Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00260201 Renewal 02/24/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The Annual Self-Assessment completed 01/24/25 was done outside of the allowable timeframe.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.Agency Program Specialists and Supervisors were trained on 3/4/25, by DCQM, regarding the appropriate timelines to complete the Annual Self-Assessment. Attachment #3a. 03/04/2025 Implemented
SIN-00189767 Renewal 06/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144At the time of the 6/30/21 inspection, the following PRN medications for Individual #1 were not available in the home: Orajel Maximum Strength, Ondansetron 4mg, Mi-Acid Gas Relieftab, and M*B*X Susp Compound-120.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. The pharmacy was contacted on 06/30/21 by the direct support staff the same day the deficiency was noted. The pharmacy contacted the physician and Orajel, MBX Suspension, Mi-acid and Zofran were all discontinued. The Pharmacy faxed the discontinuation order to the CRS office and supervisory discontinued these medications. See Attachments #5a, #5b and #5c. 01/08/2022 Implemented
6400.165(c)Individual #1's original prescription order from Doctor for Pantoprazole stated that the medication was to be discontinued on 1/1/21. This medication was administered to Individual #1 until 1/13/21. Individual #1's original prescription for Prevident 5000 was issued on 5/20/20. At that time, Doctor original order was for Individual #1 to brush with this prescription twice daily. On 4/28/21, Dr. updated the order to brush three times daily. The January 2021 through June 2021 Medication Administration Records indicate that this prescription is only being utilized once daily. Individual #1's prescription order issued by Dr. for Clearlax dated 9/23/20 indicates that the medication is to be administered twice daily, 6 hours apart. Beginning 5/1/21, this medication has been administered 7 hours apart instead of the prescribed 6 hours.A prescription medication shall be administered as prescribed.Staff who continued to administer the Pantoprazole was retrained by supervisory staff who are medication administration trainers on the correct procedure to follow when a medication order is received, and a medication is discontinued. See attachment #6a. 01/08/2022 Implemented
6400.166(a)(11)There is no diagnosis or purpose listed for the following medications on Individual #1's Medication Administration Record: SF 5000+ Cream, Mucus Relief DM, Loratadine, and Clearlax Powder.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.These diagnoses were listed on the current MARS for July by CRS staff. See Attachment #7a 01/08/2022 Implemented
6400.213(1)(i)Individual #1's face sheet lists their religion as "N/A."Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Resident #1s Face Sheet was updated on 7/16/21. At this time, she chose no formal religion to profess. This was noted on the Face Sheet as Resident's #1 choosing not to be affiliated with any religion. Face Sheets of other individuals will be reviewed and eliminate any Not Applicable. Please note that this could not be updated any earlier as this resident was on vacation until 7/16/21. See Attachment #8a. 08/10/2021 Implemented
SIN-00104646 Renewal 12/14/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The written evacuation procedure plan did not include staff and individual 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
6400.113(a)Individual #1 and Individual #2 did not receive fire safety training annually. Fire safety training was completed on 4/29/15 and 10/26/16. 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. Supervisors were notified as to pertaining to the annual fire training regulation for the individuals. A checklist has been implemented for supervisors to track individual's fire training upon admission and annually thereafter. See ATTACHMENT #11. 04/30/2017 Implemented
SIN-00204649 Renewal 05/10/2022 Compliant - Finalized
SIN-00161456 Renewal 10/16/2019 Compliant - Finalized
SIN-00068684 Renewal 10/20/2014 Compliant - Finalized