client who was admitted to the facility on 08/06/14 with diagnoses which included Wolf-Hirschhorn Syndrome, profound intellectual disabilities and epilepsy. The IPP also revealed, ". . . Right Assessment: It has been assessed that [C5's Name] does not understand [his/her] rights and would not be able to advocate for [himself/herself] in the event [his/her] rights were violated in some way . . . Any recommendations for goals relating to rights: none at this time . . . Limitations of Rights: . . . 11. The right to privacy. Why is this limitation being recommended? [C5's Name] has a live time monitor in [his/her] room to monitor for safety due to brittle bones-to help staff be aware of [his/her] safety needs . . ." There was no documented evidence of a behavior plan to address the right restriction nor any evidence of a restoration plan to restore the right.

Observation on 10/01/25 at 11:50 AM of C5's bedroom revealed a live video monitoring system.

During an interview on 10/04/25 at 9:15 AM, the facility Director confirmed there was no right restoration plan in place for C5's privacy restriction. The Director stated it was suggested by C5's father. The facility Director also confirmed there was no physical support plan in place either.
W0137 PROTECTION OF CLIENTS RIGHTS
CFR(s): 483.420(a)(12)

The facility must ensure the rights of all clients. Therefore, the facility must ensure that clients have the right to retain and use appropriate personal possessions and clothing.


This STANDARD is not met as evidenced by:
Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure staff encouraged and trained clients to use age-appropriate materials and not reinforce childlike socialization for one of eight sampled clients (Client (C) 8). C8 commonly had with him/her a babydoll; however, staff engaged in social interaction with the adult client in a childlike manner. This failure placed the client at risk for stigmatization and diminished opportunity for growth.

Findings include:

Review of the facility's policy titled, "Board of Directors Policy on Resident Rights," revised 08/2022, revealed, "It is the policy of [Facility Name] to provide age appropriate assistance to individuals who are admitted to [Facility Name] . . . Individual Rights Assessment . . . 1.Right to be treated as an adult and not be discriminated against based on race, religion, sex, age, or disability . . ."

Review of C8's "Comprehensive Functional Assessment (CFA)," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities.

Review of C8's "Individual Program Plan (IPP)," dated 02/20/25 and provided by the facility, revealed no documented evidence of any program objective encouraging age-appropriate socialization.

During an observation on 09/30/25 at 1:35 PM at the Health and Wellness Center, C8 was sitting in his/her wheelchair at the end of a table with peers. The client was not engaged in any meaningful activity and was holding a child's babydoll.

During an interview on 10/01/25 at 9:47 AM, when asked about C8 having a children's babydoll with him/her throughout the day, the Qualified Intellectual Disability Professional (QIDP) stated the client usually gets upset if it was taken away from him/her. The QIDP stated it was like his/her child and the babydoll's name was Butterly. The QIDP stated he/she saw the babydoll as an emotional support for the client. The QIDP stated it was not incorporated in C8's Individual Program Plan (IPP) to promote an age-appropriate environment and socialization as he/she saw C8 having the babydoll as emotionally supportive. When asked if there was anything in the client's IPP to support the rational of emotional support or that other more age-appropriate alternatives had been attempted, the QIDP stated "no."

During an observation on 10/03/25 at 3:11 PM of C8's medication administration, C8 was in the living area of the home with no other clients in the living area. C8 was in his/her wheelchair, reclined, and had two child toys, one being a babydoll and the other a red stuffed animal, and sitting in front of the television watching a cartoon (Sponge Bob). Licensed Practical Nurse (LPN) 3 took the red stuffed animal lying on C2's chest and started playing and interacting with the client in a child-like manner. The LPN talked in a baby/child voice during the interaction.

During an interview on 10/03/25 at 3:25 PM, when asked about his/her interaction with C8, LPN3 stated he/she had only been employed by the facility for two days and he/she was not aware that interacting with C8 and playing with the client was not appropriate.

During an interview on 10/03/25 at 3:44 PM, Resident Aide (RA) 4 stated he/she had been employed at the facility for one year. The RA stated C8 carried his/her babydolls around all of the time and had a bunch in his/her room. When asked how old C8 was, RA4 stated the client was 34 years old. When asked if it was age appropriate for staff to interact and promote the use of children's toy when interacting with a 34 year old adult client, RA4 stated he/she had worked in a nursing home where it was common to see residents having babydolls. RA4 also stated if it made C2 happy, then the client should have the babydolls. RA4 further stated he/she was the person who turned the cartoons on for C8. RA4 stated he/she asked C8 if he/she wanted to watch cartoons, and C8 stated "yes." When asked if the client liked tv programs that were not cartoons, the RA stated yes and named some adult tv shows C8 enjoyed.

During an interview on 10/04/25 at 6:41 PM, the facility Director stated it was his/her expectation staff would have discouraged C8 from childlike socialization. The Director stated he/she had addressed this with the home's staff before; however, they did not understand not to encourage things that were not age appropriate for the client.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure staff encouraged and trained clients to use age-appropriate materials and not reinforce childlike socialization for one of eight sampled clients (Client (C) 8). C8 commonly had with him/her a babydoll; however, staff engaged in social interaction with the adult client in a childlike manner. This failure placed the client at risk for stigmatization and diminished opportunity for growth.

Findings include:

Review of the facility's policy titled, "Board of Directors Policy on Resident Rights," revised 08/2022, revealed, "It is the policy of [Facility Name] to provide age appropriate assistance to individuals who are admitted to [Facility Name] . . . Individual Rights Assessment . . . 1.Right to be treated as an adult and not be discriminated against based on race, religion, sex, age, or disability . . ."

Review of C8's "Comprehensive Functional Assessment (CFA)," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities.

Review of C8's "Individual Program Plan (IPP)," dated 02/20/25 and provided by the facility, revealed no documented evidence of any program objective encouraging age-appropriate socialization.

During an observation on 09/30/25 at 1:35 PM at the Health and Wellness Center, C8 was sitting in his/her wheelchair at the end of a table with peers. The client was not engaged in any meaningful activity and was holding a child's babydoll.

During an interview on 10/01/25 at 9:47 AM, when asked about C8 having a children's babydoll with him/her throughout the day, the Qualified Intellectual Disability Professional (QIDP) stated the client usually gets upset if it was taken away from him/her. The QIDP stated it was like his/her child and the babydoll's name was Butterly. The QIDP stated he/she saw the babydoll as an emotional support for the client. The QIDP stated it was not incorporated in C8's Individual Program Plan (IPP) to promote an age-appropriate environment and socialization as he/she saw C8 having the babydoll as emotionally supportive. When asked if there was anything in the client's IPP to support the rational of emotional support or that other more age-appropriate alternatives had been attempted, the QIDP stated "no."

During an observation on 10/03/25 at 3:11 PM of C8's medication administration, C8 was in the living area of the home with no other clients in the living area. C8 was in his/her wheelchair, reclined, and had two child toys, one being a babydoll and the other a red stuffed animal, and sitting in front of the television watching a cartoon (Sponge Bob). Licensed Practical Nurse (LPN) 3 took the red stuffed animal lying on C2's chest and started playing and interacting with the client in a child-like manner. The LPN talked in a baby/child voice during the interaction.

During an interview on 10/03/25 at 3:25 PM, when asked about his/her interaction with C8, LPN3 stated he/she had only been employed by the facility for two days and he/she was not aware that interacting with C8 and playing with the client was not appropriate.

During an interview on 10/03/25 at 3:44 PM, Resident Aide (RA) 4 stated he/she had been employed at the facility for one year. The RA stated C8 carried his/her babydolls around all of the time and had a bunch in his/her room. When asked how old C8 was, RA4 stated the client was 34 years old. When asked if it was age appropriate for staff to interact and promote the use of children's toy when interacting with a 34 year old adult client, RA4 stated he/she had worked in a nursing home where it was common to see residents having babydolls. RA4 also stated if it made C2 happy, then the client should have the babydolls. RA4 further stated he/she was the person who turned the cartoons on for C8. RA4 stated he/she asked C8 if he/she wanted to watch cartoons, and C8 stated "yes." When asked if the client liked tv programs that were not cartoons, the RA stated yes and named some adult tv shows C8 enjoyed.

During an interview on 10/04/25 at 6:41 PM, the facility Director stated it was his/her expectation staff would have discouraged C8 from childlike socialization. The Director stated he/she had addressed this with the home's staff before; however, they did not understand not to encourage things that were not age appropriate for the client.
W0148 COMMUNICATION WITH CLIENTS, PARENTS &
CFR(s): 483.420(c)(6)

The facility must notify promptly the client's parents or guardian of any significant incidents, or changes in the client's condition including, but not limited to, serious illness, accident, death, abuse, or unauthorized absence.


This STANDARD is not met as evidenced by:
The facility failed to ensure parents and/or guardians were notified of abuse or allegations of abuse for two of eight sampled clients (Client (C) 3 and C4). Both C3 and C4 were victims of abuse from their peers; however, notifications of the abuse were not made to the family/guardian.

Findings include:

Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment, revised 03/08/22, revealed, ". . . Abuse' Physical: Any assault by an employee upon an individual served and includes, but not limited to: hitting, kicking, pinching, slapping, or otherwise striking an individual or using excessive force regardless of whether an injury results . . ." The policy did not identify one client hitting another client as peer to peer abuse.

Review of the facility's policy titled, "Policy on Incident Reporting," revised 08/2022, revealed, "Significant incidents and actions taken involving [Facility's Name] residents must be reported and documented by the responsible staff on duty within 24 hours of the incident to the CEO [Chief Executive Officer] . . .A family member or representative of the resident must be informed by the Program manager, in consultation with CEO of the incident and actions taken by the staff at the earliest possible time . . . Suspected physical/sexual abuse, neglect, or exploitation, which may have reliably occurred, are to be reported and verified no later than 24 hours . . ."

1. Review of C2's "Comprehensive Functional Assessment (CFA)," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. The CFA identified client had a behavior support plan (BSP) and identified target behaviors of physical aggression, verbal aggression, and self-injurious behavior (SIB); however, through record review and interview, it was confirmed C2 did not have any type of behavior plan.

Review of C3's "Individual Program Plan (IPP)," dated 05/09/25 and provided by the facility, revealed the client was a 71 year old client who was admitted to the facility 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities.

Review of C2's " Therap (name of EMR system) Communication Log (T-Log)," note dated 09/09/25 and located in the client's electronic medical record (EMR) under the "T-Log" tab, revealed, "This afternoon at approximately 2:45 p.m. during Health and Wellness, [C2's name] exhibited ATO [aggression towards others] behavior and struck a peer on the right arm. The hit was not forceful; however, [C2's name] displayed signs of aggression and agitation."

Review of C3's "T-Log," note dated 09/09/25 and located in the client's EMR under the "T-Log" tab, revealed, "During Health and Wellness, [C3's name] was struck on the right arm by another

peer. [C3's name] did not report or display any signs of pain at the time of the incident. Staff monitored [him/her] and no further concerns were observed."

2. Review C4's "CFA," dated 12/12/24 and provided by the facility revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C3's "T-Log" note dated 09/18/25 and located in the client's EMR under the "T-Log" tab revealed "Overheard RA [Resident Aide] telling resident to go to room. Upon entering the dining room resident noted to be agitated and fussing at other resident and staff. Resident was instructed to go to room for cooling off period. Resident attempted to hit me with [his/her] elbow. Resident finally went to [his/her] room. When asked what happened another resident [C4] stated [he/she] [C3] hit me. PD [program director] and PC [program coordinator] notified."

During an interview on 10/02/25 at 1:07 PM, the facility Director stated he/she was not aware that a client hitting another client would be considered abuse. The Director stated the facility considered and documented that as ATO (aggression towards others). The facility Director confirmed the facility did not notify the client's parents/guardians of the peer to peer abuse.

The facility failed to ensure parents and/or guardians were notified of abuse or allegations of abuse for two of eight sampled clients (Client (C) 3 and C4). Both C3 and C4 were victims of abuse from their peers; however, notifications of the abuse were not made to the family/guardian.

Findings include:

Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment, revised 03/08/22, revealed, ". . . Abuse' Physical: Any assault by an employee upon an individual served and includes, but not limited to: hitting, kicking, pinching, slapping, or otherwise striking an individual or using excessive force regardless of whether an injury results . . ." The policy did not identify one client hitting another client as peer to peer abuse.

Review of the facility's policy titled, "Policy on Incident Reporting," revised 08/2022, revealed, "Significant incidents and actions taken involving [Facility's Name] residents must be reported and documented by the responsible staff on duty within 24 hours of the incident to the CEO [Chief Executive Officer] . . .A family member or representative of the resident must be informed by the Program manager, in consultation with CEO of the incident and actions taken by the staff at the earliest possible time . . . Suspected physical/sexual abuse, neglect, or exploitation, which may have reliably occurred, are to be reported and verified no later than 24 hours . . ."

1. Review of C2's "Comprehensive Functional Assessment (CFA)," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. The CFA identified client had a behavior support plan (BSP) and identified target behaviors of physical aggression, verbal aggression, and self-injurious behavior (SIB); however, through record review and interview, it was confirmed C2 did not have any type of behavior plan.

Review of C3's "Individual Program Plan (IPP)," dated 05/09/25 and provided by the facility, revealed the client was a 71 year old client who was admitted to the facility 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities.

Review of C2's " Therap (name of EMR system) Communication Log (T-Log)," note dated 09/09/25 and located in the client's electronic medical record (EMR) under the "T-Log" tab, revealed, "This afternoon at approximately 2:45 p.m. during Health and Wellness, [C2's name] exhibited ATO [aggression towards others] behavior and struck a peer on the right arm. The hit was not forceful; however, [C2's name] displayed signs of aggression and agitation."

Review of C3's "T-Log," note dated 09/09/25 and located in the client's EMR under the "T-Log" tab, revealed, "During Health and Wellness, [C3's name] was struck on the right arm by another

peer. [C3's name] did not report or display any signs of pain at the time of the incident. Staff monitored [him/her] and no further concerns were observed."

2. Review C4's "CFA," dated 12/12/24 and provided by the facility revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C3's "T-Log" note dated 09/18/25 and located in the client's EMR under the "T-Log" tab revealed "Overheard RA [Resident Aide] telling resident to go to room. Upon entering the dining room resident noted to be agitated and fussing at other resident and staff. Resident was instructed to go to room for cooling off period. Resident attempted to hit me with [his/her] elbow. Resident finally went to [his/her] room. When asked what happened another resident [C4] stated [he/she] [C3] hit me. PD [program director] and PC [program coordinator] notified."

During an interview on 10/02/25 at 1:07 PM, the facility Director stated he/she was not aware that a client hitting another client would be considered abuse. The Director stated the facility considered and documented that as ATO (aggression towards others). The facility Director confirmed the facility did not notify the client's parents/guardians of the peer to peer abuse.
W0149 STAFF TREATMENT OF CLIENTS
CFR(s): 483.420(d)(1)

The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client.


This STANDARD is not met as evidenced by:
Based on interview and review of the facility's abuse policy, the facility failed to ensure their abuse policy identified instances of peer to peer aggression as abuse to prohibit client abuse. This failure had the potential to affect all 15 clients who resided at the facility.

Findings include:

Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment," revised 03/08/22, revealed, ". . . Abuse' Physical: Any assault by an employee upon an individual served and includes, but not limited to: hitting, kicking, pinching, slapping, or otherwise striking an individual or using excessive force regardless of whether an injury results. Assault used in this definition implies intent. Physical injury, as used herein, is defined as impairment of physical condition or substantial pain . . . Neglect: Failure to carry out a duty through reckless conduct, carelessness, inattention, or disregard of duty whereby the individual served is exposed to harm or risk of harm, and includes, but is not limited to: failing to appropriately supervise individuals or otherwise leaving individuals served unattended, failing to ensure that an individual's basic needs for safety, nutrition, medical care and personal attention are met, failing to provide treatment in accordance with the individual support plan/person directed planning or failing to develop a program plan, and utilizing treatment techniques, restraints (unless authorized with express written consent to promote an individual's safety), seclusion (unless as. part of a behavior support plan and reviewed by the Human Rights

Committee), etc., in violation of standards, whether or not injury results . . ." The policy did not identify one client hitting another client as peer to peer abuse.

During an interview on 10/02/25 at 1:07 PM, the facility Director stated the facility did not consider a client being physically aggressive with another client as abuse. The facility considered it aggression towards others, which they deemed a behavior. The facility Director confirmed the facility's current abuse policy did not include peer to peer abuse as an example or in the definition of abuse.

Based on interview and review of the facility's abuse policy, the facility failed to ensure their abuse policy identified instances of peer to peer aggression as abuse to prohibit client abuse. This failure had the potential to affect all 15 clients who resided at the facility.

Findings include:

Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment," revised 03/08/22, revealed, ". . . Abuse' Physical: Any assault by an employee upon an individual served and includes, but not limited to: hitting, kicking, pinching, slapping, or otherwise striking an individual or using excessive force regardless of whether an injury results. Assault used in this definition implies intent. Physical injury, as used herein, is defined as impairment of physical condition or substantial pain . . . Neglect: Failure to carry out a duty through reckless conduct, carelessness, inattention, or disregard of duty whereby the individual served is exposed to harm or risk of harm, and includes, but is not limited to: failing to appropriately supervise individuals or otherwise leaving individuals served unattended, failing to ensure that an individual's basic needs for safety, nutrition, medical care and personal attention are met, failing to provide treatment in accordance with the individual support plan/person directed planning or failing to develop a program plan, and utilizing treatment techniques, restraints (unless authorized with express written consent to promote an individual's safety), seclusion (unless as. part of a behavior support plan and reviewed by the Human Rights

Committee), etc., in violation of standards, whether or not injury results . . ." The policy did not identify one client hitting another client as peer to peer abuse.

During an interview on 10/02/25 at 1:07 PM, the facility Director stated the facility did not consider a client being physically aggressive with another client as abuse. The facility considered it aggression towards others, which they deemed a behavior. The facility Director confirmed the facility's current abuse policy did not include peer to peer abuse as an example or in the definition of abuse.
W0153 STAFF TREATMENT OF CLIENTS
CFR(s): 483.420(d)(2)

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.


This STANDARD is not met as evidenced by:
The facility failed to ensure allegations and/or instances of abuse were immediately reported to the facility's Director and to the State Survey Agency (SSA) for two of eight sampled clients (Client (C) 3 and C4). Both C3 and C4 were victims of abuse from their peers. The facility's Director was not immediately notified nor was the SSA notified within 24 hours of the allegation/abuse. These failures place all 15 clients of the facility at risk for action not to be taken to prevent further abuse.

Findings include:

Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment," revised 03/08/22, revealed, ". . . Abuse' Physical: Any assault by an employee upon an individual served and includes, but not limited to: hitting, kicking, pinching, slapping, or otherwise striking an individual or using excessive force regardless of whether an injury results . . . Procedures for reporting and investigating: 1. All suspected incidents of abuse (physical or sexual), neglect, exploitation, or mistreatment, including all injuries of unknown sources, must be reported IMMEDIATELY to the Program Manager/QDDP [Qualified Developmental Disability Professional] or to your immediate supervisor . . ."

Review of the facility's "Abuse, Neglect, Mistreatment and Exploitation Training Document," revised 03/28/22, revealed, ". . . Procedures for Reporting and Investigating. All suspected incidents of abuse, neglect, exploitation, or mistreatment, including all injuries of unknown sources, must be reported IMMEDIATELY to the Program Director and/or your Direct Supervisor and/or the Chief Operating Officer Human Resources Director (COO/HRD) . . . The Program Director and COO/HRD will immediately report the allegations to the Alabama Department of Mental Health Development Disabilities Division (ADMFVDD) and to the Alabama Department of Human Resources (ADHR). All abuse and neglect which is criminal in nature, must also be reported as soon as possible, to local law enforcement. (i.e., Talladega Sheriff Department) . . ."

1. Review of C2's "Comprehensive Functional Assessment (CFA)," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. The CFA identified the client had a behavior support plan (BSP) and identified target behaviors of physical aggression, verbal aggression, and self-injurious behavior (SIB); however, through record review and interview, it was confirmed C2 did not have any type of behavior plan.

Review of C3's "Individual Program Plan (IPP)," dated 05/09/25 and provided by the facility, revealed the client was a 71 year old client who was admitted to the facility on 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities.

Review of C2's " Therap (name of electronic medical record system) Communication Log (T-Log)," note dated 09/09/25 and located in the client's electronic medical record (EMR) under the "T-Log" tab revealed "This afternoon at approximately 2:45 p.m. during Health and Wellness, [C2's name] exhibited ATO [aggression towards others] behavior and struck a peer on the right arm. The hit was not forceful; however, [C2's name] displayed signs of aggression and agitation."

Revie of C3's ")"T-Log" note, dated 09/09/25 and located in the client's EMR under the "T-Log" tab revealed "During Health and Wellness, [C3's name] was struck on the right arm by another peer. [C3's name] did not report or display any signs of pain at the time of the incident. Staff monitored [him/her] and no further concerns were observed."

