Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00280295 Unannounced Monitoring 12/19/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)There was a leak in the hallway from the ceiling in front of the entry way to Unit 3. The space is shared by both Units 2 and 3. Floors, walls, ceilings and other surfaces shall be free of hazards.The water leak was identified and reported to the landlord immediately upon discovery, prior to the licensing inspection. The landlord retained a licensed roofer, and roof repairs were completed prior to the inspection date. Management staff monitored the affected area regularly for any additional moisture or water intrusion following the repair. Individuals were not exposed to unsafe conditions, and the area remained usable and monitored during the repair process. Following roof repair, the landlord advised a brief observation period to confirm the leak was fully resolved prior to completing drywall and cosmetic restoration. The provider will continue to observe the area during rain events. If no further water intrusion is identified, drywall repair and restoration will be completed by 2/15/26 by the landlord, or by the provider if necessary. Completion of repairs will be verified and documented through maintenance records and photographs. 12/12/2025 Implemented
6400.18(b)(2)Prescription orders shall be kept current, adhering to the most recent prescription for a medication. An After Visit Summary (AVS) from Mercer Community Behavioral Health dated 11/17/2025 reflects a change in the prescription for Hydroxyzine 50 mg (Atarax) from three times daily scheduled to three times daily as needed. Review of Individual #1's December Medication Administration Record (MAR) revealed that Hydroxyzine was administered as a scheduled medication three times daily, despite the updated PRN order. On 12/07/2025, the order was discontinued in the MAR by the provider and re-entered with an incorrect schedule of three times daily scheduled. The order was then discontinued by the provider again on 12/10/2025 and re-entered as twice daily scheduled. The medication order was discontinued by the provider again on 12/14/2025 and correctly re-entered on 12/15/2025 to reflect Hydroxyzine 50 mg three times daily as needed for anxiety. Per communication with the provider, no additional changes regarding Hydroxyzine have been prescribed other than 11/17/2025. Administration of Hydroxyzine was not accurately reflected in the MAR in accordance with the physician's most recent order on 11/17/2025. Incidents in EIM should have been entered for any administration that did not align with the current physician order.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.On 12/15/2025, the Medication Administration Record (MAR) was corrected to accurately reflect the physician's most recent order: Hydroxyzine 50 mg, three times daily as needed for anxiety. All prior incorrect MAR entries were formally discontinued. Staff involved received targeted retraining on... MAR entry and discontinuation procedures Medication order verification Scheduled vs. PRN administration requirements (Training completed 1/28/2026). 12/15/2025 Implemented
6400.165(b)Prescription orders shall be kept current, adhering to the most recent prescription for a medication. An After Visit Summary (AVS) from Mercer Community Behavioral Health dated 11/17/2025 reflects a change in the prescription for Hydroxyzine 50 mg (Atarax) from three times daily scheduled to three times daily as needed. Review of Individual #1's December Medication Administration Record (MAR) revealed that Hydroxyzine was administered as a scheduled medication three times daily, despite the updated PRN order. On 12/07/2025, the order was discontinued in the MAR by the provider and re-entered with an incorrect schedule of three times daily scheduled. The order was then discontinued by the provider again on 12/10/2025 and re-entered as twice daily scheduled. The medication order was discontinued by the provider again on 12/14/2025 and correctly re-entered on 12/15/2025 to reflect Hydroxyzine 50 mg three times daily as needed for anxiety. Per communication with the provider, no additional changes regarding Hydroxyzine have been prescribed other than 11/17/2025. Administration of Hydroxyzine was not accurately reflected in the MAR in accordance with the physician's most recent order on 11/17/2025. Incidents in EIM should have been entered for any administration that did not align with the current physician order.A prescription order shall be kept current.The provider reviewed the most recent physician order and updated the MAR on 1/1/2026 to accurately reflect the prescription change from three times daily scheduled to three times daily as needed. Incident was entered on 1-28-2026 into the EIM 9776581 01/01/2026 Implemented
6400.165(c)Prescription medications shall be administered as ordered. Review of the December Medication Administration Record (MAR) revealed multiple medication order changes during the month. It was observed that when prescription orders were discontinued and re-entered, staff initialed the MAR in a manner that indicated administration of both the discontinued order and the newly entered order. On 12/07/2025, multiple medications for Individual #1 were initialed as administered twice, including Sertraline, Divalproex, Hydroxyzine, Jencycla, Omega-3 Acid, Oxcarbazepine, Protonix, Prazosin, Vitamin B-12, and Xarelto. On 12/10/2025, Divalproex and Hydroxyzine were again initialed as administered twice. [REPEAT Violation 11/10/2025]A prescription medication shall be administered as prescribed.On 1/1/2026, the Nurse, House Manager, and Residential Program Director reviewed and verified all MARs against current physician medication orders to ensure medications were being administered as prescribed. 01/01/2026 Implemented
