Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00285316 Renewal 03/10/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water in the home exceeded the regulatory 120 degrees. The hot water in the home measured 143.2 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water heater regulator was lowered for the temperature to be below 120 degrees. 04/10/2026 Implemented
6400.144Health services including obtaining pharmaceuticals are not planned for or arranged. Individual #1 is prescribed Vitamin D 1.25mcg weekly. This medication was not available in the home to be administered on 3/8/26. At the time of the inspection, the medication had not been obtained and was still unavailable in the home.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. During the inspection the director called the pharmacy and ordered the Vitamin D and the Polyglycol powder for the home. the pharmacy delivered the medications two hours later to the home. 04/10/2026 Implemented
6400.165(c)Medications are not administered as prescribed. Individual #1 is prescribed Polyethylene Glycol, take 1 capful daily. The bottle of medication contained a 30-day supply and was last filled on 12/29/25. The bottle located in Individual #1's mediation basket was approximately ¼ full. If the medication was administered as prescribed, it would have needed at least one refill since 12/29/25. Individual #1 is prescribed Flonase nasal spray, 1 spray in each nostril daily. The bottle contained a 60-day supply and was last filled on 12/20/25. There was also a second bottle of this mediation in the home that was filled on 1/30/26 that was not opened. The original bottle that was filled on 12/20/25 contained approximately ¼ bottle. If the medication was administered as prescribed, the bottle dated 12/20/25 would have been empty. Individual #1 is prescribed Vitamin D 1.25mcg weekly. This medication was not administered as prescribed on 3/8/26. Documentation on the back of the medication administration record indicated that the medication was not available in the home. At the time of the inspection, the medication had not been obtained and was still unavailable in the home.A prescription medication shall be administered as prescribed.During the inspection the director called the pharmacy and ordered the Vitamin D and the Polyglycol powder for the home. the pharmacy delivered the medications two hours later to the home. 04/10/2026 Implemented
SIN-00240657 Renewal 04/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101At time of inspection a double cylinder deadbolt was found at the rear door of the home. The deadbolt was operated by key on both sides. There was no key for the lock available in the home. Double cylinder deadbolts operated by key on both sides are not permissible as the key required inside lock obstructs egress.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. the dead bolt lock was changed from a key lock to a latch lock to avoid any obstructs of egress from the individual or staff. 05/02/2024 Implemented
6400.112(h)Fire drills reviewed for the location did not include documentation that the individual evacuated to a designated meeting place outside the building or within the fire safe area during each fire drill. The meeting place was recorded on the fire drill forms but the form lacked documentation that all individuals made it to the designated meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.the fire drills have been redone, so that when staff are completing the fire drill they will be documenting that each individual did or did not make it to the meeting place during the fire drills. 05/02/2024 Implemented
SIN-00265462 Renewal 04/16/2025 Compliant - Finalized