2. Review C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C3's "T-Log" note, dated 09/18/25 and located in the client's EMR under the "T-Log" tab, revealed, "Overheard RA [Resident Aide] telling resident to go to room. Upon entering the dining room resident noted to be agitated and fussing at other resident and staff. Resident was instructed to go to room for cooling off period. Resident attempted to hit me with [his/her] elbow. Resident finally went to [his/her] room. When asked what happened another resident [C4] stated [he/she] [C3] hit me. PD [program director] and PC [program coordinator] notified."

During an interview on 10/02/25 at 1:07 PM, the facility Director stated he/she was not aware that a client hitting another client would be considered abuse. The Director stated the facility considered and documented that as ATO (aggression towards others). The facility Director confirmed the facility did not report the incidents as abuse to the SSA or other required entities.

The facility failed to ensure allegations and/or instances of abuse were immediately reported to the facility's Director and to the State Survey Agency (SSA) for two of eight sampled clients (Client (C) 3 and C4). Both C3 and C4 were victims of abuse from their peers. The facility's Director was not immediately notified nor was the SSA notified within 24 hours of the allegation/abuse. These failures place all 15 clients of the facility at risk for action not to be taken to prevent further abuse.

Findings include:

Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment," revised 03/08/22, revealed, ". . . Abuse' Physical: Any assault by an employee upon an individual served and includes, but not limited to: hitting, kicking, pinching, slapping, or otherwise striking an individual or using excessive force regardless of whether an injury results . . . Procedures for reporting and investigating: 1. All suspected incidents of abuse (physical or sexual), neglect, exploitation, or mistreatment, including all injuries of unknown sources, must be reported IMMEDIATELY to the Program Manager/QDDP [Qualified Developmental Disability Professional] or to your immediate supervisor . . ."

Review of the facility's "Abuse, Neglect, Mistreatment and Exploitation Training Document," revised 03/28/22, revealed, ". . . Procedures for Reporting and Investigating. All suspected incidents of abuse, neglect, exploitation, or mistreatment, including all injuries of unknown sources, must be reported IMMEDIATELY to the Program Director and/or your Direct Supervisor and/or the Chief Operating Officer Human Resources Director (COO/HRD) . . . The Program Director and COO/HRD will immediately report the allegations to the Alabama Department of Mental Health Development Disabilities Division (ADMFVDD) and to the Alabama Department of Human Resources (ADHR). All abuse and neglect which is criminal in nature, must also be reported as soon as possible, to local law enforcement. (i.e., Talladega Sheriff Department) . . ."

1. Review of C2's "Comprehensive Functional Assessment (CFA)," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. The CFA identified the client had a behavior support plan (BSP) and identified target behaviors of physical aggression, verbal aggression, and self-injurious behavior (SIB); however, through record review and interview, it was confirmed C2 did not have any type of behavior plan.

Review of C3's "Individual Program Plan (IPP)," dated 05/09/25 and provided by the facility, revealed the client was a 71 year old client who was admitted to the facility on 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities.

Review of C2's " Therap (name of electronic medical record system) Communication Log (T-Log)," note dated 09/09/25 and located in the client's electronic medical record (EMR) under the "T-Log" tab revealed "This afternoon at approximately 2:45 p.m. during Health and Wellness, [C2's name] exhibited ATO [aggression towards others] behavior and struck a peer on the right arm. The hit was not forceful; however, [C2's name] displayed signs of aggression and agitation."

Revie of C3's ")"T-Log" note, dated 09/09/25 and located in the client's EMR under the "T-Log" tab revealed "During Health and Wellness, [C3's name] was struck on the right arm by another peer. [C3's name] did not report or display any signs of pain at the time of the incident. Staff monitored [him/her] and no further concerns were observed."

2. Review C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C3's "T-Log" note, dated 09/18/25 and located in the client's EMR under the "T-Log" tab, revealed, "Overheard RA [Resident Aide] telling resident to go to room. Upon entering the dining room resident noted to be agitated and fussing at other resident and staff. Resident was instructed to go to room for cooling off period. Resident attempted to hit me with [his/her] elbow. Resident finally went to [his/her] room. When asked what happened another resident [C4] stated [he/she] [C3] hit me. PD [program director] and PC [program coordinator] notified."

During an interview on 10/02/25 at 1:07 PM, the facility Director stated he/she was not aware that a client hitting another client would be considered abuse. The Director stated the facility considered and documented that as ATO (aggression towards others). The facility Director confirmed the facility did not report the incidents as abuse to the SSA or other required entities.
W0154 STAFF TREATMENT OF CLIENTS
CFR(s): 483.420(d)(3)

The facility must have evidence that all alleged violations are thoroughly investigated.


This STANDARD is not met as evidenced by:
The facility failed to ensure allegations and/or instances of abuse were investigated for two of eight sampled clients (Client (C) 3 and C4). It was witnessed that C3 was abused by his/her peer, and C4 alleged that a peer hit him/her. Neither of these instances were investigated as abuse. These failures place all 15 clients at risk of being victims of abuse with no corrective action due to the facility not completing the investigations.

Findings include:

Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment, revised 03/08/22, revealed, ". . . 3. The Program Manager/QDDP will direct the Safety Committee to thoroughly investigate the allegations pursuant to [Facility's Name] Policy on Significant Incidents . . . 7. The Investigation Report must be submitted to the CEO [Chief Executive Office] and the Program Manager/QDDP [Qualified Developmental Disability Professional] within five (5) working days following the incident . . ."

Review of the facility's "Abuse, Neglect, Mistreatment and Exploitation Training Document," revised 03/28/22, revealed, ". . . Procedures for Reporting and Investigating . . . 3. The Program Director will report the suspected incident to the Chief Operating Officer Human Resources Director (COO/HRD) who will report the suspected incident to the Chief Executive Officer (CEO) and direct the Quality Enhancement Director to immediately conduct an investigation of the reported incident and to thoroughly investigate the allegations pursuant to the ROI Policy on Significant Incidents . . . 5. The Investigation Report must be submitted to the CEO, COO/HRD and the Program Director within five (5) working days following the incident. 6. The Program Director will report the results of the investigation to the ADMTI/DD [Admissions/Direct Supports for Individuals with Mental Illness/Developmental Disabilities] . . ."

1. Review of C2's "Comprehensive Functional Assessment (CFA)," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type and impulse disorder. The CFA identified client had a behavior support plan (BSP) and identified target behaviors of physical aggression, verbal aggression, and self-injurious behavior (SIB); however, through record review and interview, it was confirmed C2 did not have any type of behavior plan.

Review of C3's "Individual Program Plan (IPP)," dated 05/09/25 and provided by the facility, revealed the client was a 71 year old client who was admitted to the facility on 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities.

Review of C2's "Therap (name of electronic medical record system) Communication Log (T-Log)" note, dated 09/09/25 and located in the client's electronic medical record (EMR) under the "T-Log" tab, revealed, "This afternoon at approximately 2:45 p.m. during Health and Wellness, [C2's name] exhibited ATO [aggression towards others] behavior and struck a peer on the right arm. The hit was not forceful; however, [C2's name] displayed signs of aggression and agitation."

Revie of C3's "T-Log" note, dated 09/09/25 and located in the client's EMR under the "T-Log" tab, revealed, "During Health and Wellness, [C3's name] was struck on the right arm by another

peer. [C3's name] did not report or display any signs of pain at the time of the incident. Staff monitored [him/her] and no further concerns were observed."

2. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client and admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C3's "T-Log" note, dated 09/18/25 and located in the client's EMR under the "T-Log" tab, revealed, "Overheard RA [Resident Aide] telling resident to go to room. Upon entering the dining room resident noted to be agitated and fussing at other resident and staff. Resident was instructed to go to room for cooling off period. Resident attempted to hit me with [his/her] elbow. Resident finally went to [his/her] room. When asked what happened another resident [C4] stated [he/she] [C3] hit me. PD [program director] and PC [program coordinator] notified."

During an interview on 10/02/25 at 1:07 PM, the facility Director stated he/she was not aware that a client hitting another client would be considered abuse. The Director stated the facility considered and documented that as ATO (aggression towards others). The facility Director confirmed the facility did not investigate the incidents as abuse.

The facility failed to ensure allegations and/or instances of abuse were investigated for two of eight sampled clients (Client (C) 3 and C4). It was witnessed that C3 was abused by his/her peer, and C4 alleged that a peer hit him/her. Neither of these instances were investigated as abuse. These failures place all 15 clients at risk of being victims of abuse with no corrective action due to the facility not completing the investigations.

Findings include:

Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment, revised 03/08/22, revealed, ". . . 3. The Program Manager/QDDP will direct the Safety Committee to thoroughly investigate the allegations pursuant to [Facility's Name] Policy on Significant Incidents . . . 7. The Investigation Report must be submitted to the CEO [Chief Executive Office] and the Program Manager/QDDP [Qualified Developmental Disability Professional] within five (5) working days following the incident . . ."

Review of the facility's "Abuse, Neglect, Mistreatment and Exploitation Training Document," revised 03/28/22, revealed, ". . . Procedures for Reporting and Investigating . . . 3. The Program Director will report the suspected incident to the Chief Operating Officer Human Resources Director (COO/HRD) who will report the suspected incident to the Chief Executive Officer (CEO) and direct the Quality Enhancement Director to immediately conduct an investigation of the reported incident and to thoroughly investigate the allegations pursuant to the ROI Policy on Significant Incidents . . . 5. The Investigation Report must be submitted to the CEO, COO/HRD and the Program Director within five (5) working days following the incident. 6. The Program Director will report the results of the investigation to the ADMTI/DD [Admissions/Direct Supports for Individuals with Mental Illness/Developmental Disabilities] . . ."

1. Review of C2's "Comprehensive Functional Assessment (CFA)," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type and impulse disorder. The CFA identified client had a behavior support plan (BSP) and identified target behaviors of physical aggression, verbal aggression, and self-injurious behavior (SIB); however, through record review and interview, it was confirmed C2 did not have any type of behavior plan.

Review of C3's "Individual Program Plan (IPP)," dated 05/09/25 and provided by the facility, revealed the client was a 71 year old client who was admitted to the facility on 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities.

Review of C2's "Therap (name of electronic medical record system) Communication Log (T-Log)" note, dated 09/09/25 and located in the client's electronic medical record (EMR) under the "T-Log" tab, revealed, "This afternoon at approximately 2:45 p.m. during Health and Wellness, [C2's name] exhibited ATO [aggression towards others] behavior and struck a peer on the right arm. The hit was not forceful; however, [C2's name] displayed signs of aggression and agitation."

Revie of C3's "T-Log" note, dated 09/09/25 and located in the client's EMR under the "T-Log" tab, revealed, "During Health and Wellness, [C3's name] was struck on the right arm by another

peer. [C3's name] did not report or display any signs of pain at the time of the incident. Staff monitored [him/her] and no further concerns were observed."

2. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client and admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C3's "T-Log" note, dated 09/18/25 and located in the client's EMR under the "T-Log" tab, revealed, "Overheard RA [Resident Aide] telling resident to go to room. Upon entering the dining room resident noted to be agitated and fussing at other resident and staff. Resident was instructed to go to room for cooling off period. Resident attempted to hit me with [his/her] elbow. Resident finally went to [his/her] room. When asked what happened another resident [C4] stated [he/she] [C3] hit me. PD [program director] and PC [program coordinator] notified."

During an interview on 10/02/25 at 1:07 PM, the facility Director stated he/she was not aware that a client hitting another client would be considered abuse. The Director stated the facility considered and documented that as ATO (aggression towards others). The facility Director confirmed the facility did not investigate the incidents as abuse.
W0158 FACILITY STAFFING
CFR(s): 483.430

The facility must ensure that specific facility staffing requirements are met.


This CONDITION is not met as evidenced by:
Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure qualified staff were employed or contracted by the facility when they failed to have a Qualified Intellectual and Disability Professional (QIDP) who met all regulatory requirements of the position and who ensured clients received the provision of services to meet each clients' needs, which included continuous and aggressive active treatment and behavior health supports. The failure to have an effective QIDP negatively impacted all 15 clients who resided at the facility.

On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures related to the QIDP constituted Immediate Jeopardy. It was determined the Immediate Jeopardy existed on 03/18/25 when an unqualified QIDP was placed in the QIDP position.

The facility presented an acceptable plan of removal on 10/04/25 at 2:35 PM.

The facility's removal plan included:

1. The facility Director and a part-time Qualified Intellectual and Disability Professional (QIDP) will cover the functions of a QIDP until a candidate who meets the minimum requirements is hired.

2. The facility Director and part-time QIDP will complete an updated Comprehensive Functional Assessment (CFA), including having the vocational section completed by a qualified individual on all 15 clients who reside at the facility.

3. The facility is in the process of developing a day treatment program to fit each clients' need based on the CFA to ensure all 15 clients who reside at the facility receive continuous active treatment.

4. The facility Director has consulted with a Board-Certified Behavior Analyst (BCBA) to complete a comprehensive behavior assessment on C2.

Through observation, interview, and record review, the survey team validated all components of the removal plan were implemented, and the Immediate Jeopardy was removed effective 10/04/25 at 6:15 PM.

Findings include:

1. The Qualified Intellectual Disability Professional (QIDP), who was not qualified for the position, failed to ensure clients' Individual Program Plans (IPPs) were monitored quarterly with data to support progression or regression, including documented observation of clients during program implementation for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). Additionally, the QIDP failed to promote competent interactions of residential staff when he/she received notification of C2 engaging in high frequency episodes of self-injurious behavior (SIB) and did not ensure the client had the needed behavior supports. C2 sustained harm for SIBs. These failures placed all 15 clients of the home at risk for not receiving the services needed for their active treatment program. Cross Reference: W159.

2. The facility failed to ensure they employed a QIDP who had at least one year of experience working with persons with intellectual disability or other development disabilities. This failure placed all 15 clients of the facility at risk of not receiving the programs and supports for aggressive active treatment to retain skills or obtain new skills for a meaningful and independent quality of life. Cross Reference: W160.

3. The facility failed to ensure the QIDP ensured clients received coordinated program services and supports for aggressive active treatment and adaptive behaviors for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, C8). Also, the facility failed to ensure the Comprehensive Functional Assessment included an appropriate vocational assessment which identified skills or needed skills to maintain or obtain and implemented in a day training program. Additionally, the QIDP was aware of C2's high frequency in SIB; however, the QIDP failed to ensure the client received behavioral services to reduce the client's behavior and the client sustained actual harm. These failures placed all 15 clients at risk of regression in skills and impeded their ability to obtain new skills for a meaningful and independent quality of life as possible. Cross Reference: W164.

4. The facility failed to ensure direct care staff received formal training on each clients' IPP objectives for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, C8). The failure to receive formal training by the author of each clients' written objective placed the clients at risk of the program objective not being properly implemented. Cross Reference: W169.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure qualified staff were employed or contracted by the facility when they failed to have a Qualified Intellectual and Disability Professional (QIDP) who met all regulatory requirements of the position and who ensured clients received the provision of services to meet each clients' needs, which included continuous and aggressive active treatment and behavior health supports. The failure to have an effective QIDP negatively impacted all 15 clients who resided at the facility.

On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures related to the QIDP constituted Immediate Jeopardy. It was determined the Immediate Jeopardy began on 03/18/25 when an unqualified QIDP was placed in the QIDP position.

Findings include:

1. The Qualified Intellectual Disability Professional (QIDP), who was not qualified for the position, failed to ensure clients' Individual Program Plans (IPPs) were monitored quarterly with data to support progression or regression, including documented observation of clients during program implementation for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). Additionally, the QIDP failed to promote competent interactions of residential staff when he/she received notification of C2 engaging in high frequency episodes of self-injurious behavior (SIB) and did not ensure the client had the needed behavior supports. C2 sustained harm for SIBs. These failures placed all 15 clients of the home at risk for not receiving the services needed for their active treatment program. Cross Reference: W159.

2. The facility failed to ensure they employed a QIDP who had at least one year of experience working with persons with intellectual disability or other development disabilities. This failure placed all 15 clients of the facility at risk of not receiving the programs and supports for aggressive active treatment to retain skills or obtain new skills for a meaningful and independent quality of life. Cross Reference: W160.

3. The facility failed to ensure the QIDP ensured clients received coordinated program services and supports for aggressive active treatment and adaptive behaviors for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, C8). Also, the facility failed to ensure the Comprehensive Functional Assessment included an appropriate vocational assessment which identified skills or needed skills to maintain or obtain and implemented in a day training program. Additionally, the QIDP was aware of C2's high frequency in SIB; however, the QIDP failed to ensure the client received behavioral services to reduce the client's behavior and the client sustained actual harm. These failures placed all 15 clients at risk of regression in skills and impeded their ability to obtain new skills for a meaningful and independent quality of life as possible. Cross Reference: W164.

4. The facility failed to ensure direct care staff received formal training on each clients' IPP objectives for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, C8). The failure to receive formal training by the author of each clients' written objective placed the clients at risk of the program objective not being properly implemented. Cross Reference: W169.

The facility presented an acceptable plan of removal on 10/04/25 at 2:35 PM.

The facility's removal plan included:

1. The facility Director and a part-time Qualified Intellectual and Disability Professional (QIDP) will cover the functions of a QIDP until a candidate who meets the minimum requirements is hired.

2. The facility Director and part-time QIDP will complete an updated Comprehensive Functional Assessment (CFA), including having the vocational section completed by a qualified individual on all 15 clients who reside at the facility.

3. The facility is in the process of developing a day treatment program to fit each clients' need based on the CFA to ensure all 15 clients who reside at the facility receive continuous active treatment.

4. The facility Director has consulted with a Board-Certified Behavior Analyst (BCBA) to complete a comprehensive behavior assessment on C2.

Through observation, interview, and record review, the survey team validated all components of the removal plan were implemented, and the Immediate Jeopardy was removed effective 10/04/25.
W0159 QIDP
CFR(s): 483.430(a)

Each client's active treatment program must be integrated, coordinated and monitored by a qualified intellectual disability professional who-


This STANDARD is not met as evidenced by:
Based on observation, interview, record review, and review of the facility's policy, the Qualified Intellectual Disability Professional (QIDP), who was not qualified for the position, failed to ensure clients' Individual Program Plans (IPPs) were monitored quarterly with data to support progression or regression including documented observation of clients during program implementation for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). Additionally, the QIDP failed to promote competent interactions of residential staff when he/she received notification of C2 engaging in high frequency episodes of self-injurious behavior (SIB) and did not ensure the client had the needed behavior supports. C2 sustained harm for SIBs. These failures placed all 15 clients of the home at risk for not receiving the services needed for their active treatment program.

Findings include:

Review of the facility's job description for the QIDP titled, "ICF/IID QIDP- Qualified Intellectual Disability Professional," revised 02/17/25, revealed, "Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: Duties. Responsible for integrating, coordinating, and monitoring active treatment plans (IPPS). This includes the following responsibilities: Train all staff on active treatment plans (IPPs), Manage a training binder with signatures, Monitoring staff implementation of active treatment plans . . . Respond to all t-logs related to behaviors and major/minor incidents. Complete quarterly summaries of each individual's overall progress to review with families/program director. Maintain a binder with Quarterly Information for each individual . . . Conducts monitoring of direct care staff to ensure correct methods are followed for achieving goals as outlined in all resident ' s treatment plan . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) as well as any behavior support plan (BSP), psychotropic medication plan, or other support systems (e.g., educational opportunities, employment services, activity programs, meal programs, safety programs, and transportation services) . . ."

1. Review of C1's "CFA," dated 05/011/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post traumatic stress disorder (PTSD).

Review of C1's annual "IPP," provided by the facility revealed it was completed on 05/2025. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's interdisciplinary team (IDT).

Review of C1's "QIDP Binder" and C1's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C1's electronic medical record (EMR) revealed no documented evidence of quarterly progress notes completed by the QIDP.

2. Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder.

Review of C2's annual "IPP," provided by the facility, revealed the annual IPP was completed on 11/21/24. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT. Additionally, there were no special team meeting notes or quarterly progress notes of C2's increase of behaviors including the high frequency of SIB episodes.

Review of C2's "QIDP Binder" and C2's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C2's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

3. Review of C3's annual "IPP," provided by the facility, revealed the annual IPP was completed on 05/09/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C3's "QIDP Binder" and C3's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C3's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

4. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C4's annual "IPP," provided by the facility, revealed the annual IPP was completed on 12/12/24. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C4's "QIDP Binder" and C4's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C4's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

5. Review of C5's annual "IPP," provided by the facility, revealed the annual IPP was completed on 08/20/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C5's "QIDP Binder" and C5's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C5's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

6. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder.

Review of C6's annual "IPP," provided by the facility revealed the annual IPP was completed on 02/06/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C6's "QIDP Binder" and C6's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C6's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

7. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities.

