Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00292422 Renewal 07/15/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.24The Controlled Substances Act of 1970 require accurate counts to be recorded at each shift change. The counts for Individual 1 were not recorded on 07/08/2026 or 07/09/2026 for Vimpat 50mg tablets, Nayzilam 5mg spray, or Fycompa 12mg tablets.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.On 8/4/2026, Staff #1, who administered the medication on 7/8/2026, completed retraining on Controlled Substance Management provided by the Compliance Manager. The retraining emphasized the importance of completing accurate controlled substance counts at each shift change and properly documenting all counts in the organization's electronic medication record to support ongoing compliance with this requirement. (Attachment 1) Staff #2, who administered the medication on 7/9/2026, will complete the same Controlled Substance Management retraining provided by the Compliance Manager, upon their return to work and prior to working their next scheduled shift. 08/06/2026 Implemented