Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00260198 Renewal 02/24/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)REPEAT 3/11/24- On 8/31/24, Individual #1's funds were used to purchase bedding, which is included in room and board.Individual funds and property shall be used for the individual's benefit. Individual has been reimbursed for the expenditure of bedding purchased on 8/31/2024. Check #47776 has been issued for $42.00 on 3/5/2025 for reimbursement of $22.00 for the comforter and $10.00 each for the 2 sheet sets Attachment #9a. Reimbursement amounts calculated by the controller. An email was sent by the program specialist to the agency on 3/7/25 that new bedding is not to be purchased with client funds under the average cost as specified by the controller office. Reimbursement of the average cost of bedding would be credited to the individual. Attachment #9b. 03/10/2025 Implemented
6400.22(d)(1)REPEAT 3/11/24- Individual #1's property record is not current and up to date. Individual #1 purchased two pieces of wall art totaling $296.78 that were not added to the personal inventory. Individual #1 purchased Ghost sneakers for 139.99 on 9/28/24. This item was not added to the inventory log. Individual #1 had a PAB Credit Card log in May 2024. $31.75 was spent and deducted from the balance of $331.85. The balance should have been logged as $300.10 but was documented as 299.60. This was not rectified.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. The current inventory for individual #1 was updated on 3/7/25 to include all items over $50 value and sentimental items and current inventory of individual's personal belongings Attachment#10a (4 pages). Financial ledger for the PAB gift card was not incorrect at the time of licensing. Attachment #10b. Citation states that $31.75 was deducted from $331.85, and the result was $299.60, however, the balance on the log reads $31.75 was deducted from $331.35 and there is no $0.50 discrepancy. All financial records are reviewed every shift change, by staff, to ensure accuracy. Discrepancies are to be reported to the program specialist immediately to ensure compliance. 03/07/2025 Implemented
6400.22(e)(1)REPEAT 3/11/24--Individual #1's FS balance increased from $722.37 on 8/31/24 to $967.37 on 9/24/24. No deposit was documented. The balance increased from 650.24 on 10/7/24 to 901.24 on 10/21/24. No deposit was documented. The balance increased from 133.18 on 10/31/24 to 384.18 on 11/23/24. No deposit was documented. The Snap balance increased from 157.78 on 11/30/24 to 408.78 on 12/26/24. 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. Deposit amounts were added to the SNAP ledgers by Program Specialist on 3/7/25 as late entries. Attachment #11a (3 pages). Snap ledger has been rectified to ***Staff will call in for a SNAP benefits balance every Friday. Indicate the deposits and balance inquiry on the ledger sheet weekly. *** by program specialist on 3/5/2025. Attachment #11b. 03/10/2025 Implemented
6400.141(c)(7)REPEAT 3/11/24-Individual #1 had a gynecology exam on 9/21/21 and not again until 12/20/24. Individual #1 is recommended to have a gynecological exam every three years. The exam was to be held by 9/21/24.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Program Specialist contacted the individual's healthcare provider and discussed the need for individual # 1 to have a Pap test, gynecological exam, and a breast exam on an annual basis on 3/7/25. The practitioner reviewed individual # 1's file and made the correct determination and indicated it in a letter stating the appropriate frequency for the examinations to be completed for this individual. The letter from the healthcare provider was added to individual's main file when received on 3/11/25 by program specialist. Attachment #12a. The electronic calendar, utilized by staff in the home, has been implemented and updated on 3/11/2025 by program specialist to reflect all appointments and due dates. Attachment #12c. Individual is scheduled for their next gynecological exam on 12/1/25, along with their annual physical. Attachment #12b. The need for a gynecological exam/ PAP test will be reviewed by the healthcare provider every year on the date of the physical exam. 03/11/2025 Implemented
6400.143(a)Individual #1 is to follow a 1500 calorie diet. There are many days that Individual #1's calorie intake exceeds the recommended amount. There is no documentation that Individual #1 is educated on the importance of following doctor's recommendations.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. All staff in-home were retrained on individuals mealtime plan and menu by program specialist on 3/7/25. Attachment #13a. Menu has been updated on 3/1/2025 by program specialist to include carb reduction. Attachment #13b (2 pages). Education documentation has been added to individuals goal for tracking and included in the training packet. Attachment #13c. Additional training in-house assigned on Relias platform to educate staff on diabetes management by program specialist on 3/7/2025 to be completed by 3/19/2025. 03/19/2025 Implemented