Review of C7's "IPP," provided by the facility, revealed the annual IPP was completed on 07/10/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C7's "QIDP Binder" and C7s program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C7's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

8. Review of C8's "CFA," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities.

Review of C8's "IPP," provided by the facility, revealed the annual IPP was completed on 02/20/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C8's "QIDP Binder" and C8's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C8's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

During an interview on 10/01/25 at 9:47 AM, when asked where the monthly and/or quarterly meeting progress notes could be found, the QIDP stated he/she had been working on the binders and that was why all the clients' binders were in his/her office. The QIDP stated he/she would be off the rest of the week on vacation; however, the surveyor would be able to access the binders in his/her office and all the information needed would be in the binders. The QIDP stated he/she was working on getting the binders caught up before he/she left for the day.

During an interview on 10/04/25 at 6:41 PM, the facility Director stated it was his/her expectation that the IPP trainings to staff and monitoring of the implementation would have been completed by the QIDP. The Director confirmed the binders containing the monitoring notes were not up to date.

Based on observation, interview, record review, and review of the facility's policy, the Qualified Intellectual Disability Professional (QIDP), who was not qualified for the position, failed to ensure clients' Individual Program Plans (IPPs) were monitored quarterly with data to support progression or regression including documented observation of clients during program implementation for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). Additionally, the QIDP failed to promote competent interactions of residential staff when he/she received notification of C2 engaging in high frequency episodes of self-injurious behavior (SIB) and did not ensure the client had the needed behavior supports. C2 sustained harm for SIBs. These failures placed all 15 clients of the home at risk for not receiving the services needed for their active treatment program.

Findings include:

Review of the facility's job description for the QIDP titled, "ICF/IID QIDP- Qualified Intellectual Disability Professional," revised 02/17/25, revealed, "Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: Duties. Responsible for integrating, coordinating, and monitoring active treatment plans (IPPS). This includes the following responsibilities: Train all staff on active treatment plans (IPPs), Manage a training binder with signatures, Monitoring staff implementation of active treatment plans . . . Respond to all t-logs related to behaviors and major/minor incidents. Complete quarterly summaries of each individual's overall progress to review with families/program director. Maintain a binder with Quarterly Information for each individual . . . Conducts monitoring of direct care staff to ensure correct methods are followed for achieving goals as outlined in all resident ' s treatment plan . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) as well as any behavior support plan (BSP), psychotropic medication plan, or other support systems (e.g., educational opportunities, employment services, activity programs, meal programs, safety programs, and transportation services) . . ."

1. Review of C1's "CFA," dated 05/011/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post traumatic stress disorder (PTSD).

Review of C1's annual "IPP," provided by the facility revealed it was completed on 05/2025. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's interdisciplinary team (IDT).

Review of C1's "QIDP Binder" and C1's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C1's electronic medical record (EMR) revealed no documented evidence of quarterly progress notes completed by the QIDP.

2. Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder.

Review of C2's annual "IPP," provided by the facility, revealed the annual IPP was completed on 11/21/24. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT. Additionally, there were no special team meeting notes or quarterly progress notes of C2's increase of behaviors including the high frequency of SIB episodes.

Review of C2's "QIDP Binder" and C2's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C2's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

3. Review of C3's annual "IPP," provided by the facility, revealed the annual IPP was completed on 05/09/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C3's "QIDP Binder" and C3's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C3's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

4. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C4's annual "IPP," provided by the facility, revealed the annual IPP was completed on 12/12/24. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C4's "QIDP Binder" and C4's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C4's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

5. Review of C5's annual "IPP," provided by the facility, revealed the annual IPP was completed on 08/20/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C5's "QIDP Binder" and C5's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C5's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

6. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder.

Review of C6's annual "IPP," provided by the facility revealed the annual IPP was completed on 02/06/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C6's "QIDP Binder" and C6's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C6's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

7. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities.

Review of C7's "IPP," provided by the facility, revealed the annual IPP was completed on 07/10/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C7's "QIDP Binder" and C7s program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C7's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

8. Review of C8's "CFA," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities.

Review of C8's "IPP," provided by the facility, revealed the annual IPP was completed on 02/20/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C8's "QIDP Binder" and C8's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C8's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

During an interview on 10/01/25 at 9:47 AM, when asked where the monthly and/or quarterly meeting progress notes could be found, the QIDP stated he/she had been working on the binders and that was why all the clients' binders were in his/her office. The QIDP stated he/she would be off the rest of the week on vacation; however, the surveyor would be able to access the binders in his/her office and all the information needed would be in the binders. The QIDP stated he/she was working on getting the binders caught up before he/she left for the day.

During an interview on 10/04/25 at 6:41 PM, the facility Director stated it was his/her expectation that the IPP trainings to staff and monitoring of the implementation would have been completed by the QIDP. The Director confirmed the binders containing the monitoring notes were not up to date.
W0160 QIDP
CFR(s): 483.430(a)(1)

The qualified mental retardation professional has at least one year of experience working directly with persons with mental retardation or other developmental disabilities.


This STANDARD is not met as evidenced by:
Based on interview, employee record review, review of employee job description, and review of the facility's policy, the facility failed to employ a Qualified Intellectual Disability Professional (QIDP) who had at least one year of experience working with persons with intellectual disability or other development disabilities. This failure placed all 15 clients of the facility at risk of not receiving the programs and supports for aggressive active treatment to retain skills or obtain new skills for a meaningful and independent quality of life.

Findings include:

Review of the facility's job description titled, "ICF/IID QIDP-Qualified Intellectual Disability Professional," dated 02/17/25, revealed, ". . . Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) . . . experience . . . including at least two years working with persons with developmental disabilities . . ."

Review of the facility's policy titled, "Individual Rights Handbook," dated 08/2022, revealed the clients had the right to ". . . QIDP . . . the person who arranges services to meet your needs and helps you achieve your goals . . ."

Review of the facility's QIDP employee file revealed no documented evidence under the work experience of the QIDP's application of any work experience of working with and/or in an intellectual disability setting.

During an interview on 10/01/25 at 9:47 AM, the QIDP stated he/she started the position on 03/18/25. The QIDP stated his/her previous work experiences included working at a religious home in which there were children removed from their homes by social services. The QIDP stated there were no children in this home with intellectual disabilities. The QIDP stated in addition, he/she worked as a substitute teacher in the special needs department but only worked approximately 50 days. The QIDP stated he/she had an adult son with intellectual disabilities and was told by the facility that he/she was qualified for the position.

During an interview on 10/04/25 at 6:41 PM, the facility Director stated he/she was not aware the QIDP was not qualified. The Director stated he/she was misled by the QIDP and the references who spoke of his/her ability to work with individuals with intellectual disabilities.

Based on interview, employee record review, review of employee job description, and review of the facility's policy, the facility failed to employ a Qualified Intellectual Disability Professional (QIDP) who had at least one year of experience working with persons with intellectual disability or other development disabilities. This failure placed all 15 clients of the facility at risk of not receiving the programs and supports for aggressive active treatment to retain skills or obtain new skills for a meaningful and independent quality of life.

Findings include:

Review of the facility's job description titled, "ICF/IID QIDP-Qualified Intellectual Disability Professional," dated 02/17/25, revealed, ". . . Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) . . . experience . . . including at least two years working with persons with developmental disabilities . . ."

Review of the facility's policy titled, "Individual Rights Handbook," dated 08/2022, revealed the clients had the right to ". . . QIDP . . . the person who arranges services to meet your needs and helps you achieve your goals . . ."

Review of the facility's QIDP employee file revealed no documented evidence under the work experience of the QIDP's application of any work experience of working with and/or in an intellectual disability setting.

During an interview on 10/01/25 at 9:47 AM, the QIDP stated he/she started the position on 03/18/25. The QIDP stated his/her previous work experiences included working at a religious home in which there were children removed from their homes by social services. The QIDP stated there were no children in this home with intellectual disabilities. The QIDP stated in addition, he/she worked as a substitute teacher in the special needs department but only worked approximately 50 days. The QIDP stated he/she had an adult son with intellectual disabilities and was told by the facility that he/she was qualified for the position.

During an interview on 10/04/25 at 6:41 PM, the facility Director stated he/she was not aware the QIDP was not qualified. The Director stated he/she was misled by the QIDP and the references who spoke of his/her ability to work with individuals with intellectual disabilities.
W0164 PROFESSIONAL PROGRAM SERVICES
CFR(s): 483.430(b)(1)

Each client must receive the professional program services needed to implement the active treatment program defined by each client's individual program plan.


This STANDARD is not met as evidenced by:
Based on interview, record review, and review of the facility's policy, the facility failed to ensure a Qualified Intellectual Disability Professional (QIDP) ensured clients received coordinated program services and supports for aggressive active treatment and adaptive behaviors for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, C8). Also, the facility failed to ensure the Comprehensive Functional Assessment (CFA) included an appropriate vocational assessment which identified skills or needed skills to maintain or obtain and be implemented in a day training program. Additionally, the QIDP was aware of C2's high frequency in Self-Injurious Behavior (SIB); however, the QIDP failed to ensure the client received behavioral services to reduce the client's behavior and the client sustained actual harm. These failures placed all 15 clients at risk of regression in skills and impeded their ability to obtain new skills for a meaningful and independent quality of life as possible.

Findings include:

Review of the facility's job description titled, "ICF/IID QIDP-Qualified Intellectual Disability Professional," dated 02/17/25, revealed, ". . . Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: Duties: -Responsible for integrating, coordinating, and monitoring active treatment plans (IPPS [individual Program Plans]) -Manage a training binder with signatures . . . Respond to all t-logs related to behaviors and major/minor incidents . . . Participates in guidance and educational programs to obtain a working knowledge of all policies, standards, and regulations to maintain compliance. Conducts in-service trainings for all ICF/IID direct care staff on each resident ' s active care plans; works with ICF/IID staff on methods of collecting data and achieving goals as outlined in care plans. Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) as well as any behavior support plan (BSP), psychotropic medication plan, or other support systems (e.g., educational opportunities, employment services, activity programs, meal programs, safety programs, and transportation services) . . . Presents new and revised IPP ' s and BSP ' s with rights restrictions to HRC for review and approval . . . Reviews all rules and regulations of the licensing and certifying agencies regarding ICF/IID resident care, staffing requirements and all other applicable standards and assists the ICF/IID Program Director with ensuring that the ICF/IID ' s are in compliance . . . Coordinates all other support systems and related services for residents on assigned caseload . . ."

1. Review of C1's "Comprehensive Functional Assessment (CFA)," dated 05/011/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post-traumatic stress disorder (PTSD). Continued review of C1's CFA revealed, ". . . Vocational Skills: There are no plans for [C1's Name] to participate in the vocational program. [C1's Name] enjoys doing things like answering the phone and helping with paperwork. We will be asking and assisting [him/her] in things that [he/she] can do to be involved in the process in the ICF. [C1's Name] would love to make bracelets and sell them to others. [His/Her] dream is to make enough that [he/she] can donate bracelets to the Cancer floor at the children's hospital . . ." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional.

During an interview on 10/01/25 at 12:25 PM, C1 stated he/she would love to have a job on the facility's campus. C1 stated currently he/she bought materials with his/her own money to make bracelets and tried to sell them on his/her own. C1 stated he/she could see himself/herself working in the community as a door greeter at a department store such as Walmart. C1 further stated it was very important to him/her to have and live an independent life as he/she could.

During an interview on 09/30/25 at 1:45 PM, when asked about the facility's vocational program, the QIDP stated the facility did not have or focus on "vocational training." The QIDP stated they just try and keep the clients involved in activities and games. The QIDP stated a lot of the clients who resided at the facility wanted to work. When asked why the clients were not given the opportunity to work, the QIDP stated the reason he/she was given was because the residential work location staff would not be able to provide the clients with toileting assistance. When asked about C1, the QIDP stated C1 really wanted a job in the community, and he/she would love to be able to just have a job. The QIDP further stated independence was very important to C1 and that his/her independence is not restricted.

2. Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. Continued review of C2's CFA revealed, ". . . Vocational Skills: [C2's] name no longer attends the workshop due to [his/her] behavioral issues and [his/her] desire to go to the Wellness Center instead. [He/She] was not able to concentrate on the work-short attention span and had stopped being productive in workshop setting. [He/She] attends the [Facility Name] activities center every afternoon Monday-Friday. At the Activity Center, [he/she] receives training in the informal areas of gross motor, fine motor, social skills, cognitive and sensory skills, and money skills . . ." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional staff; and did not identify any behavioral supports to assist the client in a vocational setting.

Continued review of C2's "CFA," revealed the CFA identified the client had a behavior support plan (BSP) and identified target behaviors of physical aggression, verbal aggression, and self-injurious behavior (SIB).

Review of C2's EMR and paper medical record revealed no documented evidence of an active plan for behavior supports.

During an interview on 10/01/25 at 3:50 PM, when asked about C2's BSP, the QIDP stated the client did not have any type of behavior plan at this time. The QIDP stated there should have been a BSP a long time ago. The QIDP also confirmed there had not been any behavior functional assessments completed to his/her knowledge. The QIDP further stated he/she was not aware that the QIDP position was the person responsible for ensuring clients receive all of the services they needed including behavior support services.

3. Review of C3's electronic medical record (EMR) and paper medical record revealed no documented evidence that the QIDP completed or ensured that a CFA had been completed on the client in the past year. C3's Individual Program Plan (IPP) was completed on 05/09/25.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed he/she could not locate an up to date CFA for C3. The Director stated QIDP was on vacation; however, he/she communicated with the QIDP and still could not locate the CFA.

4. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities. Continued review of the CFA revealed the QIDP failed to complete the vocational assessment section of the client's CFA.

5. Review of C5's EMR and paper medical record revealed no documented evidence that the QIDP completed or ensured that a CFA had been completed on the client in the past year. C5's IPP was completed on 08/20/25.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed he/she could not locate an up to date CFA for C5. The Director stated QIDP was on vacation; however, he/she communicated with the QIDP and still could not locate the CFA.

6. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder. Continued review of the CFA revealed, ". . . Vocational Skills. [C6's Name] has not shown an interest in attending the workshop and when afforded the opportunity to do so, [he/she] did not focus on the tasks at hand. Due to [C6's name] lack of interest in a workshop, [his/her] inability to focus on tasks, and [his/her] need of constant supervision, [he/she] is more suited for the ICF/IID Health and Wellness setting. At the ICF and HWC [Health and Wellness Center] [he/she] is able to engage in activities [he/she] enjoys but also serves to improve [his/her] current functional limitations. [He/She] attends Health and Wellness Center generally 2-3 days per week ..." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional staff. Additionally, the vocational assessment indicated C6 was afforded the opportunity to attend a "workshop;" however, the facility did not have a workshop in place.

7. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities. Continued review of the CFA revealed the QIDP failed to complete the vocational assessment section of the client's CFA.

During an interview on 09/30/25 at 5:02 PM, when asked if he/she worked here at the facility, C7 stated "No." When asked if he/she had ever worked at the facility doing a job, C7 stated he/she stated "yes," that he/she answered phones at the Wellness Center. When asked why he/she no longer did that job, C7 stated "I don ' t know." The client stated he/she missed working. When asked why he/she missed it, C7 stated because he/she made money.

9. Review of C8's "CFA," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities. Continued review of the CFA revealed, ". . . Vocational Skills. [C8's Name] is unable to perform work tasks available at the sheltered workshop. Due to [his/her] physical limitations, placement in the vocational setting is not recommended at this time. [He/She] attends the activity center at he Health and Wellness Center where [he/she] is able to engage in activities [he/she] enjoys, do physical/ROM [range of motion] exercises, and work on skills to improve [his/her] current level of functioning . . ." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional staff. Additionally, the vocational assessment indicated the facility had a sheltered workshop; however, it had been verified there were no workshops or vocational programs at the facility.

During an interview on 10/01/25 at 8:06 AM, RA3 stated he/she had been employed by the facility for five years. RA3 stated the facility at one time had different programming which included vocational training and jobs for the clients. RA3 stated he/she believed C7 used to have a job in a vocational setting at the facility at one time. RA3 also stated C1 wanted to have a job where he/she could make money. The RA stated being independent and making his/her own money was very important to C1.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure a Qualified Intellectual Disability Professional (QIDP) ensured clients received coordinated program services and supports for aggressive active treatment and adaptive behaviors for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, C8). Also, the facility failed to ensure the Comprehensive Functional Assessment (CFA) included an appropriate vocational assessment which identified skills or needed skills to maintain or obtain and be implemented in a day training program. Additionally, the QIDP was aware of C2's high frequency in Self-Injurious Behavior (SIB); however, the QIDP failed to ensure the client received behavioral services to reduce the client's behavior and the client sustained actual harm. These failures placed all 15 clients at risk of regression in skills and impeded their ability to obtain new skills for a meaningful and independent quality of life as possible.

Findings include:

Review of the facility's job description titled, "ICF/IID QIDP-Qualified Intellectual Disability Professional," dated 02/17/25, revealed, ". . . Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: Duties: -Responsible for integrating, coordinating, and monitoring active treatment plans (IPPS [individual Program Plans]) -Manage a training binder with signatures . . . Respond to all t-logs related to behaviors and major/minor incidents . . . Participates in guidance and educational programs to obtain a working knowledge of all policies, standards, and regulations to maintain compliance. Conducts in-service trainings for all ICF/IID direct care staff on each resident ' s active care plans; works with ICF/IID staff on methods of collecting data and achieving goals as outlined in care plans. Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) as well as any behavior support plan (BSP), psychotropic medication plan, or other support systems (e.g., educational opportunities, employment services, activity programs, meal programs, safety programs, and transportation services) . . . Presents new and revised IPP ' s and BSP ' s with rights restrictions to HRC for review and approval . . . Reviews all rules and regulations of the licensing and certifying agencies regarding ICF/IID resident care, staffing requirements and all other applicable standards and assists the ICF/IID Program Director with ensuring that the ICF/IID ' s are in compliance . . . Coordinates all other support systems and related services for residents on assigned caseload . . ."

1. Review of C1's "Comprehensive Functional Assessment (CFA)," dated 05/011/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post-traumatic stress disorder (PTSD). Continued review of C1's CFA revealed, ". . . Vocational Skills: There are no plans for [C1's Name] to participate in the vocational program. [C1's Name] enjoys doing things like answering the phone and helping with paperwork. We will be asking and assisting [him/her] in things that [he/she] can do to be involved in the process in the ICF. [C1's Name] would love to make bracelets and sell them to others. [His/Her] dream is to make enough that [he/she] can donate bracelets to the Cancer floor at the children's hospital . . ." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional.

During an interview on 10/01/25 at 12:25 PM, C1 stated he/she would love to have a job on the facility's campus. C1 stated currently he/she bought materials with his/her own money to make bracelets and tried to sell them on his/her own. C1 stated he/she could see himself/herself working in the community as a door greeter at a department store such as Walmart. C1 further stated it was very important to him/her to have and live an independent life as he/she could.

During an interview on 09/30/25 at 1:45 PM, when asked about the facility's vocational program, the QIDP stated the facility did not have or focus on "vocational training." The QIDP stated they just try and keep the clients involved in activities and games. The QIDP stated a lot of the clients who resided at the facility wanted to work. When asked why the clients were not given the opportunity to work, the QIDP stated the reason he/she was given was because the residential work location staff would not be able to provide the clients with toileting assistance. When asked about C1, the QIDP stated C1 really wanted a job in the community, and he/she would love to be able to just have a job. The QIDP further stated independence was very important to C1 and that his/her independence is not restricted.

2. Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. Continued review of C2's CFA revealed, ". . . Vocational Skills: [C2's] name no longer attends the workshop due to [his/her] behavioral issues and [his/her] desire to go to the Wellness Center instead. [He/She] was not able to concentrate on the work-short attention span and had stopped being productive in workshop setting. [He/She] attends the [Facility Name] activities center every afternoon Monday-Friday. At the Activity Center, [he/she] receives training in the informal areas of gross motor, fine motor, social skills, cognitive and sensory skills, and money skills . . ." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional staff; and did not identify any behavioral supports to assist the client in a vocational setting.

Continued review of C2's "CFA," revealed the CFA identified the client had a behavior support plan (BSP) and identified target behaviors of physical aggression, verbal aggression, and self-injurious behavior (SIB).

Review of C2's EMR and paper medical record revealed no documented evidence of an active plan for behavior supports.

During an interview on 10/01/25 at 3:50 PM, when asked about C2's BSP, the QIDP stated the client did not have any type of behavior plan at this time. The QIDP stated there should have been a BSP a long time ago. The QIDP also confirmed there had not been any behavior functional assessments completed to his/her knowledge. The QIDP further stated he/she was not aware that the QIDP position was the person responsible for ensuring clients receive all of the services they needed including behavior support services.

