Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00271510 Unannounced Monitoring 07/16/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At 12:02PM, a spray bottle of Clorox Clean-Up Multi-Surface Cleaner and Bleach was unlocked and accessible in the cabinet under the sink in the kitchen of the home. Individual #1's service plan, last updated 6/17/2025, reads, "Due to [Individual #1's] history of attempting to hurt [themselves] in the past, it is recommended that supervision be provided with chemicals and potential hazards." [Repeat Violation, 12/22/2022, 11/22/2023, 3/19/2024, 12/18/2024]Poisonous materials shall be kept locked or made inaccessible to individuals. Actions Taken to Resolve the Issue: The spray bottle of Clorox Clean-Up Multi-Surface Cleaner and Bleach was immediately removed from the unlocked cabinet and secured in a locked location. Upon review, it was determined that Individual #1¿s ISP was out of date. The Supports Coordinator was contacted on 8/7/2025 to request an update to the ISP to accurately reflect current supervision needs and chemical safety protocols. Responsibility & Compliance Monitoring: The Program Specialist ensured all hazardous chemicals remain locked and inaccessible to Individual #1 until the ISP was updated. Monthly home inspections will be conducted by supervisors to verify compliance. 08/07/2025 Implemented
6400.141(c)(1)Individual #2's most recent physical examination, completed 3/18/2025, did not include a review of medical history.The physical examination shall include: A review of previous medical history. Actions Taken to Resolve the Issue: The physical examination form was updated on 7/25/2025 to include a clearly marked section for the reviewing physician to document the individual¿s medical history. Staff have been instructed to use the updated form for all future physical examinations. Responsibility & Compliance Monitoring: The Program Specialist will review each completed physical examination form upon submission to verify that the medical history section is completed. Any omissions will be addressed immediately with the medical provider. 07/25/2025 Implemented
6400.171At 12:12PM, a partially used, unsealed package of frozen Tyson Chicken Patties were in the freezer in the kitchen of the home. [Repeat Violation, 12/22/2022, 2/21/2024, 8/15/2024, 10/2/2024, 12/18/2024, 1/25/2025, 3/6/2025]Food shall be protected from contamination while being stored, prepared, transported and served. Actions Taken to Resolve the Issue: The package was properly sealed on the day of the inspection. Staff were reminded of and re-trained on the importance of sealing food products to prevent contamination and maintain quality. Responsibility & Compliance Monitoring: The House Manager will conduct weekly kitchen checks to ensure all opened food packages are properly sealed. Any issues found will be corrected immediately and documented. 08/01/2025 Not Implemented
6400.182(c)Individual #1's assessment, completed 3/20/2025 states that Individual #1 is safe with poisons. Individual #1's service plan, last updated, 6/17/2025, reads, "Due to [Individual #1's] history of attempting to hurt [themselves] in the past, it is recommended that supervision be provided with chemicals and potential hazards." Individual #1's assessment, completed 3/20/2025 states that Individual #1 is able to independently evacuate in the event of a fire. Individual #1's service plan, last updated, 6/17/2025, reads, "[Individual #1] can evacuate during a fire drill with verbal prompts. [Individual #1] may need an initial verbal prompt from staff to begin evacuation."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.We contacted the Supports Coordinator to address and reconcile inconsistencies between Individual #1¿s assessment and service plan. The Supports Coordinator is in the process of updating the service plan to ensure information is accurate and consistent across all documents. Responsibility & Compliance Monitoring: The Program Specialist ensured all hazardous chemicals remain locked and inaccessible to Individual #1 until the ISP was updated. Monthly home inspections will be conducted by supervisors to verify compliance. 08/07/2025 Not Implemented
SIN-00262050 Unannounced Monitoring 03/06/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(b)On 3/06/2025 Individual #1's prescription label for Hydrocortisone 2.5% Cream stated, "please see attached for detailed instructions". The prescription order was not attached.A prescription order shall be kept current.Actions Taken to Resolve the Issue: The prescription order was immediately relocated and attached to the medication as required. Staff were retrained on proper medication documentation on 3/14/2025. A full review of all medications was conducted to ensure proper documentation placement. Responsibility & Compliance Monitoring: Supervisors and Program Specialist will conduct weekly audits to verify all prescription orders are correctly attached and ensure ongoing compliance. Direct Support Professionals (DSPs) will check for attached orders during medication administration. 03/14/2025 Implemented