6400.144Individual #1 is to follow a 1500 calorie diet. Staff are documenting Individual #1's calorie intake with each meal but are not consistently totaling up the calories to determine if the individual exceeded the recommended amount. Individual #1 has a blood sugar protocol that documents if their blood sugar exceeds 200, they are to limit their carbohydrates and increase their fluid intake. Individual #1's blood sugar levels were over 200 on the following dates: 3/13, 315, 3/16, 5/20, 6/29, 9/6, 9/12, 9/18, 11/14, 11/26, 12/7, 12/12, 12/26, 1/7, 1/22, and 1/27. There is no documentation that Individual #1's carbs were limited. Many times, the meals the individual ate on those dates were high in carbs.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. All staff in-home were retrained on individual's mealtime plan and menu by program specialist 3/7/2025. Attachment #13a. Menu has been updated on 3/1/2025 by program specialist to include a spot for documentation of carb reduction. Attachment #13b. Education documentation has been added to individuals' goal for tracking and included in the training packet. Attachment #13c. Additional training in-house assigned on Relias platform to educate staff on diabetes management by program specialist on 3/7/2025 to be completed by 3/19/2025. Staff will be trained on low carb foods by program specialist by 3/19/25. 03/19/2025 Implemented
6400.145(3)The emergency medical plan for Individual #1 does not document what the emergency staffing plan will be.The home shall have a written emergency medical plan listing the following: An emergency staffing plan.A new Emergency Medical Information sheet was created by DCQM on 3/3/2025 and updated companywide by the management team for all individuals in CRS care, to include names and phone contacts for all doctors. Emergency staffing plan updated to include current staffing plans, ambulance services and all medical contact information. Attachment #14a and #14b (2pages). Individuals current plan has been updated on 3/7/2025 by program specialist. 03/19/2025 Implemented
6400.211(b)(3)Individual #1's demographic information does not include the name, address, or phone number of who to contact for medical consent.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. Program specialist reviewed and updated individual's face sheet on 2/26/2025. Attachment #15a (2 pages). DCQM emailed management team to include emergency medical consent on face sheets for all individuals on 3/6/25. Clarification was noted on the emergency medical consent and contact information was added. Attachment #15b. 03/06/2025 Implemented
6400.18(b)(2)Individual #1 did not receive their pm dose of Risperidone on 5/24/24. Individual #1 did not receive their morning dose of Escitalopram on 6/30/24 or their morning dose of Perphenazine on 7/24/24. None of these med errors were reported to EIM.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.EIM's were entered in the HCSIS website by CRS incident manager on 2/26/2025. Attachment #16a (5 pages) and #16b (5 pages). Program Specialist and Supervisor were re-trained on reporting medication errors in the EIM system on 3/7/2025 by DCQM. Attachment #16c. 03/08/2025 Implemented
6400.162(a)Staff #1 did not receive medication administration training on alternative routes, specifically training on administering injections. Staff #1 did administer Individual #1 their Ozempic injection on 10/23/24, 11/20/24, and 12/18/24.A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.Staff #1 was trained in Ozempic injections on 9/4/24, however the program specialist failed to provide proper documentation of the training at the time of licensing. All house staff are scheduled for retraining on 4/1/2025 by a licensed diabetes specialist. Attachment #17a (2 pages) and #17b. All Ozempic injection administrations will be given only by those who have their current injection training status. If staff working in home on days individual required her injection, program specialist or program supervisor will be on site to administer her medication. 04/01/2025 Implemented
6400.162(b)(2)(vi)Staff #1 did not receive medication administration training on alternative routes, specifically training on administering injections.A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Medications, injections, procedures and treatments as permitted by applicable statutes and regulations.All house staff are scheduled for retraining on administering injections on 4/1/2025 by a licensed diabetes specialist. Attachments #17a (2 pages) and #17b. All Ozempic injection administrations will be given only by those who have their current injection training status. If staff working in home on days individual required her injection, program specialist or program supervisor will be on site to administer her medication. 04/01/2025 Implemented
