Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00282042 Renewal 01/13/2026 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light bulb in the stairs heading from the first floor to the 2nd floor was out as well as the bathroom light in the 3rd floor bathroom.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light bulbs on the stairway from the first floor to the second floor and in the third-floor bathroom were replaced to restore proper lighting. 01/30/2026 Implemented
6400.82(f)The 2nd floor bathroom did not have hand soap.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Hand soap was immediately placed in the second-floor bathroom. 01/14/2026 Implemented
6400.111(a)The fire extinguisher in the laundry room was not fully charged. The indicator on the extinguisher was in the recharge zone.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The fire extinguisher in the laundry room was replaced during the inspection 01/13/2026 Implemented
6400.113(a)There was no fire safety training in file for individual 1. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Fire safety training for Individual #1has been completed and documented in the individual's record to ensure compliance with training requirements. 02/03/2026 Submitted
6400.141(c)(6)There was no Tuberculin skin testing in file for individual 1.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. An appointment has been scheduled for Individual #1 to receive Tuberculin skin testing with the primary care provider on February 26, 2026. Documentation will be obtained and placed in the individual's record upon completion. 01/31/2026 Submitted
6400.144The 10/14/25 physical exam for individual 1 recommends annual labs and PT/OT for left knee and there was no record of the labs or PT/OT in file. The 12/15/25 physical exam for individual 1 recommends PRN Diclofenac gel for left knee, PRN ibuprofen, PRN acetaminophen and PRN loratadine and there is no record in file that of these medications have been prescribed to the individual.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.Individual #1 attends physical therapy weekly for the left knee. Physical therapy visit summaries have been obtained and added to the individual's file. Required lab orders and results will be followed up with the primary care provider and documented in the record as received. Individual has an appointment with their PCP on March 4th 2026 at 11:20 am 01/31/2026 Implemented
6400.181(a)There is no complete annual assessment for individual 1. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. A complete annual assessment for Individual #1 will be completed and added to the individual's record to ensure compliance with assessment requirements. 02/04/2026 Not Accepted
6400.183(c)There was no ISP team sign in sheet in file for individual 1 listing the persons who participated in the meeting.The list of persons who participated in the individual plan meeting shall be kept.The Supports Coordinator was contacted to obtain a copy of the ISP team sign-in sheet listing all participants for Individual #1. The sign-in sheet will be added to the individual's record upon receipt. 03/02/2026 Not Accepted
6400.213(1)(i)The content of records for individual 1 did not include the individual's race, color of hair, color of eyes, identifying marks, and religeous affiliation.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The individual's record has been updated to include all required identifying information, including race, hair color, eye color, identifying marks, and religious affiliation. 02/02/2026 Implemented