6400.166(a)(7)On 3/06/2025 Individual #1's March 2025 medication administration record documented Hydrocortisone 2.5% cream, every other day as needed sparingly. It did not include a dose of medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Actions Taken to Resolve the Issue: Staff were retrained on 3/14/2025 on ensuring all medication records include complete dosage instructions. The prescribing physician was contacted, and on 3/20/2025, the prescription was updated to state: "Apply 1 gram to affected area QOD PRN." The MAR was corrected to reflect the updated prescription. A full review of all MARs was conducted to identify and correct any similar documentation issues. esponsibility & Compliance Monitoring: Supervisors and Program Specialist will conduct weekly MAR audits to ensure all medication records are accurate and complete. Direct Support Professionals (DSPs) will verify medication documentation when administering medications and report any discrepancies. 03/18/2025 Implemented
6400.166(a)(8)On 3/06/2025 Individual #1's March 2025 medication administration record documented Hydrocortisone 2.5% cream, every other day as needed sparingly. It did not include a route of administration.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.Actions Taken to Resolve the Issue: A request was made to the physician for updated orders to specify the route of administration (e.g., topically applied to affected area). Staff were retrained on 3/14/2025 to ensure that all medication documentation includes the route of administration. Responsibility & Compliance Monitoring: Supervisors and Program Specialist will conduct weekly audits to ensure all MAR entries include complete information, including the route of administration. Direct Support Professionals (DSPs) will verify all information is correctly documented during medication administration and report any discrepancies. 03/18/2025 Implemented
SIN-00258012 Unannounced Monitoring 12/18/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At 11:32AM on 12/18/2024, the closet in the hallway across from the kitchen was left unlocked and unattended leaving the following poisonous substances accessible, Tide Pods, Clorox Stain-Fighting Gel, Fabuloso, Clorox, Lysol spray, Windex and Clorox Toilet Cleaner. Individual #1's Service Plan, completed 12/16/2024, reads, "[Individual #1 requires] SUPERVISION AT ALL TIMES FROM STAFF WITHIN VISUAL RANGE WHEN SHOWING AGITATION, MEDICATIONS, POISONS, AND BREAKABLE AND SHARP OBJECTS MONITORED WHEN AROUND [Individual #1] AND LOCKED WHEN NOT IN USE." [Repeat Violation, 12/22/2022]Poisonous materials shall be kept locked or made inaccessible to individuals. This violation was received due to the staff not locking up the closet that contained poisonous substances after use and leaving it unattended when Individual #1 requires supervision around poisonous substances. The issue was resolved immediately on 12/18/2024 when staff immediately locked up the closet and ensured that they do not leave it accessible without oversight. Staff locked up the closet containing poisonous substances and made sure to supervise when being in use. 12/18/2024 Implemented
6400.181(d)Program Specialist #1 did not sign Individual #1's assessment, completed 3/21/2024. Program Specialist #1 did not sign Individual #2's assessment, completed 3/22/2024.The program specialist shall sign and date the assessment. We received this violation on 12/18/2024 due to Individual¿s assessment not containing program specialist signature for both individual #1 and Individual #2. The program binder was retrieved from the residential homes and was promptly corrected by signing both assessments and thoroughly looking through any other errors that maybe be observed. To resolve immediately, Program Specialist made sure that the assessments for both Individual #1 and #2 were signed in the corresponding areas. 12/20/2024 Implemented
6400.216(a)At 11:32AM on 12/18/2024, the closet in the hallway was unlocked and unattended leaving Individual #1 and #2's personal documents accessible. [Repeat Violation, 12/22/2022, et.al.} An individual's records shall be kept locked when unattended. We received this violation due to the closet containing personal information for both Individual #1 and individual #2 being left unlocked and unattended by staff. The closet was immediately locked to refrain from having individuals¿ personal documents accessible when not in use and unattended. To resolve immediately, The closet where personal documents are kept was securely locked on 12/18/2024 12/29/2023 Implemented
6400.166(a)(11)Individual #2's December 2024 Medication Administration Record did not include the diagnosis or purpose for Olanzapine. [Repeat Violation, 12/22/2022, et.al.]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.We received this violation due to not writing in the reason for the olanzapine on the MAR. To resolve this issue, Victory Health Inc wrote in the reason for olazapine on the MAR. Victory Health Inc Director and Supervisors are responsible for maintaining compliance. 01/15/2025 Implemented