3. Review of C3's electronic medical record (EMR) and paper medical record revealed no documented evidence that the QIDP completed or ensured that a CFA had been completed on the client in the past year. C3's Individual Program Plan (IPP) was completed on 05/09/25.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed he/she could not locate an up to date CFA for C3. The Director stated QIDP was on vacation; however, he/she communicated with the QIDP and still could not locate the CFA.

4. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities. Continued review of the CFA revealed the QIDP failed to complete the vocational assessment section of the client's CFA.

5. Review of C5's EMR and paper medical record revealed no documented evidence that the QIDP completed or ensured that a CFA had been completed on the client in the past year. C5's IPP was completed on 08/20/25.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed he/she could not locate an up to date CFA for C5. The Director stated QIDP was on vacation; however, he/she communicated with the QIDP and still could not locate the CFA.

6. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder. Continued review of the CFA revealed, ". . . Vocational Skills. [C6's Name] has not shown an interest in attending the workshop and when afforded the opportunity to do so, [he/she] did not focus on the tasks at hand. Due to [C6's name] lack of interest in a workshop, [his/her] inability to focus on tasks, and [his/her] need of constant supervision, [he/she] is more suited for the ICF/IID Health and Wellness setting. At the ICF and HWC [Health and Wellness Center] [he/she] is able to engage in activities [he/she] enjoys but also serves to improve [his/her] current functional limitations. [He/She] attends Health and Wellness Center generally 2-3 days per week ..." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional staff. Additionally, the vocational assessment indicated C6 was afforded the opportunity to attend a "workshop;" however, the facility did not have a workshop in place.

7. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities. Continued review of the CFA revealed the QIDP failed to complete the vocational assessment section of the client's CFA.

During an interview on 09/30/25 at 5:02 PM, when asked if he/she worked here at the facility, C7 stated "No." When asked if he/she had ever worked at the facility doing a job, C7 stated he/she stated "yes," that he/she answered phones at the Wellness Center. When asked why he/she no longer did that job, C7 stated "I don ' t know." The client stated he/she missed working. When asked why he/she missed it, C7 stated because he/she made money.

9. Review of C8's "CFA," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities. Continued review of the CFA revealed, ". . . Vocational Skills. [C8's Name] is unable to perform work tasks available at the sheltered workshop. Due to [his/her] physical limitations, placement in the vocational setting is not recommended at this time. [He/She] attends the activity center at he Health and Wellness Center where [he/she] is able to engage in activities [he/she] enjoys, do physical/ROM [range of motion] exercises, and work on skills to improve [his/her] current level of functioning . . ." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional staff. Additionally, the vocational assessment indicated the facility had a sheltered workshop; however, it had been verified there were no workshops or vocational programs at the facility.

During an interview on 10/01/25 at 8:06 AM, RA3 stated he/she had been employed by the facility for five years. RA3 stated the facility at one time had different programming which included vocational training and jobs for the clients. RA3 stated he/she believed C7 used to have a job in a vocational setting at the facility at one time. RA3 also stated C1 wanted to have a job where he/she could make money. The RA stated being independent and making his/her own money was very important to C1.
W0169 PROFESSIONAL PROGRAM SERVICES
CFR(s): 483.430(b)(4)

Professional program staff must participate in on-going staff development and training in both formal and informal settings with other professional, paraprofessional, and nonprofessional staff members.


This STANDARD is not met as evidenced by:
Based on record review, interview, and review of the facility's policy, the facility failed to ensure direct care staff received formal training on each clients' Individual Program Plan (IPP) objectives for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, C8). The failure to receive formal training by the author of each clients' written objective placed the clients at risk of the program objectives not being properly implemented.

Findings include:

Review of the facility's undated policy titled, "Individual Program Planning," revealed, ". . . QDDP [QIDP (Qualified Intellectual Disability Professional)] The monitor is the person who sees that the program is carried out as scheduled and is responsible for seeing that a quarterly summary of progress is completed . . . The QDDP is responsible for developing a PCP for each individual participating in ROI programs. Specific goals and objectives will be established on an on-going basis and prioritized by the individual or their guardian. These will be developed in coordination with the individual, [his/her] parents/guardian - unless excluded by a legally competent individual, ROI residential staff, vocational staff, and consultants when necessary . . ."

Review of the facility's "Job Title: ICF/IID QIDP-Qualified Intellectual Disability Professional (QIDP)," revised 02/17/25, revealed, ". . . Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: Duties. Responsible for integrating, coordinating, and monitoring active treatment plans (IPPS). This includes the following responsibilities: Train all staff on active treatment plans (IPPs) . . . Conducts in-service trainings for all ICF/IID direct care staff on each resident ' s active care plans; works with ICF/IID staff on methods of collecting data and achieving goals as outlined in care plans . . ."

1. Review of C1's "Individual Program Plan (IPP)," provided by the facility, revealed the date of completion was 05/20/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

2. Review of C2's "IPP," provided by the facility, revealed the date of completion was 11/21/24. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

3. Review of C3's "IPP," provided by the facility, revealed the date of completion was 05/09/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

4. Review of C4's "IPP," provided by the facility, revealed the date of completion was 12/12/24. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

5. Review of C5's "IPP," provided by the facility, revealed the date of completion was 08/20/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

6. Review of C6's "IPP," provided by the facility, revealed the date of completion was 02/06/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

7. Review of C7's "IPP," provided by the facility, revealed the date of completion was 07/10/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

8. Review of C8's "IPP," provided by the facility, revealed the date of completion was 02/20/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

During an interview on 10/01/25 at 8:06 PM, when asked if he/she had been trained on the clients' current program objectives they are working on with the client in the home, Resident Aide (RA) 3 stated they used to receive training from the QIDP on each training objective and would have to sign a sheet for the training; however, that had not happened in some time. The RA stated it had probably been over a year.

During an interview on 10/01/25 at 6:15 PM, RA2 stated he/she had not received any type of training on the clients' objectives they are working on with the clients; however, he/she could see the objectives in the facilities EMR to read how to implement. The RA stated it had been a long time since anyone has come in and actually trained them on the objectives.

During an interview on 10/04/25 at 6:41 PM, the facility Director stated it was his/her expectation the QIDP would have completed formal training for all staff on each clients' IPP objectives. The Director stated the QIDP was the person responsible for completing the training.

Based on record review, interview, and review of the facility's policy, the facility failed to ensure direct care staff received formal training on each clients' Individual Program Plan (IPP) objectives for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, C8). The failure to receive formal training by the author of each clients' written objective placed the clients at risk of the program objectives not being properly implemented.

Findings include:

Review of the facility's undated policy titled, "Individual Program Planning," revealed, ". . . QDDP [QIDP (Qualified Intellectual Disability Professional)] The monitor is the person who sees that the program is carried out as scheduled and is responsible for seeing that a quarterly summary of progress is completed . . . The QDDP is responsible for developing a PCP for each individual participating in ROI programs. Specific goals and objectives will be established on an on-going basis and prioritized by the individual or their guardian. These will be developed in coordination with the individual, [his/her] parents/guardian - unless excluded by a legally competent individual, ROI residential staff, vocational staff, and consultants when necessary . . ."

Review of the facility's "Job Title: ICF/IID QIDP-Qualified Intellectual Disability Professional (QIDP)," revised 02/17/25, revealed, ". . . Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: Duties. Responsible for integrating, coordinating, and monitoring active treatment plans (IPPS). This includes the following responsibilities: Train all staff on active treatment plans (IPPs) . . . Conducts in-service trainings for all ICF/IID direct care staff on each resident ' s active care plans; works with ICF/IID staff on methods of collecting data and achieving goals as outlined in care plans . . ."

1. Review of C1's "Individual Program Plan (IPP)," provided by the facility, revealed the date of completion was 05/20/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

2. Review of C2's "IPP," provided by the facility, revealed the date of completion was 11/21/24. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

3. Review of C3's "IPP," provided by the facility, revealed the date of completion was 05/09/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

4. Review of C4's "IPP," provided by the facility, revealed the date of completion was 12/12/24. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

5. Review of C5's "IPP," provided by the facility, revealed the date of completion was 08/20/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

6. Review of C6's "IPP," provided by the facility, revealed the date of completion was 02/06/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

7. Review of C7's "IPP," provided by the facility, revealed the date of completion was 07/10/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

8. Review of C8's "IPP," provided by the facility, revealed the date of completion was 02/20/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives.

During an interview on 10/01/25 at 8:06 PM, when asked if he/she had been trained on the clients' current program objectives they are working on with the client in the home, Resident Aide (RA) 3 stated they used to receive training from the QIDP on each training objective and would have to sign a sheet for the training; however, that had not happened in some time. The RA stated it had probably been over a year.

During an interview on 10/01/25 at 6:15 PM, RA2 stated he/she had not received any type of training on the clients' objectives they are working on with the clients; however, he/she could see the objectives in the facilities EMR to read how to implement. The RA stated it had been a long time since anyone has come in and actually trained them on the objectives.

During an interview on 10/04/25 at 6:41 PM, the facility Director stated it was his/her expectation the QIDP would have completed formal training for all staff on each clients' IPP objectives. The Director stated the QIDP was the person responsible for completing the training.
W0195 ACTIVE TREATMENT SERVICES
CFR(s): 483.440

The facility must ensure that specific active treatment services requirements are met.


This CONDITION is not met as evidenced by:
Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure clients were provided a continuous and aggressive active treatment program which included a day training program. The facility failed to have all facets for clients to obtain and maintain the independence and autonomy to live a normal adult life. These failures negatively impacted all 15 clients who resided at the facility.

On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures constituted Immediate Jeopardy related to the facility's failure to have a continuous and aggressive active treatment program.. It was determined the Immediate Jeopardy existed on 07/14/23 when the facility failed to provide an active day training program.

The facility presented an acceptable plan of removal of the Immediate Jeopardy on 10/04/25 at 2:35 PM.

The facility's removal plan included:

1. The facility Director and a part-time Qualified Intellectual and Disability Professional (QIDP) will cover the functions of a QIDP until a candidate who meets the minimum requirements is hired.

2. The facility Director and part-time QIDP will complete an updated Comprehensive Functional Assessment (CFA), including having the vocational section completed by a qualified individual on all 15 clients who reside at the facility.

3. The facility is in the process of developing a day treatment program to fit each clients' need based on the CFA to ensure all 15 clients who reside at the facility receive continuous active treatment.

4. The facility Director has consulted with a Board-Certified Behavior Analyst (BCBA) to ensure clients have the behavior supports and services needed including having a comprehensive behavioral assessment to determine if and what behavioral supports clients may need.

Through interview and record review, the survey team validated the facility began the implementation of all components of the removal plan, and the Immediately Jeopardy was removed on 10/04/25 at 6:15 PM.

Findings include:

1. The facility failed to ensure each client received a continuous and aggressive active treatment program to acquire behaviors and skills to live an independent life as possible that mirrored a normal living experience as much as possible for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility failed to have a Qualified Intellectual Disability Professional (QIDP) to ensure the facility had a day training program for the clients to obtain or maintain vocational skills and promote vocational readiness with an on the job training program, and/or other program bases on a Comprehensive Functional Assessment (CFA) completed by a person or persons with the competency needed to complete all sections of the CFA including the Vocational section. Thes failures negatively impacted all 15 clients of the facility. Cross Reference: W196.

2. The facility failed to ensure the comprehensive functional assessment (CFA) for one of eight clients (Client (C) 2) addressed specific behavioral supports needed to address aggressive behavior towards himself/herself or others. The Qualified Intellectual Disability Professional (QIDP) was aware of C2's high frequency in self-injurious behavior (SIB) and physical aggression towards others; however, the CFA did not include a functional behavioral assessment or a referral for a functional behavioral assessment completed by a qualifying professional. This failure impaired C2's everyday life and the client was neglected during SIB episodes, which eventually caused actual harm to the client. Cross Reference: W214.

3. The facility failed to ensure the CFA included an individualized vocational assessment for all domains for what skills clients can and cannot do and addressed job sampling, job development, on-site job training, and long term follow-up for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility did not have a day training program for clients to be able to be properly assessed, learn new skills, and maintain the skills they have. This failure had the potential to negatively impact all 15 clients who resided at the facility. Cross Reference: W225.

4. The facility failed to ensure the Human Rights Committee (HRC) approved all client restrictions before the restrictions were imposed for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The clients did not have freedom of movement to access common areas of their home. Clients were restricted from their kitchen; and the clients' front door to their home was equipped with delayed egress locking hardware and required a key code to exit. These restrictions were not taken before the HRC, and clients were not afforded due process. Additionally, the right restrictions approved by the HRC and identified in the clients' CFA did not include a behavior plan which included a rights restoration plan. These restrictions affected all 15 clients who resided in the home. Cross Reference: W262.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure clients were provided a continuous and aggressive active treatment program which included a day training program. The facility failed to have all facets for clients to obtain and maintain the independence and autonomy to live a normal adult life. These failures negatively impacted all 15 clients who resided at the facility.

On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures constituted Immediate Jeopardy related to the facility's failure to have a continuous and aggressive active treatment program.. It was determined the Immediate Jeopardy existed on 07/14/23 when the facility failed to provide an active day training program.

Findings include:

1. The facility failed to ensure each client received a continuous and aggressive active treatment program to acquire behaviors and skills to live an independent life as possible that mirrored a normal living experience as much as possible for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility failed to have a Qualified Intellectual Disability Professional (QIDP) to ensure the facility had a day training program for the clients to obtain or maintain vocational skills and promote vocational readiness with an on the job training program, and/or other program bases on a Comprehensive Functional Assessment (CFA) completed by a person or persons with the competency needed to complete all sections of the CFA including the Vocational section. Thes failures negatively impacted all 15 clients of the facility. Cross Reference: W196.

2. The facility failed to ensure the comprehensive functional assessment (CFA) for one of eight clients (Client (C) 2) addressed specific behavioral supports needed to address aggressive behavior towards himself/herself or others. The Qualified Intellectual Disability Professional (QIDP) was aware of C2's high frequency in self-injurious behavior (SIB) and physical aggression towards others; however, the CFA did not include a functional behavioral assessment or a referral for a functional behavioral assessment completed by a qualifying professional. This failure impaired C2's everyday life and the client was neglected during SIB episodes, which eventually caused actual harm to the client. Cross Reference: W214.

3. The facility failed to ensure the CFA included an individualized vocational assessment for all domains for what skills clients can and cannot do and addressed job sampling, job development, on-site job training, and long term follow-up for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility did not have a day training program for clients to be able to be properly assessed, learn new skills, and maintain the skills they have. This failure had the potential to negatively impact all 15 clients who resided at the facility. Cross Reference: W225.

4. The facility failed to ensure the Human Rights Committee (HRC) approved all client restrictions before the restrictions were imposed for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The clients did not have freedom of movement to access common areas of their home. Clients were restricted from their kitchen; and the clients' front door to their home was equipped with delayed egress locking hardware and required a key code to exit. These restrictions were not taken before the HRC, and clients were not afforded due process. Additionally, the right restrictions approved by the HRC and identified in the clients' CFA did not include a behavior plan which included a rights restoration plan. These restrictions affected all 15 clients who resided in the home. Cross Reference: W262.

**********************************

The facility presented an acceptable plan of removal of the Immediate Jeopardy on 10/04/25 at 2:35 PM.

The facility's removal plan included:

1. The facility Director and a part-time Qualified Intellectual and Disability Professional (QIDP) will cover the functions of a QIDP until a candidate who meets the minimum requirements is hired.

2. The facility Director and part-time QIDP will complete an updated Comprehensive Functional Assessment (CFA), including having the vocational section completed by a qualified individual on all 15 clients who reside at the facility.

3. The facility is in the process of developing a day treatment program to fit each clients' need based on the CFA to ensure all 15 clients who reside at the facility receive continuous active treatment.

4. The facility Director has consulted with a Board-Certified Behavior Analyst (BCBA) to ensure clients have the behavior supports and services needed including having a comprehensive behavioral assessment to determine if and what behavioral supports clients may need.

Through interview and record review, the survey team validated the facility began the implementation of all components of the removal plan, and the Immediately Jeopardy was removed on 10/04/25.
W0196 ACTIVE TREATMENT
CFR(s): 483.440(a)(1)

Each client must receive a continuous active treatment program, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services described in this subpart, that is directed toward: (i) The acquisition of the behaviors necessary for the client to function with as much self determination and independence as possible; and (ii) The prevention or deceleration of regression or loss of current optimal functional status.


This STANDARD is not met as evidenced by:
Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure each client received a continuous and aggressive active treatment program to acquire behaviors and skills to live an independent life as possible that mirrored a normal living experience as possible for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility failed to have a Qualified Intellectual Disability Professional (QIDP) to ensure the facility had a day training program for the clients to obtain or maintain vocational skills and promote vocational readiness with an on the job training program, and/or other program bases on a Comprehensive Functional Assessment (CFA) completed by a person or persons with the competency needed to complete all sections of the CFA including the Vocational section. Thes failures negatively impacted all 15 clients of the facility.

Findings include:

Review of the facility's job description for the QIDP titled, "ICF/IID QIDP- Qualified Intellectual Disability Professional," revised 02/17/25, revealed, "Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: Duties. Responsible for integrating, coordinating, and monitoring active treatment plans (IPPS). This includes the following responsibilities: Train all staff on active treatment plans (IPPs), Manage a training binder with signatures, Monitoring staff implementation of active treatment plans . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) . . . or other support systems (e.g., educational opportunities, employment services, activity programs, meal programs, safety programs, and transportation services) . . ."

1. Review of C1's "CFA," dated 05/01/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post traumatic stress disorder (PTSD). The CFA documented C1's desire to be independent as possible including working to make money and to be able to exercise his/her independence to socialize and independently visit with friends who live on campus; however, the facility's lack of programing that was meaningful to C1 impeded the client from self-determination.

Review of C1's "Individual Program Plan (IPP)," dated 05/01/25 and provided by the facility, revealed, ". . . What are [his/her] daily routines? Morning: 6:30 [am]-wake up, get dressed. 7:30-breakfast, brush teeth, take a shower, 8:00-take meds, 9:00-11:30- HWC [Health and Wellness Center], 11:30-1:30 [pm]- lunch. Afternoon: 1:30-HWC for activities and goal training, 3:30-return to house . . ." The IPP did not incorporate in C1's schedule a day training program where goals and objectives meaningful to him/her were implemented.

2. Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. The CFA documented under the "Vocational Skills" section that C2 no longer participated in the workshop due to the client's behavioral issues. The CFA documented the client was no longer able to concentrate and had short attention span; however, it did not identify other alternatives attempted or other work areas such as a less stimulating environment to complete his/her task.

Review of C2's "IPP," dated 11/21/24 and provided by the facility, revealed, ". . . What are [his/her] daily routines? Morning: 6:30 [am]-wake up, get dressed, 7:00-shower, 730-breakfast, chores, meds, 9:00-11:00 HWC, 10:30-hydration/snack, 11:00 home for lunch. Afternoon: 12:00 [pm]- brush teeth, 1:30-3:30 HWC for activities, 2:30-hydration break, 3:30-return home . . ."

During an observation on 09/30/25 at 1:35 PM of the HWC, C2 was sitting in a chair at table with several peers. C2 had his/her hands over his/her ears. Staff attempted to get C2 to engage in writing something on a paper fan. C2 appeared to become over stimulated and began engaging in SIB. The QIDP asked C2 if he/she wanted to go home. The QIDP did not attempt to assist the client to a less stimulating environment to work on any task. The HWC was one open room and there were approximately 20 clients from both ICF facilities. The clients were not engaged in any meaningful active treatment or programing.

3. Review of C3's electronic medical record (EMR) and paper medical record revealed no documented evidence that a CFA had been completed in the past year.

Review of C3's "IPP," dated 05/09/25 and provided by the facility, revealed the client was a 71 year old client who was admitted to the facility 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities. The IPP also revealed, ". . . What are [his/her] daily routines? Morning: 6:00 wake up, toilet, get dressed, 7:30-breakfast, brush teeth, meds, 900-Health and Wellness Activities, 10:30-Hydration, 11:30-Lunch. Afternoon: 1:00-return to HWC (activities and goal training), 3:00-retun home, 4:30-dinner, watch television/movies/leisure time . . . Summary of Employment and Educational Background/Vocational History . . . Describe [his/her] employment history: [C2's Name] worked on Honda parts . . . Past years vocational progress: Vocational goals prior to moving into ICF . . . Counting 30 e-lids, setting up/using and replacing [his/her] foot stool, increasing [his/her] earning by 5% and navigating to employment site on computer . . . Employment goals: No Vocational goals as [he/she] now attends Health and Wellness Center . . ." There is no opportunity for the client to work or other vocational opportunities as the facility no longer has a day training program.

During an observation on 09/30/25 at 1:33 PM at the HWC, C3 was sitting at a table with several of his/her peers. C3 stated he/she was waiting on a fan so he/she could sign his/her name. The client's schedule had him/her arriving at the HWC at 1:00 PM indicating the client had not been engaged in meaningful active treatment since arriving.

4. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C4's "IPP," dated 12/12/24 and provided by the facility, revealed, ". . . F. What are [his/her] daily routines? Morning: 6:00-wake, shower, 7:30-breakfast, meds, brush teeth, 10:00-break, 11:00 lunch. Afternoon: 1:00 go to HWC, 3:00-return home . . . Summary of Employment and Educational Background/Vocational History . . . Describe [his/her] educational history: Pre-vocational program, Competitive employment part time at Auburn Hotel and Dixon Conference, and sheltered workshop at [facility name] . . . Past year's vocational progress: Discharged from the Vocational Program 04/30/21 . . ." The IPP indicated the client was very independent with most daily tasks and activities of daily living (ADLs); however, the client is not receiving any type of skills training or afforded the opportunity to use his/her strength of independence in an aggressive active treatment program.

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5. Review of C5's EMR and paper medical record revealed no documented evidence a CFA had been completed in the past year.

Review of C5's "IPP," dated 08/20/25 and provided by the facility, revealed the client was a 44 year old client who was admitted to the facility on 08/06/14 with diagnoses which included Wolf-Hirschhorn Syndrome, profound intellectual disabilities, and epilepsy. The IPP also revealed, ". . . F. What are [his/her] daily routines? Morning: 7:15AM- Get up cleanup/bath, dressed, 8:00AM-First Feeding-peg tube (take meds with feeding); brush teeth during waiting intervals. 10:15-10:30 AM-return to bed and check brief, 11:30-Second feeding-peg tube (take meds with feeding); check brief. Afternoon: 1:00 PM-Health and Wellness Center, 2:30PM-Lie Down, 4:00 PM-third feeding-peg tube and check brief . . ." The schedule did not include any type of meaningful active treatment or other type of training program.

6. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder.

Review of C6's "IPP," dated 02/06/25 and provided by the facility, revealed, ". . . F. What are [his/her] daily routines? Morning: 6:00 AM-Wake up, shower and get dresses, 7:30-breakfast, 8:00-take meds, 9:00-go to HWC, 11:30-Return to [facility home name] for lunch. Afternoon: 12:30-brush teeth, 1:00 Go to HWC center, 4:00 return to house . . ."

During an interview on 10/03/25 at 1:11 PM, Family Member (F) 6 stated the facility used to have better programs than what they do now. F6 stated this morning he/she went to the HWC with C6. F6 stated there were several clients in the building from both facilities and they played one game of bingo with the clients and then all the clients sat there doing nothing while staff talked to each other. F6 stated C6 did not even like bingo. When asked if C6 would be interested in learning a new skill for vocational or work, F6 stated C6 could not work a real job. When asked if C6 could complete tasks independently or even with staff help of something like stringing a bead on a string, or moving items from one place to another, F6 stated "Yes, that would be good for [him/her]." F6 stated C6 did help with laundry in the home by pushing the laundry cart to the laundry room door. F6 stated he/she wished the facility would bring back the programming like they once had.

7. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities.

Review of C7's "IPP," dated 07/10/25 and provided by the facility, revealed, ". . . F. What are [his/her] daily routines? Morning: 6:00-Wake up, shower, dress, 7:30-breakfast, ears cleaned, medications, 9:00 -Go to HWC, 11"30-lunch, brush teeth. Afternoon: 1:00 go to HWC, 4:00-return to [home name] for dinner . . ."

During an interview on 09/30/25 at 5:02 PM, when asked if he/she worked or had a job at the facility, C7 stated "No." When asked if he/she had ever worked since he/she had been at the facility, C7 stated "Yes." C7 stated he/she answered phones for the wellness center at one time. When asked why he/she did not work there anymore, C7 stated "I don ' t know." When asked if he/she missed working, C7 stated "Yes." C7 stated he/she missed working because he/she made money.

8. Review of C8's "CFA," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities.

Review of C8's "IPP," dated 02/20/25 and provided by the facility, revealed, ". . .F. What are [his/her] daily routines? Morning: 6:00-wake up, shower, and get dressed. 7:30-breakfast, brush teeth, meds, 9:00-Health and Wellness Activities, 10:30 Hydration, 11:30/12:00-lunch and meds, and personal grooming. Afternoon: 1:00-return to HWC for activities and goal training, 3:00 return to house, 4:30-dinner, watch tv/movies, leisure . . ." C8's activity schedule did not include any training programing due to facility not having a day training program.

The facility did not have a day training program and only activities and games were offered to the clients each day.

During an interview on 09/30/25 at 1:45 PM, the QIDP stated the facility did not focus on any type of vocational training for the clients. The QIDP stated the facility just tried to keep the clients involved in games and activities. The QIDP also stated that a lot of the clients wanted to work.

During an interview on 10/01/25 at 3:50 PM, when asked how often the CFA was to be completed or updated, the QIDP stated he/she thought the CFA was to be completed annually. When asked again about the Vocational section of the CFA, the QIDP stated he/she did not complete or ensure a vocational assessment was completed because even though at least 50 percent of the clients of the facility wanted to work or learn skills, the facility did not have a day program to teach these skills or jobs the clients could work.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed the facility did not have a day program for the clients.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure each client received a continuous and aggressive active treatment program to acquire behaviors and skills to live an independent life as possible that mirrored a normal living experience as possible for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility failed to have a Qualified Intellectual Disability Professional (QIDP) to ensure the facility had a day training program for the clients to obtain or maintain vocational skills and promote vocational readiness with an on the job training program, and/or other program bases on a Comprehensive Functional Assessment (CFA) completed by a person or persons with the competency needed to complete all sections of the CFA including the Vocational section. Thes failures negatively impacted all 15 clients of the facility.

Findings include:

Review of the facility's job description for the QIDP titled, "ICF/IID QIDP- Qualified Intellectual Disability Professional," revised 02/17/25, revealed, "Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: Duties. Responsible for integrating, coordinating, and monitoring active treatment plans (IPPS). This includes the following responsibilities: Train all staff on active treatment plans (IPPs), Manage a training binder with signatures, Monitoring staff implementation of active treatment plans . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) . . . or other support systems (e.g., educational opportunities, employment services, activity programs, meal programs, safety programs, and transportation services) . . ."

1. Review of C1's "CFA," dated 05/01/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post traumatic stress disorder (PTSD). The CFA documented C1's desire to be independent as possible including working to make money and to be able to exercise his/her independence to socialize and independently visit with friends who live on campus; however, the facility's lack of programing that was meaningful to C1 impeded the client from self-determination.

Review of C1's "Individual Program Plan (IPP)," dated 05/01/25 and provided by the facility, revealed, ". . . What are [his/her] daily routines? Morning: 6:30 [am]-wake up, get dressed. 7:30-breakfast, brush teeth, take a shower, 8:00-take meds, 9:00-11:30- HWC [Health and Wellness Center], 11:30-1:30 [pm]- lunch. Afternoon: 1:30-HWC for activities and goal training, 3:30-return to house . . ." The IPP did not incorporate in C1's schedule a day training program where goals and objectives meaningful to him/her were implemented.

2. Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. The CFA documented under the "Vocational Skills" section that C2 no longer participated in the workshop due to the client's behavioral issues. The CFA documented the client was no longer able to concentrate and had short attention span; however, it did not identify other alternatives attempted or other work areas such as a less stimulating environment to complete his/her task.

Review of C2's "IPP," dated 11/21/24 and provided by the facility, revealed, ". . . What are [his/her] daily routines? Morning: 6:30 [am]-wake up, get dressed, 7:00-shower, 730-breakfast, chores, meds, 9:00-11:00 HWC, 10:30-hydration/snack, 11:00 home for lunch. Afternoon: 12:00 [pm]- brush teeth, 1:30-3:30 HWC for activities, 2:30-hydration break, 3:30-return home . . ."

During an observation on 09/30/25 at 1:35 PM of the HWC, C2 was sitting in a chair at table with several peers. C2 had his/her hands over his/her ears. Staff attempted to get C2 to engage in writing something on a paper fan. C2 appeared to become over stimulated and began engaging in SIB. The QIDP asked C2 if he/she wanted to go home. The QIDP did not attempt to assist the client to a less stimulating environment to work on any task. The HWC was one open room and there were approximately 20 clients from both ICF facilities. The clients were not engaged in any meaningful active treatment or programing.

3. Review of C3's electronic medical record (EMR) and paper medical record revealed no documented evidence that a CFA had been completed in the past year.

Review of C3's "IPP," dated 05/09/25 and provided by the facility, revealed the client was a 71 year old client who was admitted to the facility 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities. The IPP also revealed, ". . . What are [his/her] daily routines? Morning: 6:00 wake up, toilet, get dressed, 7:30-breakfast, brush teeth, meds, 900-Health and Wellness Activities, 10:30-Hydration, 11:30-Lunch. Afternoon: 1:00-return to HWC (activities and goal training), 3:00-retun home, 4:30-dinner, watch television/movies/leisure time . . . Summary of Employment and Educational Background/Vocational History . . . Describe [his/her] employment history: [C2's Name] worked on Honda parts . . . Past years vocational progress: Vocational goals prior to moving into ICF . . . Counting 30 e-lids, setting up/using and replacing [his/her] foot stool, increasing [his/her] earning by 5% and navigating to employment site on computer . . . Employment goals: No Vocational goals as [he/she] now attends Health and Wellness Center . . ." There is no opportunity for the client to work or other vocational opportunities as the facility no longer has a day training program.

During an observation on 09/30/25 at 1:33 PM at the HWC, C3 was sitting at a table with several of his/her peers. C3 stated he/she was waiting on a fan so he/she could sign his/her name. The client's schedule had him/her arriving at the HWC at 1:00 PM indicating the client had not been engaged in meaningful active treatment since arriving.

4. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C4's "IPP," dated 12/12/24 and provided by the facility, revealed, ". . . F. What are [his/her] daily routines? Morning: 6:00-wake, shower, 7:30-breakfast, meds, brush teeth, 10:00-break, 11:00 lunch. Afternoon: 1:00 go to HWC, 3:00-return home . . . Summary of Employment and Educational Background/Vocational History . . . Describe [his/her] educational history: Pre-vocational program, Competitive employment part time at Auburn Hotel and Dixon Conference, and sheltered workshop at [facility name] . . . Past year's vocational progress: Discharged from the Vocational Program 04/30/21 . . ." The IPP indicated the client was very independent with most daily tasks and activities of daily living (ADLs); however, the client is not receiving any type of skills training or afforded the opportunity to use his/her strength of independence in an aggressive active treatment program.

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5. Review of C5's EMR and paper medical record revealed no documented evidence a CFA had been completed in the past year.

Review of C5's "IPP," dated 08/20/25 and provided by the facility, revealed the client was a 44 year old client who was admitted to the facility on 08/06/14 with diagnoses which included Wolf-Hirschhorn Syndrome, profound intellectual disabilities, and epilepsy. The IPP also revealed, ". . . F. What are [his/her] daily routines? Morning: 7:15AM- Get up cleanup/bath, dressed, 8:00AM-First Feeding-peg tube (take meds with feeding); brush teeth during waiting intervals. 10:15-10:30 AM-return to bed and check brief, 11:30-Second feeding-peg tube (take meds with feeding); check brief. Afternoon: 1:00 PM-Health and Wellness Center, 2:30PM-Lie Down, 4:00 PM-third feeding-peg tube and check brief . . ." The schedule did not include any type of meaningful active treatment or other type of training program.

6. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder.

Review of C6's "IPP," dated 02/06/25 and provided by the facility, revealed, ". . . F. What are [his/her] daily routines? Morning: 6:00 AM-Wake up, shower and get dresses, 7:30-breakfast, 8:00-take meds, 9:00-go to HWC, 11:30-Return to [facility home name] for lunch. Afternoon: 12:30-brush teeth, 1:00 Go to HWC center, 4:00 return to house . . ."

During an interview on 10/03/25 at 1:11 PM, Family Member (F) 6 stated the facility used to have better programs than what they do now. F6 stated this morning he/she went to the HWC with C6. F6 stated there were several clients in the building from both facilities and they played one game of bingo with the clients and then all the clients sat there doing nothing while staff talked to each other. F6 stated C6 did not even like bingo. When asked if C6 would be interested in learning a new skill for vocational or work, F6 stated C6 could not work a real job. When asked if C6 could complete tasks independently or even with staff help of something like stringing a bead on a string, or moving items from one place to another, F6 stated "Yes, that would be good for [him/her]." F6 stated C6 did help with laundry in the home by pushing the laundry cart to the laundry room door. F6 stated he/she wished the facility would bring back the programming like they once had.

7. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities.

Review of C7's "IPP," dated 07/10/25 and provided by the facility, revealed, ". . . F. What are [his/her] daily routines? Morning: 6:00-Wake up, shower, dress, 7:30-breakfast, ears cleaned, medications, 9:00 -Go to HWC, 11"30-lunch, brush teeth. Afternoon: 1:00 go to HWC, 4:00-return to [home name] for dinner . . ."

During an interview on 09/30/25 at 5:02 PM, when asked if he/she worked or had a job at the facility, C7 stated "No." When asked if he/she had ever worked since he/she had been at the facility, C7 stated "Yes." C7 stated he/she answered phones for the wellness center at one time. When asked why he/she did not work there anymore, C7 stated "I don ' t know." When asked if he/she missed working, C7 stated "Yes." C7 stated he/she missed working because he/she made money.

8. Review of C8's "CFA," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities.

Review of C8's "IPP," dated 02/20/25 and provided by the facility, revealed, ". . .F. What are [his/her] daily routines? Morning: 6:00-wake up, shower, and get dressed. 7:30-breakfast, brush teeth, meds, 9:00-Health and Wellness Activities, 10:30 Hydration, 11:30/12:00-lunch and meds, and personal grooming. Afternoon: 1:00-return to HWC for activities and goal training, 3:00 return to house, 4:30-dinner, watch tv/movies, leisure . . ." C8's activity schedule did not include any training programing due to facility not having a day training program.

The facility did not have a day training program and only activities and games were offered to the clients each day.

During an interview on 09/30/25 at 1:45 PM, the QIDP stated the facility did not focus on any type of vocational training for the clients. The QIDP stated the facility just tried to keep the clients involved in games and activities. The QIDP also stated that a lot of the clients wanted to work.

During an interview on 10/01/25 at 3:50 PM, when asked how often the CFA was to be completed or updated, the QIDP stated he/she thought the CFA was to be completed annually. When asked again about the Vocational section of the CFA, the QIDP stated he/she did not complete or ensure a vocational assessment was completed because even though at least 50 percent of the clients of the facility wanted to work or learn skills, the facility did not have a day program to teach these skills or jobs the clients could work.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed the facility did not have a day program for the clients.
W0214 INDIVIDUAL PROGRAM PLAN
CFR(s): 483.440(c)(3)(iii)

The comprehensive functional assessment must identify the client's specific developmental and behavioral management needs.


This STANDARD is not met as evidenced by:
Based on observation, interview, record review and review of the facility's policy, the facility failed to ensure the comprehensive functional assessment (CFA) for one of eight clients (Client (C) 2) addressed specific behavioral supports needed to address aggressive behavior towards himself/herself or others. The Qualified Intellectual Disability Professional (QIDP) was aware of C2's high frequency of self-injurious behavior (SIB) and physical aggression towards others; however, the CFA did not include a functional behavioral assessment or a referral for a functional behavioral assessment completed by a qualifying professional. This failure impaired C2's everyday life, and the client was neglected during SIB episodes, which eventually caused actual harm to the client.

Findings include:

Review of the facility's job description titled, "ICF/IID QIDP-Qualified Intellectual Disability Professional," dated 02/17/25, revealed, ". . . Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) as well as any behavior support plan (BSP), psychotropic medication plan, or other support systems (e.g., educational opportunities . . . Coordinates all other support systems and related services for residents on assigned caseload . . ."

Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. Continued review of the CFA revealed, ". . . Developmental & Behavioral Management Needs. [C2's Name] has a Behavior Support Plan (BSP) in place [inaccurate] . . . Targeted behaviors include: physical aggression, verbal aggression, and self-injury . . . Vocational Skills. [C2's Name] no longer attends the workshop due to [his/her] behavioral issues . . . Recommendations: 1. Continue placement in the ICF/IID [Facility Name] due to needing for help with daily self-care, medical appointments . . . behavioral issues . . ." The CFA did not include any recommendations for any behavioral supports and/or services.

Review of C2's "IPP," dated 11/21/24 and provided by the facility, revealed, ". . . II. Behavior/Psych Support . . . Is there a behavioral support plan (BSP) in place: NO. Summary: A Behavioral Support Plan was in place for [C2's Name] due to target behaviors such as verbal and physical aggression and self-injurious behaviors. If the previous behaviors began to cause issues they will be tracked and a new BSP might be implemented . . ."

Review of C2's EMR and paper medical records revealed no documented evidence behavioral data was being obtained, collected, monitored, and reviewed at least quarterly.

Review of C2's "Therap [Name of EMR] Communication Log (T-Log)," dated 11/13/24 and located in the client's EMR under the "T-Log" tab, revealed, "While assisting resident to bathroom he/she was walking towards toilet and went to head-butt padded area on wall, [he/she] missed the pad and head-butted wall hard and resident stated 'ouch.' Nurse notified . . ."

Review of C2's "T-Log," dated 12/20/24 and located in the client's EMR under the "T-Log" tab, revealed, "[C2's Name] came out [his/her] room with [his/her] breakfast plate and [Resident Aide (RA) 1's name] told [him/her] to go back in [his/her] room and [he/she] did not then [he/she] saw me and I told [him/her] to go back into [his/her] room and walked past [him/her] to go help [RA1's name] and then [he/she] throws [his/her] breakfast plate towards my back and it fell into the floor."

Review of C2's "T-Log," dated 12/22/24 and located in the client's EMR under the "T-Log" tab, revealed, "Approximately around 2:30pm I was telling resident to go back into [his/her] room per quarantine instructions. While trying to re-direct resident to [his/her] room [he/she] managed to throw [himself/herself] on the floor by another residents [sic] room where [his/her] head caught the edge of the metal piece in the corner where [he/she] received a laceration. Charge nurse was notify [sic]."

Review of C2's "T-Log," dated 12/23/24 and located in the client's EMR under the "T-Log" tab, revealed, "Resident returned to facility at 8:10 P.M. from the emergency room, [he/she] was alert and good spirits. Resident received eleven staples to the back of [his/her] head."

Review of C2's "T-Log," dated 03/26/25 and located in the client's EMR under the "T-Log" tab revealed "[C2's Name] was being sent to the living/dining area to wait for breakfast, while the aid made [his/her] bed and cleaned [his/her] room. The resident became upset because [he/she] wanted to lay down instead of going to breakfast. [C2's name] proceeded to bang [his/her] head against the wall repeatedly until the nurse and aid intervened. Nurse was notified."

Review of C2's "T-Log," dated 04/04/25 and located in the client's EMR under the "T-Log" tab, revealed, "Staff reported resident head-banged wall while in bathroom, no evident injury

noted, [Name of C2's Attending Physician] made aware, neuro checks initiated, neuro intact at this time, care ongoing."

Review of C2's "T-Log," dated 04/04/25 and located in the client's EMR under the "T-Log" tab, revealed, "While showering [C2's initials] [he/she] got very agitated and when going to wash [his/her] legs [he/she] started kicking the wall. Then the aid moved so [he/she] would not get hit but when the aid went back to trying to wash the resident [he/she] hit the aid on the side of the head. The aid moved and told [C2's initials] to stop. The aid moved and the resident began hitting [himself/herself] in the face. The aid then washed off [C2's initials] and started to dry [him/her] and the resident kicked the aid in the shin. Next, the aid started to dress [C2's initials] and [he/she] hit the aid in the hand and squeezed the aids [sic] hand. The aid reported it to the nurse."

Review of C2's "T-Log," dated 06/29/25 and located in the client's EMR under the "T-Log" tab, revealed, "I happened to notice [C2's name] became irritated at lunch because [his/her] ice cream was still frozen and [he/she] could not get it out of the cup. I took [his/her] ice cream cup which had [his/her] spoon in it to the kitchen to soften it for [him/her]. When I came back [he/she] was irritated and eating [his/her] cake with [his/her] hands. At some point [he/she] had put [his/her] hands on [his/her] head and got icing in [his/her] hair and on the side of [his/her] face. [He/She] finished a little before 12pm and started to [his/her] room when I saw [his/her] face and hands covered in cake. I stopped [him/her] to wipe [his/her] hands and face and [he/she] showed discontent at first. I tried to keep [his/her] attention but [he/she] screamed and started to hit [himself/herself] in the face and got [sic] made contact a couple of times. I began to redirected [sic] [his/her] hand and [he/she] stopped for a second. Then, [he/she] started hitting [his/her] right side. I began to wipe that hand of the icing to distract [him/her] and [he/she] screamed again. I wiped [his/her] face and [he/she] continued to [his/her] room."