6400.167(a)(1)Individual #1 did not receive their pm dose of Risperidone on 5/22/24. There was a checkmark in the slot. Individual #1 did not receive their morning dose of Escitalopram on 6/30/24 or their morning dose of Perphenazine on 7/24/24.Medication errors include the following: Failure to administer a medication.EIM's were entered in the HCSIS website by CRS incident manager on 2/26/2025 Attachment #16a (5 pages) and #16b (5 pages). It was discovered that individual #1 did receive their Risperidone on 5/22/2024, however staff documented the administration on the MAR incorrectly, using a check mark. Staff was re-trained on proper documentation of medications on 3/7/2025 by program specialist. Attachment #18a. Two staff involved are sub aide status. One sub aide is on medical leave and will be retrained on 3/26/2025 prior to returning to work. The other sub aide is also on medical leave and has been notified via phone that they will be required to complete retraining prior to returning to work. 03/26/2025 Implemented
SIN-00204644 Renewal 05/10/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Individual #1 toilet contained brown spots, appearing to be fecal matter, in various places on the toilet seat and back of the toilet.Clean and sanitary conditions shall be maintained in the home. RPD informed staff to clean contaminated toilet of Individual #1 on 5/11/2022. Bathroom was immediately cleaned by staff and RPS checked this on 5/11/2022 to verify cleanliness. Other homes were inspected supervisory staff on 5/13/2022 for clean and sanitary conditions. All other homes were considered clean and sanitary. 06/09/2022 Implemented
6400.66The light located outside the lower, rear, exterior egress door was not operable at the time of the 5/11/22 inspection.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The inoperable light bulb was immediately replaced and found to be operable by the RPD on 5/11/22. Other rooms, hallways, interior stairways, outside steps, outside doorways, porches, and ramps in agency homes were checked for inoperable lighting by RPS on 5/13/22 and all other lighting was found operable. 06/09/2022 Implemented
6400.101There were 4 large car tires in the path of the rear, garage, door egress, preventing the door from opening completely.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The tires located behind the garage door, considered to be obstructing an exit from the garage, were relocated immediately on 5/11/2022 by RPD, ensuring the garage door opens freely. Winter tires have been stored elsewhere in the garage. See Attachment: Picture of door to garage with measuring tape, measuring the length of how far the tires have been relocated. Other homes were monitored for obstructed stairways, halls, doorways, passageways and exits from rooms and from the building by RPD on 5/13/22. No other obstructions were found. All other areas were free from violation. 06/09/2022 Implemented
6400.110(f)Individual #1 is deaf and Individual #2 is hard of hearing. Both individuals require adaptive equipment (strobes and shakers) to notify them in the event of a fire requiring evacuation of the home. The upstairs hallway bathroom, accessible to individuals and staff, was not equipped with a strobe light. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. RPD verbally requested a strobe light to be installed in the upstairs common bathroom to agency COO on 5/11/22. RPD additionally emailed a maintenance request to COO, for placement of strobe light in upstairs common bathroom, for the individual diagnosed with hearing loss and deafness (attachment). On 6/9/22, the contracted company that provides alarm systems and maintenance for systems for the agency responded to COO and scheduled a site survey for 6/15/22 at 1pm, to assess area strobe is required, via email (attachment). Additionally, staff were advised to encourage individuals with hearing deficits to utilize other restrooms throughout the home that are equipped with strobe lights, until the required strobe is installed. The existing schedule already provides overnight awake staff to provide assistance in response in the event of an emergency. See Attachments: 3 emails for this particular home dated 5/17/22, 6/09/22 and 06/15/22. All other homes were monitored for the need for strobe lights during fire drills by RPS on 5/13/22. One other strobe light was found to be needed at another location and a maintenance request was filed. 06/15/2022 Implemented
SIN-00119525 Renewal 08/15/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.61(a)During the fire drill conducted onsite on 8/17/17, staff had to provide Individual #1 with physical assistance to evacuate through the kitchen door egress due to the large step down at that egress point. They exited through the kitchen door that leads to the garage. That kitchen door egress route has a single, large, drop down step to the garage floor and there isn¿t a handrail to assist Individual #1. A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. Construction of step leading from kitchen to garage was done on 10/1/17 due to individual #1 needing physical assistance when evacuating. See Attachments #57a & 57c 10/01/2017 Implemented
