Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00270505 Renewal 07/28/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)There was no list of personal possessions located in individual #1's file/record.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. An inventory list for individual #1 existed, however when it was being updated, it was inadvertently placed in the staff office and not returned to the individual's record. The inventory was located and returned to individual #1's record. 09/15/2025 Implemented
6400.22(d)(2)Individual #1's gift card ledger (card ending in 2586) indicated that on 6/20/2025 $9.20 was spent at Dave's Hot Chicken, however the receipt showed that the actual amount spent was $7.67, which caused the ledger balance to be incorrect from the remainder of the month. Individual #1's other gift card ledger (card ending in 8350) indicated that on 4/24/25 the balance was $291.54. On 4/29/2025 $15.67 was spent at Subway, which should have given them a new balance of $275.87; however, staff "SV" documented that the new balance was $262.89. There is no explanation for the discrepancy. The ending card balance should be $8.54 but staff report that the new balance is $0.00.(2) Disbursements made to or for the individual. Staff who incorrectly documented the gift card ledger received a review on fiscal policies and procedures. 09/15/2025 Implemented
6400.22(e)(1)Repeated Violation - On individual #1's gift card balance ledger (card ending in 8350), staff "SV" made an entry for 5/13/2025 for a cash/check amount that did not belong on the gift card ledger. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. The specific staff who made the error received a review on fiscal policies and procedures 09/15/2025 Implemented
6400.174There were no vegetables available in the home for the individual's consumption; thus, not all the food groups were represented in the home at the time of the inspection.At least one meal each day shall contain at least one item from the dairy, protein, fruits and vegetables and grain food groups, unless otherwise recommended in writing by a licensed physician for individuals. Vegetables have been purchased and are available in the home for the individual's consumption 09/15/2025 Implemented
6400.214(b)Individual #1's record did not contain the most recent, up to date ISP. The ISP in the individuals record was dated fiscal year 7/1/24-6/30/2025 and the newest one available is dated for fiscal year 7/1/25-6/30/26 with an updated date of 7/28/2025. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The most recent, up to date ISP has been placed in the individual's record (fiscal year 7/1/25-6/30/26) 09/15/2025 Implemented
6400.32(h)Individual #1 does not use a shower curtain per his ISP due to tearing it down. There is a window in the bathroom where the individual showers and it does not have a curtain or privacy film on the bottom window to ensure privacy when the bathroom is in use. There is a deck out back so if anyone uses the back deck, they could see into the bathroom. Thus, the provider must come up with a way to address this issue in a way that ensures the individual's privacy.An individual has the right to privacy of person and possessions.A privacy film has been placed on the window 09/15/2025 Implemented
6400.166(a)(12)Individual #1's MAR did not list an administration time on date 6.13.2025 for medication "Minocycline".A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration.LNB contracted with an EHR platform to transition from paper Medication Administration Records to an eMAR system 10/01/2025 Implemented
6400.166(a)(13)Repeat Violation: Individual #1's MAR did not have the name or initials of the staff who was supposed to administer the medication "Minocycline" on 6/13/2025 (nor document a refusal). The whole line was just left blank for that specific date.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.LNB contracted with an EHR platform to transition from paper Medication Administration Records to an eMAR system 10/01/2025 Implemented
SIN-00234129 Renewal 11/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The sliding screed door to the deck was missing a door handle. The garage door did not open during the walk through. Screens, windows and doors shall be in good repair. The handle was replaced, and the garage door was repaired on 11/30/2023. 12/04/2023 Implemented
SIN-00214466 Renewal 11/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment completed on 3/25/22 did not review compliance for 6400.166d.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Management personnel were retrained in the correct method to complete a self assessment for each house. 11/16/2022 Implemented
SIN-00178924 Renewal 11/03/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The only telephone easily accessible to Individual #1 is individual's personal cell phone. At the time of inspection, this telephone did not have emergency numbers listed.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. The individual, the individual's parents (who are appointed as guardians), and the rest of the individual's team agreed that requiring the individual to place emergency numbers on the outside of their personal cell phone or requiring them to enter the numbers into their personal cell phone would be in direct conflict of both the agency and the Office of Developmental Program's core values and philosophies. LNB strives to institute ODP's "Everyday Lives, Values in Action" concept throughout all services and supports. To correct the violation and remain true to the Everyday Lives core values, a handset corded/cordless answering system has been purchased. The corded handset has been installed in the staff office. The cordless handset is located in the common area of the house where it is accessible to the individual. Both handsets contain emergency 911 information. Refer to the supporting documentation which includes a picture of the corded and cordless handsets. 11/20/2020 Implemented
6400.77(c)At the time of the inspection, there was a not a first aid manual present within the first aid kit. A first aid manual shall be kept with the first aid kit.A first aid manual has been placed with the first aid kit. Weekly home monitoring reports are completed by the Quality Manager. A section on this report is devoted to "safety issues", including checking contents of first aid kits. Refer to supporting documentation which includes a completed home monitoring report dated 11/20/20 by the Quality Manager. 11/20/2020 Implemented
SIN-00164944 Renewal 01/02/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The exterior light next to the sliding doors in the basement does not illuminate.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The exterior light was repaired on 1/9/20 by LNB's maintenance team. See attached picture. Checking all exterior lights has been added to the "Daily staff duty checklist" and will be monitored on a daily basis for each site. See attached completed checklist. 02/14/2020 Implemented
6400.110(a)There is no smoke detector in the attic, which is accessible. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. There is a crawl space located in the ceiling. There are no pull down steps attached to this space. This space is not utilized for any reason, by the individual or staff. This area was made inaccessible by LNB's maintenance team. LNB's fire drill log has been revised to monitor crawl space areas. See attached picture and revised fire drill log. 02/02/2020 Implemented
6400.111(a)There is no fire extinguisher in the attic, which is accessible.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. There is a crawl space located in the ceiling. There are no pull down steps attached to this space. This space is not utilized for any reason, by the individual or staff. This area was made inaccessible by LNB's maintenance team. LNB's fire drill log has been revised to monitor crawl space areas. See attached picture and revised fire drill log. 02/02/2020 Implemented
SIN-00195514 Renewal 11/01/2021 Compliant - Finalized