Review of C2's "T-Log," dated 06/29/25 and located in the client's EMR under the "T-Log" tab, revealed, "Resident was in bed and appeared to be sleep during 10pm rounding. By the time staff returned to the desk, [he/she] come out of [his/her] bedroom with a big smile. [He/She] said something to staff and when staff could not understand [him/her] and asked [him/her] to repeat what [he/she] said, [he/she] put [his/her] head as if looking at the floor and hands over [his/her] ears. Staff came closer to try to understand. [He/She] attempted to repeat [himself/herself] then appear frustrated. [He/She] hit [his/her] forehead and nose with the back of [his/her] hand and stomped [his/her] foot. Then [he/she] reached onto the nurses [sic] cart and grabbed a cup with spoons in it off the nursing cart. Resident put the spoons back on the cart and took the cup into [his/her] room. Approx. 10 minutes later [he/she] returned the cup to the cart. Cup which was once dry now had drips of water inside and out. Staff said keep it but [he/she] insisted on putting it back. Then [he/she] returned to [his/her] room."

Review of C2's "T-Log," dated 06/30/25 and located in the client's EMR under the "T-Log" tab revealed, "This morning when the aids went into [C2's initials] room to get [him/her] up and showered [C2's initials] hit [himself/herself] in the face eleven times, bit [himself/herself] three times, hit [his/her] head on the wall three times, pinched the aid, and screamed four times. All happened while showing and clothing [him/her]. Will continue to monitor behavior."

Review of C2's "T-Log," dated 06/30/25 and located in the client's EMR under the "T-Log" tab, revealed, "Before lunch aide was cleaning [his/her] face, [C2's initials] hit [himself/herself] in the face as well as bit [his/her] arm multiple times. After lunch, [C2's initials] was transported to the bathroom during that duration [he/she] bit [himself/herself] three times and hit [himself/herself] multiple times."

Review of C2's "T-Log," dated 07/09/25 and located in the client's EMR under the "T-Log" tab, revealed, "While getting [C2's initials] up to take [him/her] to the bathroom and shower [him/her], [he/she] was aggressive with the aide multiple times, would not comply with the aide and then had an incontinent void in the bed, bit [himself/herself] multiple times, hit [his/her] head on the wall multiple times, punched [himself/herself] in the face multiple times, kicked the wall three times, squeezed the aide's hand three times, tried to punch the aide in the face twice, and tried to head-butt the aide twice. The aide and [C2's initials] have no sign of injuries. Will continue to document behavior."

Review of C2's "T-Log," dated 07/14/25 and located in the client's EMR under the "T-Log" tab, revealed, "Resident displayed SIB numerous ways this morning while assisting with getting up, showered, and dressed. Biting wrist approx. [approximately] 10 times. Striking face approx. 20 times. Striking top on head approx. 10 times. Kicking wall in shower approx 10 times.

Review of C2's "T-Log," dated 09/04/25 and located in the client's EMR under the "T-Log" tab, revealed, "While assisting resident with toileting resident was sitting on toilet and leaned backwards and started banging head on bathroom wall, nurse notified."

During an interview on 10/01/25 at 3:50 PM, the Qualified Intellectual Disability Professional (QIDP) stated the client did not have any type of behavior plan at this time. The QIDP stated there should have been a BSP a long time ago. The QIDP also confirmed there had not been any behavior functional assessments completed to his/her knowledge.

During an interview on 10/02/25 at 4:07 PM, the Psychiatrist (Psych) stated he/she knew C2 well. The Psych stated he/she consulted with a provider who had treated C2 prior to him/her treating the client and discovered that the client had engaged in SIB for years. When asked about his/her expectation as to staff managing C2's behaviors, the Psych stated medications were not going to improve C2's behavior. The Psych stated the BCBA (Board Certified Behavior Analysis) could develop a plan with interventions. The Psych stated with the C2's autism diagnosis, he/she could benefit from a sensory room. The Psych stated when C2 was asked to do a task, and then engaged in SIB, he/she believed the function of the behavior would be "escape." The Psych stated C2 worked with a BCBA at one time; however, it may be more beneficial to C2 if they attempted to find a BCBA who works with intellectual disabilities with clients who have dual diagnoses (ID/DD and mental illness). The Psych stated it was his/her expectation when C2 engaged in SIB, especially the headbanging, staff would have been trained on keeping the client safe. The Psych also stated staff having the proper training from the appropriate discipline such as a BCBA would make the client more comfortable and give the client more autonomy.

During an interview on 10/04/25 at 6:41 PM, the facility Administrator stated a Functional Behavioral Assessment had not been completed on C2 in over a year. The Director stated it was his/her expectation when C2 started having an increase in behaviors, the QIDP would have ensured a referral for a functional behavioral assessment would have been made to include in C2's CFA.

Based on observation, interview, record review and review of the facility's policy, the facility failed to ensure the comprehensive functional assessment (CFA) for one of eight clients (Client (C) 2) addressed specific behavioral supports needed to address aggressive behavior towards himself/herself or others. The Qualified Intellectual Disability Professional (QIDP) was aware of C2's high frequency of self-injurious behavior (SIB) and physical aggression towards others; however, the CFA did not include a functional behavioral assessment or a referral for a functional behavioral assessment completed by a qualifying professional. This failure impaired C2's everyday life, and the client was neglected during SIB episodes, which eventually caused actual harm to the client.

Findings include:

Review of the facility's job description titled, "ICF/IID QIDP-Qualified Intellectual Disability Professional," dated 02/17/25, revealed, ". . . Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) as well as any behavior support plan (BSP), psychotropic medication plan, or other support systems (e.g., educational opportunities . . . Coordinates all other support systems and related services for residents on assigned caseload . . ."

Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. Continued review of the CFA revealed, ". . . Developmental & Behavioral Management Needs. [C2's Name] has a Behavior Support Plan (BSP) in place [inaccurate] . . . Targeted behaviors include: physical aggression, verbal aggression, and self-injury . . . Vocational Skills. [C2's Name] no longer attends the workshop due to [his/her] behavioral issues . . . Recommendations: 1. Continue placement in the ICF/IID [Facility Name] due to needing for help with daily self-care, medical appointments . . . behavioral issues . . ." The CFA did not include any recommendations for any behavioral supports and/or services.

Review of C2's "IPP," dated 11/21/24 and provided by the facility, revealed, ". . . II. Behavior/Psych Support . . . Is there a behavioral support plan (BSP) in place: NO. Summary: A Behavioral Support Plan was in place for [C2's Name] due to target behaviors such as verbal and physical aggression and self-injurious behaviors. If the previous behaviors began to cause issues they will be tracked and a new BSP might be implemented . . ."

Review of C2's EMR and paper medical records revealed no documented evidence behavioral data was being obtained, collected, monitored, and reviewed at least quarterly.

Review of C2's "Therap [Name of EMR] Communication Log (T-Log)," dated 11/13/24 and located in the client's EMR under the "T-Log" tab, revealed, "While assisting resident to bathroom he/she was walking towards toilet and went to head-butt padded area on wall, [he/she] missed the pad and head-butted wall hard and resident stated 'ouch.' Nurse notified . . ."

Review of C2's "T-Log," dated 12/20/24 and located in the client's EMR under the "T-Log" tab, revealed, "[C2's Name] came out [his/her] room with [his/her] breakfast plate and [Resident Aide (RA) 1's name] told [him/her] to go back in [his/her] room and [he/she] did not then [he/she] saw me and I told [him/her] to go back into [his/her] room and walked past [him/her] to go help [RA1's name] and then [he/she] throws [his/her] breakfast plate towards my back and it fell into the floor."

Review of C2's "T-Log," dated 12/22/24 and located in the client's EMR under the "T-Log" tab, revealed, "Approximately around 2:30pm I was telling resident to go back into [his/her] room per quarantine instructions. While trying to re-direct resident to [his/her] room [he/she] managed to throw [himself/herself] on the floor by another residents [sic] room where [his/her] head caught the edge of the metal piece in the corner where [he/she] received a laceration. Charge nurse was notify [sic]."

Review of C2's "T-Log," dated 12/23/24 and located in the client's EMR under the "T-Log" tab, revealed, "Resident returned to facility at 8:10 P.M. from the emergency room, [he/she] was alert and good spirits. Resident received eleven staples to the back of [his/her] head."

Review of C2's "T-Log," dated 03/26/25 and located in the client's EMR under the "T-Log" tab revealed "[C2's Name] was being sent to the living/dining area to wait for breakfast, while the aid made [his/her] bed and cleaned [his/her] room. The resident became upset because [he/she] wanted to lay down instead of going to breakfast. [C2's name] proceeded to bang [his/her] head against the wall repeatedly until the nurse and aid intervened. Nurse was notified."

Review of C2's "T-Log," dated 04/04/25 and located in the client's EMR under the "T-Log" tab, revealed, "Staff reported resident head-banged wall while in bathroom, no evident injury

noted, [Name of C2's Attending Physician] made aware, neuro checks initiated, neuro intact at this time, care ongoing."

Review of C2's "T-Log," dated 04/04/25 and located in the client's EMR under the "T-Log" tab, revealed, "While showering [C2's initials] [he/she] got very agitated and when going to wash [his/her] legs [he/she] started kicking the wall. Then the aid moved so [he/she] would not get hit but when the aid went back to trying to wash the resident [he/she] hit the aid on the side of the head. The aid moved and told [C2's initials] to stop. The aid moved and the resident began hitting [himself/herself] in the face. The aid then washed off [C2's initials] and started to dry [him/her] and the resident kicked the aid in the shin. Next, the aid started to dress [C2's initials] and [he/she] hit the aid in the hand and squeezed the aids [sic] hand. The aid reported it to the nurse."

Review of C2's "T-Log," dated 06/29/25 and located in the client's EMR under the "T-Log" tab, revealed, "I happened to notice [C2's name] became irritated at lunch because [his/her] ice cream was still frozen and [he/she] could not get it out of the cup. I took [his/her] ice cream cup which had [his/her] spoon in it to the kitchen to soften it for [him/her]. When I came back [he/she] was irritated and eating [his/her] cake with [his/her] hands. At some point [he/she] had put [his/her] hands on [his/her] head and got icing in [his/her] hair and on the side of [his/her] face. [He/She] finished a little before 12pm and started to [his/her] room when I saw [his/her] face and hands covered in cake. I stopped [him/her] to wipe [his/her] hands and face and [he/she] showed discontent at first. I tried to keep [his/her] attention but [he/she] screamed and started to hit [himself/herself] in the face and got [sic] made contact a couple of times. I began to redirected [sic] [his/her] hand and [he/she] stopped for a second. Then, [he/she] started hitting [his/her] right side. I began to wipe that hand of the icing to distract [him/her] and [he/she] screamed again. I wiped [his/her] face and [he/she] continued to [his/her] room."

Review of C2's "T-Log," dated 06/29/25 and located in the client's EMR under the "T-Log" tab, revealed, "Resident was in bed and appeared to be sleep during 10pm rounding. By the time staff returned to the desk, [he/she] come out of [his/her] bedroom with a big smile. [He/She] said something to staff and when staff could not understand [him/her] and asked [him/her] to repeat what [he/she] said, [he/she] put [his/her] head as if looking at the floor and hands over [his/her] ears. Staff came closer to try to understand. [He/She] attempted to repeat [himself/herself] then appear frustrated. [He/She] hit [his/her] forehead and nose with the back of [his/her] hand and stomped [his/her] foot. Then [he/she] reached onto the nurses [sic] cart and grabbed a cup with spoons in it off the nursing cart. Resident put the spoons back on the cart and took the cup into [his/her] room. Approx. 10 minutes later [he/she] returned the cup to the cart. Cup which was once dry now had drips of water inside and out. Staff said keep it but [he/she] insisted on putting it back. Then [he/she] returned to [his/her] room."

Review of C2's "T-Log," dated 06/30/25 and located in the client's EMR under the "T-Log" tab revealed, "This morning when the aids went into [C2's initials] room to get [him/her] up and showered [C2's initials] hit [himself/herself] in the face eleven times, bit [himself/herself] three times, hit [his/her] head on the wall three times, pinched the aid, and screamed four times. All happened while showing and clothing [him/her]. Will continue to monitor behavior."

Review of C2's "T-Log," dated 06/30/25 and located in the client's EMR under the "T-Log" tab, revealed, "Before lunch aide was cleaning [his/her] face, [C2's initials] hit [himself/herself] in the face as well as bit [his/her] arm multiple times. After lunch, [C2's initials] was transported to the bathroom during that duration [he/she] bit [himself/herself] three times and hit [himself/herself] multiple times."

Review of C2's "T-Log," dated 07/09/25 and located in the client's EMR under the "T-Log" tab, revealed, "While getting [C2's initials] up to take [him/her] to the bathroom and shower [him/her], [he/she] was aggressive with the aide multiple times, would not comply with the aide and then had an incontinent void in the bed, bit [himself/herself] multiple times, hit [his/her] head on the wall multiple times, punched [himself/herself] in the face multiple times, kicked the wall three times, squeezed the aide's hand three times, tried to punch the aide in the face twice, and tried to head-butt the aide twice. The aide and [C2's initials] have no sign of injuries. Will continue to document behavior."

Review of C2's "T-Log," dated 07/14/25 and located in the client's EMR under the "T-Log" tab, revealed, "Resident displayed SIB numerous ways this morning while assisting with getting up, showered, and dressed. Biting wrist approx. [approximately] 10 times. Striking face approx. 20 times. Striking top on head approx. 10 times. Kicking wall in shower approx 10 times.

Review of C2's "T-Log," dated 09/04/25 and located in the client's EMR under the "T-Log" tab, revealed, "While assisting resident with toileting resident was sitting on toilet and leaned backwards and started banging head on bathroom wall, nurse notified."

During an interview on 10/01/25 at 3:50 PM, the Qualified Intellectual Disability Professional (QIDP) stated the client did not have any type of behavior plan at this time. The QIDP stated there should have been a BSP a long time ago. The QIDP also confirmed there had not been any behavior functional assessments completed to his/her knowledge.

During an interview on 10/02/25 at 4:07 PM, the Psychiatrist (Psych) stated he/she knew C2 well. The Psych stated he/she consulted with a provider who had treated C2 prior to him/her treating the client and discovered that the client had engaged in SIB for years. When asked about his/her expectation as to staff managing C2's behaviors, the Psych stated medications were not going to improve C2's behavior. The Psych stated the BCBA (Board Certified Behavior Analysis) could develop a plan with interventions. The Psych stated with the C2's autism diagnosis, he/she could benefit from a sensory room. The Psych stated when C2 was asked to do a task, and then engaged in SIB, he/she believed the function of the behavior would be "escape." The Psych stated C2 worked with a BCBA at one time; however, it may be more beneficial to C2 if they attempted to find a BCBA who works with intellectual disabilities with clients who have dual diagnoses (ID/DD and mental illness). The Psych stated it was his/her expectation when C2 engaged in SIB, especially the headbanging, staff would have been trained on keeping the client safe. The Psych also stated staff having the proper training from the appropriate discipline such as a BCBA would make the client more comfortable and give the client more autonomy.

During an interview on 10/04/25 at 6:41 PM, the facility Administrator stated a Functional Behavioral Assessment had not been completed on C2 in over a year. The Director stated it was his/her expectation when C2 started having an increase in behaviors, the QIDP would have ensured a referral for a functional behavioral assessment would have been made to include in C2's CFA.
W0225 INDIVIDUAL PROGRAM PLAN
CFR(s): 483.440(c)(3)(v)

The comprehensive functional assessment must include, as applicable, vocational skills.


This STANDARD is not met as evidenced by:
Based on record review and interview, the facility failed to ensure the Comprehensive Functional Assessment (CFA) included an individualized vocational assessment for all domains for what skills clients can and cannot do and addressed job sampling, job development, on-site job training, and long-term follow-up for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility did not have a day training program for clients to be able to be properly assessed, learn new skills, and maintain the skills they have. This failure had the potential to negatively impact all 15 clients who resided at the facility.

Findings include:

Review of the facility's job description titled, "ICF/IID QIDP-Qualified Intellectual Disability Professional," dated 02/17/25, revealed, ". . . Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: Duties: -Responsible for integrating, coordinating, and monitoring active treatment plans (IPPS [individual Program Plans]) . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) . . ."

1. Review of C1's "CFA,," dated 05/011/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post-traumatic stress disorder (PTSD). Continued review of C1's CFA revealed the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities.

2. Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. Continued review of C2's CFA revealed the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities.

3. Review of C3's electronic medical record (EMR) and paper medical record revealed no documented evidence that the QIDP completed or ensured that a CFA had been completed on the client in the past year, including a vocational assessment.

4. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities. Continued review of the CFA revealed the QIDP failed to complete the vocational assessment section of the client's CFA.

5. Review of C5's EMR and paper medical record revealed no documented evidence that the QIDP completed or ensured that a CFA had been completed on the client in the past year which included a vocational assessment.

6. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder. Continued review of the CFA revealed the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities.

7. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities. Continued review of the CFA revealed the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities.

8. Review of C8's "CFA," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities. Continued review of the CFA revealed the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities.

During an interview on 09/30/25 at 1:45 PM, when asked about the vocational section of the CFAs, the QIDP stated the facility did not focus on vocational training.

During an interview on 10/01/25 at 3:50 PM, when asked how often the CFA was to be completed or updated, the QIDP stated he/she thought the CFA was to be completed annually. When asked again about the Vocational section of the CFA, the QIDP stated he/she did not complete or ensure a vocational assessment was completed because even though at least 50 percent of the clients of the facility wanted to work or learn skills, the facility did not have a day program to teach these skills or jobs the clients could work.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed the facility did not have a day training or vocational training program; however, the facility has already started working on implementing one. The Director confirmed the missing CFAs and stated his/her expectation was they would be completed timely. The Director stated it was his/her expectation the QIDP would have ensured the vocational section of the CFAs would be completed per regulatory requirement.

Based on record review and interview, the facility failed to ensure the Comprehensive Functional Assessment (CFA) included an individualized vocational assessment for all domains for what skills clients can and cannot do and addressed job sampling, job development, on-site job training, and long-term follow-up for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility did not have a day training program for clients to be able to be properly assessed, learn new skills, and maintain the skills they have. This failure had the potential to negatively impact all 15 clients who resided at the facility.

Findings include:

Review of the facility's job description titled, "ICF/IID QIDP-Qualified Intellectual Disability Professional," dated 02/17/25, revealed, ". . . Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: Duties: -Responsible for integrating, coordinating, and monitoring active treatment plans (IPPS [individual Program Plans]) . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) . . ."

1. Review of C1's "CFA,," dated 05/011/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post-traumatic stress disorder (PTSD). Continued review of C1's CFA revealed the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities.

2. Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. Continued review of C2's CFA revealed the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities.

3. Review of C3's electronic medical record (EMR) and paper medical record revealed no documented evidence that the QIDP completed or ensured that a CFA had been completed on the client in the past year, including a vocational assessment.

4. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities. Continued review of the CFA revealed the QIDP failed to complete the vocational assessment section of the client's CFA.

5. Review of C5's EMR and paper medical record revealed no documented evidence that the QIDP completed or ensured that a CFA had been completed on the client in the past year which included a vocational assessment.

6. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder. Continued review of the CFA revealed the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities.

7. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities. Continued review of the CFA revealed the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities.

8. Review of C8's "CFA," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities. Continued review of the CFA revealed the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities.

During an interview on 09/30/25 at 1:45 PM, when asked about the vocational section of the CFAs, the QIDP stated the facility did not focus on vocational training.

During an interview on 10/01/25 at 3:50 PM, when asked how often the CFA was to be completed or updated, the QIDP stated he/she thought the CFA was to be completed annually. When asked again about the Vocational section of the CFA, the QIDP stated he/she did not complete or ensure a vocational assessment was completed because even though at least 50 percent of the clients of the facility wanted to work or learn skills, the facility did not have a day program to teach these skills or jobs the clients could work.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed the facility did not have a day training or vocational training program; however, the facility has already started working on implementing one. The Director confirmed the missing CFAs and stated his/her expectation was they would be completed timely. The Director stated it was his/her expectation the QIDP would have ensured the vocational section of the CFAs would be completed per regulatory requirement.
W0262 PROGRAM MONITORING & CHANGE
CFR(s): 483.440(f)(3)(i)

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.


This STANDARD is not met as evidenced by:
Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the Human Rights Committee (HRC) approved all client restrictions before the restrictions were imposed for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The clients did not have freedom of movement to access common areas of their home. Clients were restricted from their kitchen, and the clients' front door to their home was equipped with delayed egress locking hardware and required a key code to exit. These restrictions were not taken before the HRC, and clients were not afforded due process. Additionally, the right restrictions approved by the HRC and identified in the clients' CFA did not include a behavior plan which included a rights restoration plan. These restrictions affected all 15 clients who resided in the home.

