Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00274324 Renewal 09/23/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.207(5)(II)On 9/24/2025 at 11:50AM, Individual #1's bed was observed with bilateral upper bedrails that had the potential to restrict the movement or function of Individual #1's body. Individual #1's current order by the Primary Care Physician was on the physical examination dated 11/21/24, where it indicated "Side rails for client safety while in bed" in the Health Maintenance section. Staff interviews reveal that Individual #1 is unable to easily remove the device or indication or request the immediate removal by a staff person. The agency has not made a determination that the bedrails are not a mechanical restraint or medically needed to include but not limited to the completion of the "mechanical restraint decision tree" and the attempted use of alternative devices.A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Balance or support to achieve functional body position, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement.For individual #1 identified in the deficiency, the POC must outline specific, immediate corrective actions. Individual Functional and Risk-Benefit Assessment The agency will conduct a new, comprehensive assessment for individual #1 with input from their physician and parent and/or guardian. This assessment will specifically identify the medical symptom or functional need (e.g., mobility assistance, repositioning) that the bed rails address. The assessment will be documented on the agency's standardized form and reviewed by nursing for completeness and accuracy. Medical Order Review A licensed nurse will verify that a valid, current physician's order is in place for individual #1 using bed rails. The order will specify both the type of rail and the medical symptom or diagnosis for which the bed rail is prescribed. This order will be kept on file in the resident's record and renewed annually, or sooner if there is a change in the individual's condition. ISP and HRST Update The resident's Individual Support Plan (ISP) will be updated to include the identified need for the use of bed rails, ensuring that the intervention is integrated into the person's overall plan of care and treatment supports. The resident's Health Risk Screening Tool (HRST) will also be updated to reflect the use of bed rails and the diagnosis or medical condition that necessitates their use. The assigned Program Specialist will ensure that updates are submitted to the Supports Coordinator, and nursing will verify HRST accuracy. Entrapment Mitigation Any bed rails in use will be inspected to ensure they meet manufacturer specifications and entrapment prevention standards consistent with FDA Hospital Bed Safety Workgroup (HBSW) guidelines. Informed Consent Informed consent for the use of bed rails will be reviewed and reaffirmed with the resident or their parent and/or guardian, confirming understanding of both the risks and benefits. Consent will be re-reviewed annually or with any change in the individual's condition. Documentation Review The care plan will be updated to clearly identify the medical indication for the bed rail and detail how its use assists the resident's condition. The care plan will be reviewed and updated as needed and at least annually, in conjunction with the functional and risk-benefit assessment. 12/01/2025 Implemented
SIN-00199820 Renewal 02/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(a)Individual #1 had a dental appointment on 01/09/20, and then again on 08/04/21.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. In response to this violation of 6400.142(a) discovered during the licensing inspection for the McGuire Memorial Community Home program held from 2/8 to 2/10 of 2022, the plan of correction is as follows: Effective immediately, the community home nurses shall be trained to schedule dental examinations for all residents of the community home program (18 years of age or older) that will occur annually with those residents¿ current dental provider. [Training on scheduling dental appointments, dated 3/31/22, received on 4/4/22 and reviewed on 4/19/22 by HDKP, HSLS]. 03/09/2022 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 02/19/21. The rights document did not include the following rights: 6400.32e through 6400.32g, to choose, accept risks, refusal and control the individual's schedule, activities and services; 6400.32p through 6400.32u, choosing with whom they share a bedroom, decorating and furnishing bedroom and common areas, door locks in bedrooms and to the main entrance of the home, access to food at any time, and making healthcare decisions.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.In response to this violation of 6400.34(a) discovered during the licensing inspection for the McGuire Memorial Community Home program held from 2/8 to 2/10 of 2022, the plan of correction is as follows: Effective immediately, and into the future, when explaining to and informing each individual of their rights, the individual will be informed of the following rights: 6400.32e through 6400.32g, to choose, accept risks, refusal and control the individual's schedule, activities and services; 6400.32p through 6400.32u, choosing with whom they share a bedroom, decorating and furnishing bedroom and common areas, door locks in bedrooms and to the main entrance of the home, access to food at any time, and making healthcare decisions. The updated rights will be documented for each individual who resides within our community home program and their guardians, and they will be asked to sign off that they have had these rights explained to them. This will all be completed no later than April 15, 2022. [Updated and signed Individual Rights document, dated 3/28/22, received on 4/4/22 and reviewed 4/19/22. Training, dated 3/29/22, on Individual Rights received on 4/4/22 and reviewed on 4/19/22 by HDKP, HSLS]. 04/15/2022 Implemented
SIN-00257260 Renewal 12/11/2024 Compliant - Finalized
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SIN-00147212 Renewal 12/18/2018 Compliant - Finalized
SIN-00106435 Renewal 01/10/2017 Compliant - Finalized
SIN-00073109 Renewal 12/03/2014 Compliant - Finalized