6400.62(a)Individual #1 is assessed to be unsafe around poisonous substances. Hydrogen Peroxide that contained a label to contact poison control center was unlocked and accessible in the first aid kit located in the downstairs laundry room. Poisonous materials shall be kept locked or made inaccessible to individuals.On 8/18/17 the first aid kit was locked under kitchen sink so individual #1 has no access to poisonous substances. 08/18/2017 Implemented
6400.72(b)The plastic guard on the front screen door was broken and cracked leaving it attached to the door by only three corners instead of four. Screens, windows and doors shall be in good repair. Program Specialist removed the broken plastic guard from the inside of screen door on 8/18/17. See attachment #58. 08/18/2017 Implemented
6400.80(b)Tree branches were located in and over flowing out of approximately a 6 foot section of gutter located over the back deck. Siding on the back of the house near the kitchen widow had approximately a 1-2 foot crack, exposing material underneath the siding. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Program Specialist removed the branches from the gutter on 8/18/17. See attachment #56 Siding on back of house was replaced on 10/1/17. See Attachments #57a & 57b. 10/01/2017 Implemented
6400.103REPEAT from 12/14/16 annual inspection: The written evacuation procedure indicated that 2 males living in the home will share a hotel room for their emergency shelter. No males reside in the home. There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. Program Specialist immediately updated the emergency evacuation plan on 8/17/17. See attachment #55 08/17/2017 Implemented
6400.104On 12/9/15 the home notified the fire department that Individuals #2 and #3 were independent with evacuation in the event of a fire. However Individuals #2 and #3 require visual prompting with strobes lights and the physical assistance of a bed shaker in order to evacuate the home. The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Program Specialist updated letter to fire department on 8/30/17 addressing Individual # 2 and #3 who require visual prompting with strobe lights and physical assistance of bed shaker in order to evacuate the home. See Attachments # 54a, 54b & 54c. 08/30/2017 Implemented
6400.110(f)Individual #2 is deaf and cannot hear the fire alarm. He/She requires the assistance of strobe lights and a bed shaker to notify him/her to evacuate the home in the event of a fire. Individual #2 utilizes up to 3 hours of unsupervised time at his/her home however he/she does not have a personal body device to notify him/her in the event of a fire should he/she be sleeping on couches or chairs throughout his/her home when staff are not at home. Individual #3 utilizes unsupervised time at the home however he/she also does not have a personal body device to notify him/her in the event of a fire should he/she be sleeping on couches throughout his/her home when staff are not home. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. Email sent 10/06/17 at 11:12 a.m. to Mj Shahen at ODP concerning body devices for Individual #2 and Individual #3. See Attachment #53 Intertech was called to put shakers on Living room chair and couch. Intertech ordered shaers and will put on chair and couch when received. Expected date 11/24/17. 11/24/2017 Implemented
6400.112(a)The fire drills are not unannounced. At the beginning of the year, the program specialist created a list that indicated the month, day, year, the person responsible for completing the drill, and the date and time frame for the overnight drills. This list is kept at the home in the fire drill book for all staff to see. An unannounced fire drill shall be held at least once a month. Fire Drill schedule was changed in fire book immediately on 8/17/17 as per regulation. See attachment #52 08/17/2017 Implemented
6400.185(b)Individual #1 has two new outcomes; to have staff instruct Individual #1 on a daily basis on how to open the gates on the steps and to have staff instruct Individual #2 on a daily basis on the importance of not touching or eating hot foods, eating too fast and safety risks around hot items (stove, oven, crockpot, etc). These outcomes were initiated on 8/9/17. Licensing was at the home on 8/17/17 and for the month of August after the implementation date, there was no documentation that these outcomes were worked on daily as written on 8/11, 8/12, 8/13, 8/16, or 8/17. The ISP shall be implemented as written.Memo sent to all staff and sub aides that work at Vinco home, concerning outcomes that were not documented daily as written per ISP and 6400 state regulations. See attachment ##9 10/18/2017 Implemented