Findings include:

Review of the facility's undated policy titled, Human Right Committee Procedures" revealed, ". . . The Human Rights Committee (HRC) is charged with the responsibility and duty to safeguard the rights of residents of [Facility Name] . . ."

Review of the facility's undated document titled, "What is a Rights Restriction?" revealed, "Restriction means anything that limits or prevents an individual from freely exercising his/her rights and privileges. Something is usually considered restrictive if it impedes the enjoyment of general liberties that are available to all citizens. Rights restrictions include (but are not limited to) such things as: Limitation on access to personal possessions (. . . phone . . .), to food or drink . . . Limitations to movement . . . Door/Window alarms and other environmental restrictions . . . The Committee also protects against violations to Alabama-specific rights and personal freedoms for people with development disabilities receiving supports. For the residential program, these include: . . . Exercise freedom of movement within physical environments . . ."

Review of the facility's policy titled, "Individual Rights and Grievance Procedure," revised 08/2022, revealed, ". . . It is the policy of [Facility Name] to provide age appropriate assistance to individuals who are admitted to [Facility Name] and to responsible others acting on their behalf, to exercise the same human and legal rights guaranteed all persons by the U.S. Constitution unless the individual has been specifically determined to be incompetent by judicial proceedings or otherwise legally restricted. Without regard to competency or legal restrictions, [Name of Facility] recipients have the right to provision of services within an environment that is safe, humane, and abuse free . . . In addition . . . residents have the right to appropriate quality treatment, services, and habilitation specifically designed to maximize their developmental potential within the least restrictive setting . . . HUMAN TREATMENT AND CIVIL RIGHTS. A home-like atmosphere shall be provided. A written policy concerning resident's rights shall be posted in a conspicuous location, and residents on admission shall be informed of their rights orally and in writing in plain and simple language . . ."

Review of the facility's "Individual Rights Handbook," revised 08/2022, revealed, ". . . This handbook tells you about the rights, privileges and responsibilities you have while you are receiving services in programs ...you, your family and friends can be certain that every . . . employee wants to protect your rights. While you are residing and/or receiving services . . . the Human Rights Committee and the [Facility Name] Employees will guard your rights. All of these people want to assist you and to preserve your rights . . . As a recipient of services available from [Facility Name] you have all the rights listed in this handbook the following: 1. You have the right to be treated as an adult and exercise your rights without being punished for doing it . . . 4. You have all the rights as an U.S. citizen and of the state of Alabama, unless your rights have been limited by a judge. This is only done for very good reasons. This includes the right to be considered competent until a court orders otherwise . . . 11. You should be told of your Person Centered Plan (PCP) or Individual Program Plan (IPP) and any restrictions to your rights. Sometimes, some of your rights might be restricted. You may ask your Program Director for a review of this decision if you do not agree with it . . . 25. You have the right not to be unnecessarily restrained, (physically or chemically), or isolated unless for your safety or the safety of others . . ."

Review of the facility's policy titled, "Personal Care and House Rules," dated 08/2008, revealed, ". . . to establish a home that enables the residents to progress or be maintained in the least restrictive environment. The effectiveness in providing adequate support services is to provide as much independence as possible and not provide personal care elements that are not needed . . . staff shall provide observation and precautionary measures to provide safety and protection from residents ' falling, wandering, and harm . . ."

1. During an interview on 09/30/25 at 4:23 PM, when asked how clients accessed their kitchen, Cook (CK) 1 stated the clients were not allowed in the kitchen here.

Observation on 09/30/25 at 4:25 PM of the dining room revealed signage on the wall by the door to the kitchen of "Only dietary staff permitted in the kitchen . . . Kitchen door to be locked and shut at all times . . ."

During an interview on 09/30/25 at 4:47 PM, when asked if clients of the home were able to access their kitchen, the Food Service Director (FSD) stated staff would assist the clients if they needed or wanted anything that was in the kitchen. The FSD stated normally the kitchen door was only unlocked during normal business hours.

Observation on 09/30/25 at 4:50 PM at the front door of the home (main entrance) revealed the door was equipped with delayed egress hardware and had a sign which stated if the bar was pushed for 15 seconds (consistently) the door would open. The door required a code to get out the door without a 15 second delay.

Observation on 09/30/25 at 5:06 PM revealed when this writer attempted to exit the home by pushing on the exit bar, an audible alarm sounded until the bar was released.. The door did not open, and a key code was required to exit the home.

During an interview on 10/01/25 at 7:53 AM, Resident Aide (RA) 1 stated he/she had worked at the facility for almost three years. When asked if the clients had access to their home's kitchen, RA1 stated, "No, but the clients would ask staff if they wanted a snack or a drink." RA1 also stated clients were not "allowed" to go into the kitchen.

During an interview on 10/01/25 at 8:06 AM, RA3 stated he/she had been employed at the facility for five years. RA3 stated clients were not allowed to go into the kitchen and had not been able to go into the kitchen since he/she had been employed due to safety reasons.

During an interview on 10/01/25 at 8:17 AM, the Program Coordinator (PC), who was also a Licensed Practical Nurse (LPN) stated he/she was responsible for overseeing everything in the home. The PC stated clients who lived in the home could not go into the kitchen because of safety reasons.

During an interview on 10/01/25 at 9:47 AM, when asked about the clients not having access to their own kitchen, the Qualified Intellectual Disability Professional (QIDP) stated the clients should have been able to have access to the kitchen of their home; however, the direct care staff did not allow the clients to have access because of safety reasons.

2. Review of C1's "Comprehensive Functional Assessment (CFA)," dated 05/011/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post traumatic stress disorder (PTSD). Continued review of the CFA revealed it was identified that C1 understood all of his/her rights and how to advocate, as well as the grievance process, but would feel afraid or uncomfortable doing so.

Review of C1's "Individual Program Plan (IPP)," dated 05/2025 and provided by the facility, revealed, ". . . QIDP reviewed C1's Rights Restrictions and [C1's family names] were in agreement with [his/her] restrictions. As the QIDP began talking about the goals that were formulated for [C1's Name] [he/she] went into detail about [his/her] goals and stated that [he/she] agreed with [his/her] plan . . . [C1's Name] looks forward to being challenged and especially focusing on [his/her] bracelet business and having the freedom to travel throughout the [Facility Name] community . . . [C1's Name] family is very interested in creating 'lanes' for [C1's Name] to drive [his/her] wheelchair throughout the community [facility campus] . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, individual program planning, and alternate placement . . . Why is this limitation being recommended? [C1's name] is included in the decisions concerning [him/her]. [He/She] is able to make most decisions for [himself/herself]. [He/She] may receive some guidance from [his/her] parents . . . 7. The right to freedom from the use of unnecessary medications and mechanical, chemical, or physical restraints. Why is this limitation being recommended? [C1's Name] uses bedrails on [his/her] bed and seat belts in [his/her] wheelchair and shower chair . . ." Continued review revealed the IPP identified that C1's right to freedom of movement in the home, campus grounds, and off campus grounds were not restricted. C1's IPP did not include any type of behavior plan or a plan to restore the client's rights that had been restricted. There was no documented evidence HRC had reviewed the identified restrictions.

During an interview on 10/01/25 at 12:25 PM, C1 stated living an independent life was very important to him/her. C1 stated he/she was 26 years old and wanted to visit his/her friends who lived on campus at the other houses. C1 stated he/she can independently use his/her wheelchair and has a cell phone he/she could independently use; however, at this time he/she is not allowed to make that choice. C1 stated he/she could not even independently go sit on the front porch of the home because the door stays locked by a keypad. C1 further stated he/she nor other clients were allowed to access the home's kitchen.

3. Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder.

Review of C2's "IPP," dated 11/21/24 and provided by the facility, revealed, ". . . Rights Assessment: It has been assessed that [he/she] does not understand them and didn't really want to hear them at this time. [He/She] was unable to state who [he/she] would tell if [he/she] felt [his/her] rights were violated . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of restrictive behavior and/or medical procedures . . . 9. The right to have access to, to keep, and to spend personal money. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds, and off [facility name] grounds . . . A reduction in the rights restraints will occur when [C2's name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] is no longer a resident . . . [His/Her] rights will be reviewed annually . . ." There was no documented evidence of a behavior plan addressing these restrictions nor a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

4. Review of C3's "IPP," dated 05/09/25 and provided by the facility, revealed the client was a 71 year old client who was admitted to the facility on 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities. The IPP also revealed, ". . . Rights Assessment: [C3's Name] does understand some of [his/her] rights but needs assistance with others. [His/Her] rights will be reviewed with [his/her] annual. The QIDP asked whom [he/she] would feel comfortable talking to if [he/she] felt [he/she] was being mistreated and [he/she] [identified persons] . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds . . ." There was no documented evidence the restrictions were documented in a behavior plan nor a plan to restore the restricted rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

5. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C4's "IPP," dated 12/12/24 and provided by the facility, revealed, ". . . Rights Assessment: [C4's Name] had [his/her] rights reviewed with [him/her] and it has been assessed that [he/she] does have limited understanding of [his/her] rights and how to report concerns . . . Any recommendations for goals retaining to rights: None at this time . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . ." The IPP indicated C4's right to freedom of movement in the home, vocational center, and on the facility's campus was not restricted and documented ". . . [C4's name] has freedom of movement at the health and wellness center and in the ICF. [He/She] has supervision when outdoors . . . as a safety precaution . . ." There was no documented evidence the restrictions were documented in a behavior plan nor was there a plan to restore the restricted rights. Additionally, the IPP failed to identify C4's freedom of movement was restricted in his/her home as he/she could not access his/her home's kitchen and the front door of his/her home was equipped with a delayed egress locking system.

6. Review of C5's "IPP," dated 08/20/25 and provided by the facility, revealed the client was a 44 year old client who was admitted to the facility on 08/06/14 with diagnoses which included Wolf-Hirschhorn Syndrome, profound intellectual disabilities, and epilepsy. The IPP also revealed, ". . . Right Assessment: It has been assessed that [C5's Name] does not understand [his/her] rights and would not be able to advocate for [himself/herself] in the event [his/her] rights were violated in some way . . . Any recommendations for goals relating to rights: none at this time . . . Limitations of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is the limitation being recommended? [C5's Name] uses a specialized bed with high bedrails on all four sides. [He/She] has a seatbelt, a chest strap, and thigh/trunk guides on [his/her] wheelchair . . . 8. The right to wear, to keep, to use own clothing, personal hygiene items, and personal possessions. Why is this limitation being recommended? [C5's Name] hygiene items are kept in a safe place where staff can access them. [He/She] is not able to read or understand about the hazards of various substances and may ingest harmful ones. [He/She] is physically unable to use [his/her] hygiene products on [his/her] own . . . 11. The right to privacy. Why is this limitation being recommended? [C5's Name] has a live time monitor in [his/her] room to monitor for safety due to brittle bones-to help staff be aware of [his/her] safety needs . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C5's Name] has no safety awareness and requires supervision on an off [Facility Name] grounds . . . " There was no documented evidence of a behavior plan to address the right restrictions nor any evidence of a restoration plan to restore these rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

7. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder.

Review of C6's "IPP," dated 02/06/25 and provided by the facility, revealed, ". . . Rights Assessment: . . . it was assessed that [C6's] name does not understand [his/her] rights . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [C6's Name] uses bedrails on [his/her] bed and seatbelts on [his/her] wheelchair and shower chair to prevent falls and a gait belt when walking. There are wheelchair and bed alarms to alert staff if [he/she] is in need of assistance . . . 11. The right to privacy. Why is this limitation being recommended? [C6's Name] requires standby assistance with all areas of hygiene due to seizure precautions, and therefore [his/her] right to privacy is limited for medical reasons. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C6's Name] has supervision when [he/she] is on or off [Facility Name] property. [He/She] requires help with transportation and ambulation . . . The reduction in [C6's Name] rights is congruent with [his/her] care needs. If at anytime it is shown that [C6's Name] is able to exercise these rights safely without restrictions or when [he/she] is no longer a resident, these restrictions will be removed . . . " There was no documented evidence of a behavior plan nor a restoration plan to restore the client's rights restrictions. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

8. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities.

Review of C7's "IPP," dated 07/10/25 and provided by the facility, revealed, ". . . Rights Assessment: . . . It has been assessed that [R7's Name] does not understand the rights and responsibilities due to [his/her] speech and disability . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement. Why is the limitation recommended? [C7's Name] does not understand some aspects of [his/her] care, finances, and/or legal issues. [He/She] has legal guardians to help [him/her] with decisions . . . 5. The right to make and to receive confidential phone calls. Why is the limitation recommended? [C7's Name] still has the right to make and receive phone calls in private. [His/Her] sisters who are [his/her] guardians have asked that [he/she] not have [his/her] cell phone until after the evening meal . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [He/She] [C7] uses bedrails and bed alarms due to a seizure disorder. [He/She] has a restricted wheelchair seatbelt and shower chair belt due to [his/her] seizure disorder. 8. The right to wear, to keep, and to use own clothing, personal hygiene items, and personal possessions. Why is this limitation being recommended? [C7's Name] is kept at the nurse's station to prevent [him/her] from calling people in the middle of the night. [He/She] has agreed with [his/her] sisters on this issue . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? To protect [him/her] from exploitation and to ensure safety, [he/she] is accompanied by a staff if [he/she] is outside or off the property . . . A reduction in the rights restrictions will occur when [C7's Name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] no longer is a resident of the facility . . ." There was no documented evidence the restrictions were identified in a behavior plan nor was there a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

9. Review of C8's "CFA," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities.

Review of C8's "IPP," dated 02/20/25 and provided by the facility, revealed, ". . . Rights Assessment: [C8's Name] were reviewed with [him/her]. It has been assessed that [he/she] does not understand some of [his/her] rights, but is limited to being able to advocate for [himself/herself] if [his/her] rights were violated . . . Limitation of Rights: 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [C8's Name] uses bedrails on [his/her] bed and a seatbelt in wheelchair and shower chair and a chest harness . . . 11. The right to privacy. Why is this limitation being recommended? [C8's Name] has a call bell in [his/her] bathroom in order to alert staff if [he/she] needs/wants assistance. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C8's Name] does not always pay attention around traffic and is open to exploitation. [He/She] should be supervised when outside the ICF building in the event [he/she] has a need. [He/She] needs seatbelts on wheelchair and shower and chest harness on wheelchair . . . A reduction in the rights restrictions will occur when [C8's Name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] is no longer a resident of the facility . . ." There was no documented evidence that the restrictions were identified in a behavior plan nor was there a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed that the clients not having access to their kitchen and not being able to freely go out the front door due to a delayed egress locking system that required a code to exit were not taken to HRC for approval. The director stated with the design of the home, he/she did not realize the clients were supposed to be able to access the kitchen. The facility Director confirmed all of the restrictions above did not have the required components including restoration plans for their rights.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the Human Rights Committee (HRC) approved all client restrictions before the restrictions were imposed for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The clients did not have freedom of movement to access common areas of their home. Clients were restricted from their kitchen, and the clients' front door to their home was equipped with delayed egress locking hardware and required a key code to exit. These restrictions were not taken before the HRC, and clients were not afforded due process. Additionally, the right restrictions approved by the HRC and identified in the clients' CFA did not include a behavior plan which included a rights restoration plan. These restrictions affected all 15 clients who resided in the home.

Findings include:

Review of the facility's undated policy titled, Human Right Committee Procedures" revealed, ". . . The Human Rights Committee (HRC) is charged with the responsibility and duty to safeguard the rights of residents of [Facility Name] . . ."

Review of the facility's undated document titled, "What is a Rights Restriction?" revealed, "Restriction means anything that limits or prevents an individual from freely exercising his/her rights and privileges. Something is usually considered restrictive if it impedes the enjoyment of general liberties that are available to all citizens. Rights restrictions include (but are not limited to) such things as: Limitation on access to personal possessions (. . . phone . . .), to food or drink . . . Limitations to movement . . . Door/Window alarms and other environmental restrictions . . . The Committee also protects against violations to Alabama-specific rights and personal freedoms for people with development disabilities receiving supports. For the residential program, these include: . . . Exercise freedom of movement within physical environments . . ."

Review of the facility's policy titled, "Individual Rights and Grievance Procedure," revised 08/2022, revealed, ". . . It is the policy of [Facility Name] to provide age appropriate assistance to individuals who are admitted to [Facility Name] and to responsible others acting on their behalf, to exercise the same human and legal rights guaranteed all persons by the U.S. Constitution unless the individual has been specifically determined to be incompetent by judicial proceedings or otherwise legally restricted. Without regard to competency or legal restrictions, [Name of Facility] recipients have the right to provision of services within an environment that is safe, humane, and abuse free . . . In addition . . . residents have the right to appropriate quality treatment, services, and habilitation specifically designed to maximize their developmental potential within the least restrictive setting . . . HUMAN TREATMENT AND CIVIL RIGHTS. A home-like atmosphere shall be provided. A written policy concerning resident's rights shall be posted in a conspicuous location, and residents on admission shall be informed of their rights orally and in writing in plain and simple language . . ."

Review of the facility's "Individual Rights Handbook," revised 08/2022, revealed, ". . . This handbook tells you about the rights, privileges and responsibilities you have while you are receiving services in programs ...you, your family and friends can be certain that every . . . employee wants to protect your rights. While you are residing and/or receiving services . . . the Human Rights Committee and the [Facility Name] Employees will guard your rights. All of these people want to assist you and to preserve your rights . . . As a recipient of services available from [Facility Name] you have all the rights listed in this handbook the following: 1. You have the right to be treated as an adult and exercise your rights without being punished for doing it . . . 4. You have all the rights as an U.S. citizen and of the state of Alabama, unless your rights have been limited by a judge. This is only done for very good reasons. This includes the right to be considered competent until a court orders otherwise . . . 11. You should be told of your Person Centered Plan (PCP) or Individual Program Plan (IPP) and any restrictions to your rights. Sometimes, some of your rights might be restricted. You may ask your Program Director for a review of this decision if you do not agree with it . . . 25. You have the right not to be unnecessarily restrained, (physically or chemically), or isolated unless for your safety or the safety of others . . ."

Review of the facility's policy titled, "Personal Care and House Rules," dated 08/2008, revealed, ". . . to establish a home that enables the residents to progress or be maintained in the least restrictive environment. The effectiveness in providing adequate support services is to provide as much independence as possible and not provide personal care elements that are not needed . . . staff shall provide observation and precautionary measures to provide safety and protection from residents ' falling, wandering, and harm . . ."

1. During an interview on 09/30/25 at 4:23 PM, when asked how clients accessed their kitchen, Cook (CK) 1 stated the clients were not allowed in the kitchen here.

Observation on 09/30/25 at 4:25 PM of the dining room revealed signage on the wall by the door to the kitchen of "Only dietary staff permitted in the kitchen . . . Kitchen door to be locked and shut at all times . . ."

During an interview on 09/30/25 at 4:47 PM, when asked if clients of the home were able to access their kitchen, the Food Service Director (FSD) stated staff would assist the clients if they needed or wanted anything that was in the kitchen. The FSD stated normally the kitchen door was only unlocked during normal business hours.

Observation on 09/30/25 at 4:50 PM at the front door of the home (main entrance) revealed the door was equipped with delayed egress hardware and had a sign which stated if the bar was pushed for 15 seconds (consistently) the door would open. The door required a code to get out the door without a 15 second delay.

Observation on 09/30/25 at 5:06 PM revealed when this writer attempted to exit the home by pushing on the exit bar, an audible alarm sounded until the bar was released.. The door did not open, and a key code was required to exit the home.

During an interview on 10/01/25 at 7:53 AM, Resident Aide (RA) 1 stated he/she had worked at the facility for almost three years. When asked if the clients had access to their home's kitchen, RA1 stated, "No, but the clients would ask staff if they wanted a snack or a drink." RA1 also stated clients were not "allowed" to go into the kitchen.

During an interview on 10/01/25 at 8:06 AM, RA3 stated he/she had been employed at the facility for five years. RA3 stated clients were not allowed to go into the kitchen and had not been able to go into the kitchen since he/she had been employed due to safety reasons.

During an interview on 10/01/25 at 8:17 AM, the Program Coordinator (PC), who was also a Licensed Practical Nurse (LPN) stated he/she was responsible for overseeing everything in the home. The PC stated clients who lived in the home could not go into the kitchen because of safety reasons.

During an interview on 10/01/25 at 9:47 AM, when asked about the clients not having access to their own kitchen, the Qualified Intellectual Disability Professional (QIDP) stated the clients should have been able to have access to the kitchen of their home; however, the direct care staff did not allow the clients to have access because of safety reasons.

2. Review of C1's "Comprehensive Functional Assessment (CFA)," dated 05/011/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post traumatic stress disorder (PTSD). Continued review of the CFA revealed it was identified that C1 understood all of his/her rights and how to advocate, as well as the grievance process, but would feel afraid or uncomfortable doing so.