SIN-00250642 Unannounced Monitoring 08/15/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 11:41AM, there was a thick layer of what appeared to be oil and burnt food on the inside of the oven in the kitchen of the home.Clean and sanitary conditions shall be maintained in the home. We received this violation due to staff cooking on 8/14/2024 and daily cleanup duties were not done by overnight staff as well as the house manager not verifying the tasks were completed the following day. This issue was resolved immediately by performing a deep clean on the oven more specifically spraying oven cleaner in the bottom area, letting it set for 20 minutes, then cleaning the residue on 8/15/2024. We retrained staff in the home related to kitchen cleaning on 8/16/2024. We followed up with retraining for House managers and supervisors. Responsibility lies on the House Manager. Managers, supervisors, and program specialists will make sure daily checks are performed everyday using specific tools. 08/19/2024 Not Implemented
6400.67(b)At 11:36AM, several picture frames and decorations were leaning against the wall in the dining room posing a slipping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.This violation was received because picture frames and decorations were not hanging on the wall. We resolved by going to Target to purchase picture hanging hooks for all decorations and picture frames. Provider¿s Plan to Maintain Compliance responsibility lies on the House Managers. Managers, supervisors, and program specialists will follow up to ensure compliance daily. 08/27/2024 Implemented
6400.76(a)At 11:35AM, a plastic chair with a ten-inch crack along the middle of the seat was on the patio outside the dining room of the home. Furniture and equipment shall be nonhazardous, clean and sturdy. We received this violation due to not properly checking for tears/cracks on external furniture. We got rid of the external furniture on 8/16/2024. Responsibility lies on the house managers for this violation. Managers, supervisors, and program specialists will also make sure daily checks are performed everyday and done accurately. 08/27/2024 Implemented
6400.142(a)Individual #2's most recent dental examination was completed on 7/7/2023.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. We received this violation due to a consumer refusing to go to several dental appointments. We continued to ask and gave examples on why visiting the dentist is an important part of life. We also had individual sign a refusal form. Provider¿s Plan to Maintain Compliance lies on the house managers. Supervisors and program specialists will verify this is being done. 08/28/2024 Implemented
6400.142(g)Individual #2's most recent dental hygiene plan was completed on 7/7/2023.A dental hygiene plan shall be rewritten at least annually. We received this violation due to a consumer refusing to go to several dental appointments. We continued to ask and gave examples on why visiting the dentist is an important part of life. We also had the individual sign a refusal form. Provider¿s Plan to Maintain Compliance lies on the house managers. Supervisors and program specialists will verify the use of dental plans and refusal forms. 08/28/2024 Implemented
6400.171At 11:37AM, a box of Uncrustables with instructions to "Keep Frozen," were being stored in the refrigerator of the home. At 11:38AM, a partially used, unsealed container of shredded cheese was in the refrigerator in the kitchen of the home. At 11:44AM, a partially used glass bottles of Garlic Vinaigrette and Thai-ger Sweet Chili Chef Sauce with instructions to, "refrigerate after opening," were in a cabinet in the kitchen of the home. [Repeat Violation, 12/22/2022]Food shall be protected from contamination while being stored, prepared, transported and served. We received this violation due to staff/management not paying attention to the details on labels of food and or condiments. This issue was resolved by reorganizing the food/condiments to their appropriate place in the kitchen. This issue was resolved on 8/15/2024 Responsibility lies on the staff. House managers, managers, supervisors, and program specialists to make sure daily checks are performed everyday while training staff how to properly label food and condiments. 08/19/2024 Not Implemented
6400.193(b)(1)The sharps and knives are kept locked in the home reportedly due to Individual #1's behavioral issues. Individual #1 does not have a Restrictive Procedure Plan.For each incident requiring restrictive procedures: Every attempt shall be made to anticipate and de-escalate the behavior using methods of intervention less intrusive than restrictive procedures.VT does not have a restrictive plan but the sharps remain locked. We reached out to VT¿s behavior specialist so that he could start working on the restrictive plan. Behavior specialist still working on restrictive plan. Responsibility lies on the program specialists to monitor and make sure homes remain in compliance with self-assessments and restrictive procedures. 09/20/2024 Implemented
SIN-00246378 Add an Addendum 06/14/2024 Compliant - Finalized