Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00286883 Renewal 04/14/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71There were no emergency telephone numbers posted on or by the telephone located in the home's kitchen.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Emergency telephone numbers were posted by the telephone located in the home's kitchen immediately following the inspection. 04/16/2026 Implemented
6400.112(h)The fire drill forms for this location from 01/30/2026 through 03/31/2026 lacked the following information: whether the individual participating in the fire drill evacuated to a designated meeting place outside the building or within the fire safe area during each of the fire drills. There did not appear to be a space to record this information on the fire drill form that was used by the provider. The forms recorded the location of the home's designated meeting place but did not specify whether the individual reached it during the fire drills. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.The fire drill form was updated to include a section documenting whether individuals evacuated to the designated meeting place or fire safe area during each fire drill. Staff were informed of the updated documentation requirements. 04/16/2026 Implemented
6400.113(a)Individual #1 moved into this home on 01/30/2026. There was a record showing that this individual completed a fire safety training on the date that the individual moved into the home; however, as the training form did not include an address or other information that would identify the location associated with the fire safety training, it could not be confirmed that this fire safety training contained information specific to the home, e.g., designated meeting area, evacuation routes, location of smoke alarms, etc. Fire safety training must be site specific. 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. The fire safety training form was updated to include the home address and site-specific fire safety information, including designated meeting area, evacuation routes, and smoke alarm locations. 04/17/2026 Implemented
6400.141(c)(1)Individual #1 was admitted to the provider's program effective 01/30/2026. Individual #1's initial physical examination, dated 02/04/2026, did not include the individual's medical diagnoses, which are an integral part of the individual's medical history.The physical examination shall include: A review of previous medical history. Follow-up was completed with the medical provider to obtain documentation of Individual #1's medical diagnoses. The updated documentation was added to the individual's record. 04/17/2026 Implemented
6400.151(a)Staff #1 was hired by the provider effective 01/19/2026. Staff #1's initial physical examination occurred on 01/20/2026, which was after this staff's date of hire. This staff did not have a physical examination completed within 12 months prior to employment as required. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Hiring and onboarding procedures were reviewed and updated accordingly. HR retained on regulatory requirements 04/17/2026 Implemented
6400.151(c)(2)Staff #2 was hired by The Provider effective 02/02/2026 and had an initial physical examination completed prior to hire on 01/30/2026, with the documentation completed by the physician on 02/08/2026. This initial physical examination did not include tuberculin testing. The medical practitioner completing the physical examination form noted: "No PPD results on file or Quantiferon. Ordered 02/09/2026." Staff #2's Staff Record included the results of a chest x-ray, dated 08/11/2025, which was noted as negative for active tuberculosis; however, a chest x-ray only satisfies this requirement if positive Tuberculin skin testing results are also on file for the staff. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Follow-up was completed to obtain the required tuberculin testing documentation for Staff #2. Hiring documentation requirements were reviewed with relevant staff to ensure required tuberculosis screening documentation is obtained and maintained 04/16/2026 Implemented
6400.32(r)(2)The locking doorknob on Individual #1's bedroom door was equipped with a privacy lock, which is a type of lock that can be opened from the outside without the use of a key---in this case, a thin object could be inserted into a hole on the doorknob to pop the lock open even if it were engaged from the inside. As this lock would allow anyone to access the individual's bedroom at any time without the individual's express permission, it is not a compliant lock.Access to an individual's bedroom shall be provided only in a life-safety emergency or with the express permission of the individual for each incidence of access.The non-compliant privacy lock on Individual #1's bedroom door was replaced with a compliant locking mechanism to ensure the individual's privacy rights are protected 04/17/2026 Implemented
6400.163(d)At the time of inspection, the kitchen cabinet containing Individual #1's prescription medications was found unlocked, leaving the medications accessible.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The kitchen cabinet containing Individual #1's prescription medications was secured immediately following the inspection. Relevant staff were retrained on medication storage and security requirements. 04/16/2026 Implemented
6400.165(g)Individual #1 is diagnosed with a psychiatric illness and takes medications to treat associated symptoms. Per Individual #1's Individual Record, this individual attended psychiatric appointments on 02/02/2026, 02/05/2026, 03/05/2026, and 03/16/2026 to review the prescribed psychotropic medications. With the exception of the appointment on 02/05/2026, the documentation accompanying these appointments did not note the need to continue each medication reviewed, a required component of the documentation.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Follow-up was completed to obtain clarification regarding continuation of the psychotropic medications reviewed during the psychiatric appointments dated 02/02/2026, 03/05/2026, and 03/16/2026. The updated documentation was added to the individual's record 04/20/2026 Implemented
6400.166(b)Staff administering prescription medications to Individual #1 on 04/12/2026 at 8:00pm did not initial the April 2026 Medication Administration Record (MAR) at the time of administration for any of the prescription medications given at that time.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The medication administration documentation error was reviewed with the staff involved, and the staff was retrained on MAR documentation requirements, including documenting medication administration at the time medications are administered. 04/17/2026 Implemented