6400.166(a)(11)A Medication Record shall include the diagnosis or purpose for each medication, including medications prescribed on a pro re nata (PRN) basis. Review of Individual #1's December Medication Administration Record (MAR) revealed that no diagnosis or purpose was documented for the following medications: Divalproex, Metformin, Omega-3 Acid, Pantoprazole, Prazosin, Vitamin B-12, and Ibuprofen.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.On 1/1/26, The provider updated the MAR to include the documented diagnosis or purpose for each affected medication, including PRN medications. All medication records were reviewed to confirm the diagnosis or purpose was complete and accurate for each prescribed medication. 01/01/2026 Implemented
SIN-00278600 Unannounced Monitoring 11/10/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(c)3 out of 4 trash cans outside the home were overflowing with trashTrash shall be removed from the premises at least once per week. On the day of the inspection, the three overflowing trash cans were emptied immediately, and the surrounding areas were cleaned. 11/10/2025 Implemented
6400.64(f)3 out of 4 trash cans outside the home did not have lids.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The missing trash can lids were replaced with new lids on 11-25-2025 11/25/2025 Implemented
6400.67(a)Countertop in kitchen was not attached to the cabinets. It was simply resting on an angle atop the cabinets below causing a large gap in the surface. Chipping paint was visible throughout the home.Floors, walls, ceilings and other surfaces shall be in good repair. On 11-26-25, the detached/unsecured section of the countertop was secured to the base cabinet using appropriate brackets and screws to ensure it is stable and safe. The area was inspected to confirm that no sharp edges, gaps, or hazards remained. 11/26/2025 Implemented
6400.67(b)A 1x1 opening was without vent cover, next to the bathroom toilet leaving wires exposed and hanging from the opening. Floors, walls, ceilings and other surfaces shall be free of hazards.We tightened the springs on the access panel (not vent). We put the access panel back up to cover the exposed pipes (not wires) 11/26/2025 Implemented
6400.72(b)A large gap was visible where the rear exterior door meets that floor, allowing heat to escape. Screens, windows and doors shall be in good repair. on 11-26 a rubber strip was placed at the bottom of the door. 11/26/2025 Implemented
6400.80(b)Concrete retaining wall outside the home was in dis-repair. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.on 11-26 the crack was cemented and stabilized. 11/26/2025 Implemented
6400.144Depakote 500mg tab was listed on the MAR and was initialed as having been administered from 11/1-11/9 at 8am. Not only was 11/10 8am not initialed, but the entire medication was not anywhere in her medication box. Ondansetron ODT 4 mg Tab was listed on the medication record, but was not in her medication box.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. on 11-10-2025 KELS LLC immediately reconciled the medication box and MAR. Depakote 500mg was reordered and secured in the medication box. The missed MAR initial for 11/10 was corrected using proper late-entry documentation, confirming the medication had been administered. The physician was notified per protocol. Ondansetron, which had been discontinued, was removed from the MAR, and the duplicate Depakote/Divalproex entries were corrected to reflect one accurate medication entry. 11/10/2025 Implemented
6400.165(c)Ferrous Sulfate 325mg Tablet is supposed to be administered every other day. Both 11/1 and 11/2 were initialed for administration.A prescription medication shall be administered as prescribed.On 11-10-2025 KELS LLC reviewed the medication administration and confirmed that Ferrous Sulfate was given on the correct every-other-day schedule; however, staff unintentionally initialed the wrong date due to a Therap system glitch. The MAR was corrected using proper documentation procedures, and Therap support was contacted to verify and resolve the date display issue. Staff were retrained on verifying the correct date field before initialing in Therap and instructed to cross-reference the physical MAR printout when glitches occur. 11/10/2025 Implemented
6400.165(c)There were 8 medications in her medication box that were not listed on the medication administration log, therefore I could not determine if these medications were discontinued or not.A prescription medication shall be administered as prescribed.The 8 medications that were in the medication box but not listed on the MAR were immediately removed from active medication storage until they could be verified. The prescribing physician and pharmacy were contacted the same day to confirm: Whether each medication was currently prescribed, Whether any had been discontinued, Whether any should be PRN, routine, or no longer used. The MAR was corrected to include all confirmed active medications OR discontinued meds were removed from the home and returned to the pharmacy for destruction. Staff were instructed not to administer any medication not listed on the MAR, consistent with regulation. 11/14/2025 Implemented