Review of C1's "Individual Program Plan (IPP)," dated 05/2025 and provided by the facility, revealed, ". . . QIDP reviewed C1's Rights Restrictions and [C1's family names] were in agreement with [his/her] restrictions. As the QIDP began talking about the goals that were formulated for [C1's Name] [he/she] went into detail about [his/her] goals and stated that [he/she] agreed with [his/her] plan . . . [C1's Name] looks forward to being challenged and especially focusing on [his/her] bracelet business and having the freedom to travel throughout the [Facility Name] community . . . [C1's Name] family is very interested in creating 'lanes' for [C1's Name] to drive [his/her] wheelchair throughout the community [facility campus] . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, individual program planning, and alternate placement . . . Why is this limitation being recommended? [C1's name] is included in the decisions concerning [him/her]. [He/She] is able to make most decisions for [himself/herself]. [He/She] may receive some guidance from [his/her] parents . . . 7. The right to freedom from the use of unnecessary medications and mechanical, chemical, or physical restraints. Why is this limitation being recommended? [C1's Name] uses bedrails on [his/her] bed and seat belts in [his/her] wheelchair and shower chair . . ." Continued review revealed the IPP identified that C1's right to freedom of movement in the home, campus grounds, and off campus grounds were not restricted. C1's IPP did not include any type of behavior plan or a plan to restore the client's rights that had been restricted. There was no documented evidence HRC had reviewed the identified restrictions.

During an interview on 10/01/25 at 12:25 PM, C1 stated living an independent life was very important to him/her. C1 stated he/she was 26 years old and wanted to visit his/her friends who lived on campus at the other houses. C1 stated he/she can independently use his/her wheelchair and has a cell phone he/she could independently use; however, at this time he/she is not allowed to make that choice. C1 stated he/she could not even independently go sit on the front porch of the home because the door stays locked by a keypad. C1 further stated he/she nor other clients were allowed to access the home's kitchen.

3. Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder.

Review of C2's "IPP," dated 11/21/24 and provided by the facility, revealed, ". . . Rights Assessment: It has been assessed that [he/she] does not understand them and didn't really want to hear them at this time. [He/She] was unable to state who [he/she] would tell if [he/she] felt [his/her] rights were violated . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of restrictive behavior and/or medical procedures . . . 9. The right to have access to, to keep, and to spend personal money. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds, and off [facility name] grounds . . . A reduction in the rights restraints will occur when [C2's name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] is no longer a resident . . . [His/Her] rights will be reviewed annually . . ." There was no documented evidence of a behavior plan addressing these restrictions nor a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

4. Review of C3's "IPP," dated 05/09/25 and provided by the facility, revealed the client was a 71 year old client who was admitted to the facility on 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities. The IPP also revealed, ". . . Rights Assessment: [C3's Name] does understand some of [his/her] rights but needs assistance with others. [His/Her] rights will be reviewed with [his/her] annual. The QIDP asked whom [he/she] would feel comfortable talking to if [he/she] felt [he/she] was being mistreated and [he/she] [identified persons] . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds . . ." There was no documented evidence the restrictions were documented in a behavior plan nor a plan to restore the restricted rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

5. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C4's "IPP," dated 12/12/24 and provided by the facility, revealed, ". . . Rights Assessment: [C4's Name] had [his/her] rights reviewed with [him/her] and it has been assessed that [he/she] does have limited understanding of [his/her] rights and how to report concerns . . . Any recommendations for goals retaining to rights: None at this time . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . ." The IPP indicated C4's right to freedom of movement in the home, vocational center, and on the facility's campus was not restricted and documented ". . . [C4's name] has freedom of movement at the health and wellness center and in the ICF. [He/She] has supervision when outdoors . . . as a safety precaution . . ." There was no documented evidence the restrictions were documented in a behavior plan nor was there a plan to restore the restricted rights. Additionally, the IPP failed to identify C4's freedom of movement was restricted in his/her home as he/she could not access his/her home's kitchen and the front door of his/her home was equipped with a delayed egress locking system.

6. Review of C5's "IPP," dated 08/20/25 and provided by the facility, revealed the client was a 44 year old client who was admitted to the facility on 08/06/14 with diagnoses which included Wolf-Hirschhorn Syndrome, profound intellectual disabilities, and epilepsy. The IPP also revealed, ". . . Right Assessment: It has been assessed that [C5's Name] does not understand [his/her] rights and would not be able to advocate for [himself/herself] in the event [his/her] rights were violated in some way . . . Any recommendations for goals relating to rights: none at this time . . . Limitations of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is the limitation being recommended? [C5's Name] uses a specialized bed with high bedrails on all four sides. [He/She] has a seatbelt, a chest strap, and thigh/trunk guides on [his/her] wheelchair . . . 8. The right to wear, to keep, to use own clothing, personal hygiene items, and personal possessions. Why is this limitation being recommended? [C5's Name] hygiene items are kept in a safe place where staff can access them. [He/She] is not able to read or understand about the hazards of various substances and may ingest harmful ones. [He/She] is physically unable to use [his/her] hygiene products on [his/her] own . . . 11. The right to privacy. Why is this limitation being recommended? [C5's Name] has a live time monitor in [his/her] room to monitor for safety due to brittle bones-to help staff be aware of [his/her] safety needs . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C5's Name] has no safety awareness and requires supervision on an off [Facility Name] grounds . . . " There was no documented evidence of a behavior plan to address the right restrictions nor any evidence of a restoration plan to restore these rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

7. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder.

Review of C6's "IPP," dated 02/06/25 and provided by the facility, revealed, ". . . Rights Assessment: . . . it was assessed that [C6's] name does not understand [his/her] rights . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [C6's Name] uses bedrails on [his/her] bed and seatbelts on [his/her] wheelchair and shower chair to prevent falls and a gait belt when walking. There are wheelchair and bed alarms to alert staff if [he/she] is in need of assistance . . . 11. The right to privacy. Why is this limitation being recommended? [C6's Name] requires standby assistance with all areas of hygiene due to seizure precautions, and therefore [his/her] right to privacy is limited for medical reasons. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C6's Name] has supervision when [he/she] is on or off [Facility Name] property. [He/She] requires help with transportation and ambulation . . . The reduction in [C6's Name] rights is congruent with [his/her] care needs. If at anytime it is shown that [C6's Name] is able to exercise these rights safely without restrictions or when [he/she] is no longer a resident, these restrictions will be removed . . . " There was no documented evidence of a behavior plan nor a restoration plan to restore the client's rights restrictions. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

8. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities.

Review of C7's "IPP," dated 07/10/25 and provided by the facility, revealed, ". . . Rights Assessment: . . . It has been assessed that [R7's Name] does not understand the rights and responsibilities due to [his/her] speech and disability . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement. Why is the limitation recommended? [C7's Name] does not understand some aspects of [his/her] care, finances, and/or legal issues. [He/She] has legal guardians to help [him/her] with decisions . . . 5. The right to make and to receive confidential phone calls. Why is the limitation recommended? [C7's Name] still has the right to make and receive phone calls in private. [His/Her] sisters who are [his/her] guardians have asked that [he/she] not have [his/her] cell phone until after the evening meal . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [He/She] [C7] uses bedrails and bed alarms due to a seizure disorder. [He/She] has a restricted wheelchair seatbelt and shower chair belt due to [his/her] seizure disorder. 8. The right to wear, to keep, and to use own clothing, personal hygiene items, and personal possessions. Why is this limitation being recommended? [C7's Name] is kept at the nurse's station to prevent [him/her] from calling people in the middle of the night. [He/She] has agreed with [his/her] sisters on this issue . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? To protect [him/her] from exploitation and to ensure safety, [he/she] is accompanied by a staff if [he/she] is outside or off the property . . . A reduction in the rights restrictions will occur when [C7's Name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] no longer is a resident of the facility . . ." There was no documented evidence the restrictions were identified in a behavior plan nor was there a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

9. Review of C8's "CFA," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities.

Review of C8's "IPP," dated 02/20/25 and provided by the facility, revealed, ". . . Rights Assessment: [C8's Name] were reviewed with [him/her]. It has been assessed that [he/she] does not understand some of [his/her] rights, but is limited to being able to advocate for [himself/herself] if [his/her] rights were violated . . . Limitation of Rights: 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [C8's Name] uses bedrails on [his/her] bed and a seatbelt in wheelchair and shower chair and a chest harness . . . 11. The right to privacy. Why is this limitation being recommended? [C8's Name] has a call bell in [his/her] bathroom in order to alert staff if [he/she] needs/wants assistance. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C8's Name] does not always pay attention around traffic and is open to exploitation. [He/She] should be supervised when outside the ICF building in the event [he/she] has a need. [He/She] needs seatbelts on wheelchair and shower and chest harness on wheelchair . . . A reduction in the rights restrictions will occur when [C8's Name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] is no longer a resident of the facility . . ." There was no documented evidence that the restrictions were identified in a behavior plan nor was there a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed that the clients not having access to their kitchen and not being able to freely go out the front door due to a delayed egress locking system that required a code to exit were not taken to HRC for approval. The director stated with the design of the home, he/she did not realize the clients were supposed to be able to access the kitchen. The facility Director confirmed all of the restrictions above did not have the required components including restoration plans for their rights.
W0266 CLIENT BEHAVIOR & FACILITY PRACTICES
CFR(s): 483.450

The facility must ensure that specific client behavior and facility practices requirements are met.


This CONDITION is not met as evidenced by:
Based on interview and record review the facility failed to have a policy and procedure that governed the management of inappropriate client behavior. Client (C) 2 engaged in a high frequency of inappropriate behavior including self-injurious behavior. The facility's failure to have a policy led to neglect and actual harm to the client. This failure placed all 15 clients of the facility at risk for their current behaviors or behaviors which could be manifested to not be appropriately managed.

On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures constituted Immediate Jeopardy. It was determined the Immediate Jeopardy existed on 11/13/24 when C2 was noted to have self-injurious behaviors, and the facility did not have a policy to address those behaviors.

The facility presented an acceptable plan of removal on 10/04/25 at 2:35 PM.

The facility's removal plan included:

1. The facility developed a policy that governed the management of inappropriate behaviors.

2. The facility began training staff on the developed policy and all staff will be trained prior to working their next shift.

Through interview and record review, the survey team was able to validate the facility began implementation of the removal plan, and the Immediate Jeopardy was lifted on 10/04/25 at 6:15 PM.

Findings include:

1. The facility failed to develop written policies and procedures that govern the management of inappropriate behavior. This systemic failure affected all 15 clients who resided at the facility. Cross Reference: W274.

2. The facility failed to ensure a fully enclosed barred bed which could prevent a client from leaving the bed was not used without documented behavioral assessments which clearly stated why the enclosure was necessary, the risks of using the enclosure versus not using the enclosure, and what less restrictive measures had been attempted for one of eight sampled clients (Client (C) 5). Cross Reference: W307.

Based on interview and record review the facility failed to have a policy and procedure that governed the management of inappropriate client behavior. Client (C) 2 engaged in a high frequency of inappropriate behavior including self-injurious behavior. The facility's failure to have a policy led to neglect and actual harm to the client. This failure placed all 15 clients of the facility at risk for their current behaviors or behaviors which could be manifested to not be appropriately managed.

On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures constituted Immediate Jeopardy. It was determined the Immediate Jeopardy existed on 11/13/24 when C2 was noted to have self-injurious behaviors, and the facility did not have a policy to address those behaviors.

Findings include:

1. The facility failed to develop written policies and procedures that govern the management of inappropriate behavior. This systemic failure affected all 15 clients who resided at the facility. Cross Reference: W274.

2. The facility failed to ensure a fully enclosed barred bed which could prevent a client from leaving the bed was not used without documented behavioral assessments which clearly stated why the enclosure was necessary, the risks of using the enclosure versus not using the enclosure, and what less restrictive measures had been attempted for one of eight sampled clients (Client (C) 5). Cross Reference: W307.

***********************

The facility presented an acceptable plan of removal on 10/04/25 at 2:35 PM.

The facility's removal plan included:

1. The facility developed a policy that governed the management of inappropriate behaviors.

2. The facility began training staff on the developed policy and all staff will be trained prior to working their next shift.

Through interview and record review, the survey team was able to validate the facility began implementation of the removal plan, and the Immediate Jeopardy was lifted on 10/04/25 at 6:15 PM.
W0274 MGMT OF INAPPROPRIATE CLIENT BEHAVIOR
CFR(s): 483.450(b)(1)

The facility must develop and implement written policies and procedures that govern the management of inappropriate client behavior.


This STANDARD is not met as evidenced by:
Based on interview and review of the facility's policy manual, the facility failed to develop written policies and procedures that govern the management of inappropriate behavior. This systemic failure affected all 15 clients who resided at the facility.

Findings include:

Review of the facility's policy and procedures manual located in the conference room revealed no documented evidence the facility developed a policy that governed the management of inappropriate client behavior.

During an interview on 10/02/25 at 1:07 PM, when asked if the facility had a behavior management policy that included the use of a functional behavior assessment in the development of behavior management programs, a hierarchy of least to most intrusive measures, and the incorporation of behavior management programs into the IPP, the facility Director stated "No."

Based on interview and review of the facility's policy manual, the facility failed to develop written policies and procedures that govern the management of inappropriate behavior. This systemic failure affected all 15 clients who resided at the facility.

Findings include:

Review of the facility's policy and procedures manual located in the conference room revealed no documented evidence the facility developed a policy that governed the management of inappropriate client behavior.

During an interview on 10/02/25 at 1:07 PM, when asked if the facility had a behavior management policy that included the use of a functional behavior assessment in the development of behavior management programs, a hierarchy of least to most intrusive measures, and the incorporation of behavior management programs into the IPP, the facility Director stated "No."
W0307 PHYSICAL RESTRAINTS
CFR(s): 483.450(d)(6)

Opportunity for motion and exercise must be provided and a record of such activity must be kept.


This STANDARD is not met as evidenced by:
Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure a fully enclosed barred bed which could prevent a client from leaving the bed was not used without documented behavioral assessments which clearly stated why the enclosure was necessary, the risks of using the enclosure versus not using the enclosure, and what less restrictive measures had been attempted for one of eight sampled clients (Client (C) 5).

Findings include:

Review of the facility's policy titled, "Board of Directors Policy on Resident Rights," revised 08/2022, revealed ". . . 6. Physical restraint and separation shall not be used as a routine therapeutic procedure. It may be used when protecting a resident from personal harm, from harming others, or when as a therapeutic necessity and reviewed as such by the Human Rights Committee . . ."

Observation on 10/01/25 at 11:50 AM of C5's bedroom revealed the client's bed was a fully enclosed barred bed.

Review of C5's "Individual Program Plan (IPP)," dated 08/20/25 and provided by the facility, revealed the client was a 44 year old client who was admitted to the facility on 08/06/14 with diagnoses which included Wolf-Hirschhorn Syndrome, profound intellectual disabilities, and epilepsy. The IPP also revealed ". . . Right Assessment: It has been assessed that [C5's Name] does not understand [his/her] rights and would not be able to advocate for [himself/herself] in the event [his/her] rights were violated in some way . . . Any recommendations for goals relating to rights: none at this time . . . Limitations of Rights: . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is the limitation being recommended? [C5's Name] uses a specialized bed with high bedrails on all four sides . . . Health and Safety . . . [C5's Name] has brittle bones . . . [he/she] has . . . high bedsides to prevent falls . . . H. Areas of Independence: [C5's Name] can sit up in bed or in [his/her] wheelchair and can reposition [himself/herself] . . ."

During an interview on 10/04/25 at 9:15 AM, when asked for documentation to justify the use of C5's enclosed barred bed, the facility Director stated this was approved by the Human Rights Committee (HRC); however, there was no restoration plan or any other documentation including a physical support plan, or other interventions that had been attempted. The Director stated C5's father wanted the enclosed bed.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure a fully enclosed barred bed which could prevent a client from leaving the bed was not used without documented behavioral assessments which clearly stated why the enclosure was necessary, the risks of using the enclosure versus not using the enclosure, and what less restrictive measures had been attempted for one of eight sampled clients (Client (C) 5).

Findings include:

Review of the facility's policy titled, "Board of Directors Policy on Resident Rights," revised 08/2022, revealed ". . . 6. Physical restraint and separation shall not be used as a routine therapeutic procedure. It may be used when protecting a resident from personal harm, from harming others, or when as a therapeutic necessity and reviewed as such by the Human Rights Committee . . ."

Observation on 10/01/25 at 11:50 AM of C5's bedroom revealed the client's bed was a fully enclosed barred bed.

Review of C5's "Individual Program Plan (IPP)," dated 08/20/25 and provided by the facility, revealed the client was a 44 year old client who was admitted to the facility on 08/06/14 with diagnoses which included Wolf-Hirschhorn Syndrome, profound intellectual disabilities, and epilepsy. The IPP also revealed ". . . Right Assessment: It has been assessed that [C5's Name] does not understand [his/her] rights and would not be able to advocate for [himself/herself] in the event [his/her] rights were violated in some way . . . Any recommendations for goals relating to rights: none at this time . . . Limitations of Rights: . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is the limitation being recommended? [C5's Name] uses a specialized bed with high bedrails on all four sides . . . Health and Safety . . . [C5's Name] has brittle bones . . . [he/she] has . . . high bedsides to prevent falls . . . H. Areas of Independence: [C5's Name] can sit up in bed or in [his/her] wheelchair and can reposition [himself/herself] . . ."

During an interview on 10/04/25 at 9:15 AM, when asked for documentation to justify the use of C5's enclosed barred bed, the facility Director stated this was approved by the Human Rights Committee (HRC); however, there was no restoration plan or any other documentation including a physical support plan, or other interventions that had been attempted. The Director stated C5's father wanted the enclosed bed.
W0454 INFECTION CONTROL
CFR(s): 483.470(l)(1)

The facility must provide a sanitary environment to avoid sources and transmission of infections.


This STANDARD is not met as evidenced by:
Based on observation, interview, and review of the facility's policy, the facility failed to ensure meals were prepared and served in a sanitary environment. A cook with facial hair was preparing clients' lunch meal without any covering to protect hair from falling into the food. This had the potential to affect 14 of 15 clients who received meals from the home's kitchen.

Findings include:

Review of the facility's policy titled, "Dietary Services Procedure," revised 04/08/13, revealed "All dietary employees will have good hygienic practices to prevent bacterial contamination. Employees will have an understanding of safety and sanitation guidelines and put into practice those guidelines in order to provide a safe product. Procedure: . . . 3. Employees shall wear hair restraints that are designed and worn to effectively keep their hair form contacting exposed food, clean equipment, utensils, and linens . . ."

Observation on 10/01/25 at 11:41 AM revealed Cook (CK) 2 was in the kitchen standing over the meal preparation area. The cook had facial exposed with no covering to protect the environment and/or food from contamination.

Observation on 10/01/25 at 11:45 AM revealed CK2 retrieving baked potatoes from the oven. CK2's facial hair was still exposed.

During an interview on 10/01/25 at 12:03 PM, CK2 stated he/she had only been employed at the facility for four days. CK2 stated he/she was not aware that his/her facial hair needed to be covered and had not been directed to have it covered.

During an interview on 10/01/25 at 2:19 PM, the Food Service Director (FSD) stated CK2 should have had something covering his/her facial hair. The FSD stated he/she needed to order facial hair coverings for CK2.

During an interview on 10/04/25 at 6:41 PM, the facility Director stated it was his/her expectation the cook would have his/her facial hair covered while in the kitchen preparing food.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure meals were prepared and served in a sanitary environment. A cook with facial hair was preparing clients' lunch meal without any covering to protect hair from falling into the food. This had the potential to affect 14 of 15 clients who received meals from the home's kitchen.

Findings include:

Review of the facility's policy titled, "Dietary Services Procedure," revised 04/08/13, revealed "All dietary employees will have good hygienic practices to prevent bacterial contamination. Employees will have an understanding of safety and sanitation guidelines and put into practice those guidelines in order to provide a safe product. Procedure: . . . 3. Employees shall wear hair restraints that are designed and worn to effectively keep their hair form contacting exposed food, clean equipment, utensils, and linens . . ."

Observation on 10/01/25 at 11:41 AM revealed Cook (CK) 2 was in the kitchen standing over the meal preparation area. The cook had facial exposed with no covering to protect the environment and/or food from contamination.

Observation on 10/01/25 at 11:45 AM revealed CK2 retrieving baked potatoes from the oven. CK2's facial hair was still exposed.

During an interview on 10/01/25 at 12:03 PM, CK2 stated he/she had only been employed at the facility for four days. CK2 stated he/she was not aware that his/her facial hair needed to be covered and had not been directed to have it covered.

During an interview on 10/01/25 at 2:19 PM, the Food Service Director (FSD) stated CK2 should have had something covering his/her facial hair. The FSD stated he/she needed to order facial hair coverings for CK2.

During an interview on 10/04/25 at 6:41 PM, the facility Director stated it was his/her expectation the cook would have his/her facial hair covered while in the kitchen preparing food.