SIN-00104641 Renewal 12/14/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(f)The kitchen cabinets were locked preventing Individual #1 from accessing food. An individual has the right to receive, purchase, have and use personal property. The cabinets were secured as a necessary and practical intervention to protect the health and safety of the individual. A waiver of the regulation was requested promptly after obtaining the recommendation of the treatment team and human rights committee. A technical assistance meeting with ODP staff was provided on January 18, 2017 during which it was recommended that that CRS take immediate steps to remove the locks pending a review of the waiver request and provide extra staff during all waking hours that individual #1 is home to prevent her from harm if she acquires items from the closet. As of January 27, 2017 extra staff has been assigned Monday through Friday from 3 to 8 P.M. and 10 A.M. to 6 P.M on weekends. Staff unlocks the cabinets and record instances of Individual #1¿s attempt s to access the items in the cabinets. CRS is intensifying its¿ efforts to recruit staff to make it possible to remove the locks in the event a waiver is not granted. SEE ATTACHMENT #17 02/28/2017 Implemented
6400.71The telephone in the downstairs living area did not have the poison control number on or near the phone. The telephone near the chair in the downstairs living area did not have emergency numbers posted on or near the phone.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. All telephones have emergency numbers near or on the phone. The home safety checklist that is completed monthly by staff was revised on 12/15/16 to include checking the telephones have legible emergency numbers near or on the phone that includes: nearest hospital, police department, fire department, ambulance and poison control center. See ATTACHMENT #6. 01/11/2017 Implemented
6400.80(a)The back deck and steps were covered with snow and ice. The back garage egress steps were snow covered. Outside walkways shall be free from ice, snow, obstructions and other hazards. Memo was sent to all employees that stated that all outside walkways and steps must be free of ice, snow, obstructions, and other hazards. All staff signed and dated that they read and understand the serious safety issue involving obstructed walkways and steps. See ATTACHMENT #5 01/20/2017 Implemented
6400.103The written evacuation plan did not include individual and staff responsibilities.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The written evacuation plan was revised to include individual and staff responsibilities. The revised evacuation plan was replaced in all homes and in individual files. See ATTACHMENT #1. 12/15/2016 Implemented
6400.141(c)(12)Individual #1's 8/16/16 physical exam did not include physical limits.The physical examination shall include: Physical limitations of the individual. Physical limitations was added to the physical on 12/15/2016. A physical on 01/09/2017 has been completed that includes physical limitations. See ATTACHMENTS #4 01/09/2017 Implemented
6400.164(b)Individual #1 was administered Lorazepam on 11/3/2016 at 9pm. The staff member who administered the medication did not sign off on the medication log. On 12/12/16 at 9pm, Individual #1 was administered Contulose and Thiondazine. The staff member who administered the medications did not sign off on the medication log. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. The staff member who did not initial MARS for Individual #1 was retrained on Administering Medications, five rights of medication and proper documentation on 12/21/16. See ATTACHMENTS 3A A Monthly Medication Administration Reviews will be completed monthly by the Medication Supervisor and reviewed secondly by another Medication Supervisor. See ATTACHMENT 3B 04/14/2017 Implemented
SIN-00054890 Renewal 11/18/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The sliding glass door in the dining room is used as a fire exit. The door was very difficult to open. The residents in the home would not be able to open the door in the event of an emergency.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. fully implented. Sliding glass door rollers were replaced by CRS maintenance 12/4/13. See Attachment #1 There is no validation material to submit with this citation. Provider sent a video that cannot be printed. video shows the door opening and closing easily. AH 12/04/2013 Implemented
6400.112(a)A fire drill was not conducted in June of 2013. (a) An unannounced fire drill shall be held at least once a month. ADEQUATE PROGRESS The Director will predetermine the day date that the fire drill will be conducted. The Director will keep a copy of this record to check immediately after the assigned day of the drill was done. Director will initial off on the copy verifying that the drill was completed. See Attachment #2 01/31/2014 Implemented
SIN-00179927 Renewal 08/26/2020 Compliant - Finalized
SIN-00068679 Renewal 10/20/2014 Compliant - Finalized