6400.165(c)None of the blister pack counts lined up with the number of medication log initials. No date was listed on blister packs nor next to a punch to reference what date the pack was actually started. Therefore, I was unable to determine proper administration of the medications throughout the MAR. For example: Benztropine Tab 1mg was picked up on 10.20.25. She was to take one tablet in the morning and one tablet before bed, daily. The blister pack we were reviewing was said to be the morning pack, however, no AM was noted anywhere. 1 of 2 was noted at the top and we were informed the 1 means AM. Based on the date of pick up, there should have been 21 morning punches to bring us to date. There were only 15 punch outs. Each medication continued to display this same issue.A prescription medication shall be administered as prescribed.On 11-10-2025 we counted, labeled and dated the blister packs to indicate when the med was started. 11/10/2025 Implemented
6400.186Staff within the home was not implementing the Individualized Plan in that General Health and Safety Section state that Individual One requires 2:1 staff ratio in all settings. Only one staff was present upon arrival for the initial 30 minutes of the inspection.The home shall implement the individual plan, including revisions.We would like to file a dispute claim as this is incorrect. We had 2 staff there the entire shift and can provide proof w timecards. The 2nd staff was upstairs in the restroom and appeared approximately 5 mins into the inspection. The POC is continuing to staff the individual with 2 staff during the required hours. on the day of inspection, the individual had 3 staff as the Program manager arrived shortly after. 11/27/2025 Implemented
SIN-00274411 Renewal 09/18/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)The trash receptacles found outside of the home did not have lids.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The outdoor trash bin lids were damaged during recent trash collection and were not immediately replaced. Staff failed to report the damage to the Program Manager for follow-up. Corrective Action Taken: New trash bin lids were purchased and installed on 9/19/2025. The Program Manager verified that all outdoor receptacles are now equipped with secure, functional lids. Photos were taken as documentation of correction. 09/19/2025 Implemented
6400.66There was no lighting for the back exit of the home.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The back exit area did not have an exterior light fixture installed. A new exterior light fixture was installed on 9/19/2025 to ensure the back exit is properly illuminated and safe for use during nighttime hours. The Program Manager took photo and verified that the light is fully functional. 09/19/2025 Implemented
6400.67(a)There were two missing knobs on the stove.Floors, walls, ceilings and other surfaces shall be in good repair. The stove knobs had been removed for cleaning and were misplaced. The missing parts were not reported to the Program Manager for replacement prior to inspection. Plan of correction: Replacement stove knobs were purchased and installed on 9/19/2025. The stove was tested to ensure it is in safe and proper working condition. The Program Manager took photos, verified completion of the repair and documented the correction. 09/19/2025 Implemented
6400.72(b)There were holes in the bedroom door of the back room which is used as an office. Screens, windows and doors shall be in good repair. The door was damaged by an individual during a behavioral crisis. Although the damage was reported, the repair was delayed due to pending material replacement. The door was repaired on 9/22/2025, and the Program manager verified that it is now in good condition and free from holes, photos were taken and documented completion of the repair. 09/22/2025 Implemented
6400.144The medication Lovaza 1GM Capsule was found on the MAR but not available during inspection for Individual #1. Ondansetron 4MG Tablet is listed on the MAR twice as a PRN but was not found during inspection.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Both medications were in the home's locked medication storage box at the time of inspection. Staff verified that the medications were present and matched the active prescriptions. Plan of correction: Following the inspection, the Program Manager and RN confirmed that both Lovaza 1GM Capsules and Ondansetron 4MG Tablets were in the medication box, properly labeled, and stored according to ODP medication administration requirements. Program Manager took photos were taken and submitted for documentation. 09/18/2025 Implemented
SIN-00272870 Unannounced Monitoring 08/26/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(e)During the Departments inspection on 8/26/2025 interview, Individual #3 is not allowed to use the deck area at the back of the home unless Individual #3 requests permission to use the area.An individual has the right to make choices and accept risks.The locks were replaced on the door leading to the deck and now the individual can lock and unlock the door to the deck and use the deck at her free will. 09/03/2025 Not Accepted
6400.32(h)The staff #1 was greeted by individual #3 and their conversation began with cursing as if it was the norm and terms of endearment. Licensing then asked individual #3 if we could interview them and individual #3 responded "yes". Before licensing could proceed with the interview, the staff #1 was guiding individual #1 on how they should answer what staff #1's thought the interview questions would involve. Licensing then asked staff #1 to leave the room so that individual #3 could be interviewed without disruption.An individual has the right to privacy of person and possessions.When individuals are being interviewed by an outside source staff will ask the individual if they would like them to stay or if they would like them to step out of the room. Staff will allow the individual to speak for themselves at all times. 09/03/2025 Not Accepted
6400.45(e)Individual #3 is to have 2:1 staffing from 8am-8pm, on 8/26/2025 at 10am, , during the Department's inspection of the home, only one staff member was present.An individual may not be left unsupervised solely for the convenience of the home or the direct service worker.The Program Manager has retrained staff on the importance of maintaining the supervision guidelines at all times as a break in these supervision guidelines is a health and safety risk to the individual. 09/03/2025 Not Accepted
6400.186Individual #3's ISP states they are to have 2:1 staffing from 8am-8pm. On 8/26/2025 at 10am, during the Department's inspection of the home, only one staff member was present.The home shall implement the individual plan, including revisions.The Program Manager has retrained staff on the importance of maintaining the supervision guidelines at all times as a break in these supervision guidelines is a health and safety risk to the individual. If at any time the supervision guidelines are broken the staff should immediately contact the program Manager. 09/03/2025 Not Accepted
SIN-00255556 Renewal 11/06/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)Soiled bug traps were found in the office.There may not be evidence of infestation of insects or rodents in the home. The program manager will remove the soiled bug traps immediately and replace them with clean, appropriate pest control devices. The Program Manager will verify that the area has been cleaned and sanitized following the removal of the traps. All soiled bug traps in the office will be removed and replaced to maintain a clean and sanitary environment. November 6: The program manager will remove the soiled traps and sanitize the affected areas. November 7: New traps will be installed as necessary, and all pest control devices will be placed in inconspicuous, sanitary locations. A full inspection of the site will be conducted to identify and address any additional sanitation issues. The Program Manager will ensure that a pest control log is implemented to monitor and manage the use of traps and other pest control measures. 11/07/2024 Implemented
6400.112(c)For the 08/20/24 fire drill record the time of day was entered where the evacuation time minutes should have been entered.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The Program Specialist will correct the 8/20/24 fire drill record by entering the actual evacuation time in minutes, as verified by staff involved in the drill. The Program Manager will review and approve the correction to ensure accuracy. The 8/20/24 fire drill record will be updated with the correct evacuation time in minutes. The Program Specialist will contact staff present during the 8/20/24 drill to confirm the actual evacuation time. The corrected evacuation time will be recorded on the fire drill form, with the correction signed and dated by the Program Specialist. All fire drill records from the past 12 months will be reviewed by the Program Specialist to ensure accuracy and compliance. Any errors will be corrected by December 1, 2024. The Program Manager will ensure that all fire drill records moving forward are reviewed for accuracy before being finalized and filed. 11/07/2024 Implemented
6400.166(b)There is no documentation or initialing on the MAR that all prescribed medications for 8 AM were administered despite the medications being administered to Individual 2 at 8am on 11/6/2024.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The Nurse will review the MAR for November 16, 2024, and verify the administration of the 8 a.m. medications for Individual 2. The DSP responsible for the error will complete retraining on medication documentation policies. The MAR will be updated to accurately reflect the administration of Individual 2¿s 8 a.m. medications on November 7, 2024. The DSP will initial the MAR to indicate the medications were administered as required. November 7, 2024: The Nurse will review and update the MAR for compliance. November 25, 2024: The DSP will receive retraining on Chapter 6400 medication documentation requirements and the importance of completing the MAR promptly and accurately. A full review of all MARs for the current month will be conducted to identify any other instances of missing documentation. Any discrepancies will be corrected immediately, and all staff responsible will be retrained. 11/07/2024 Implemented