Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00279031 Renewal 12/03/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.207(5)(III)On 12/4/25 at 1030 AM, Individual #1's bed contained full bed rails that restricted the movement or function of the individual's body. The agency obtained a prescription for the bedrails on 12/3/25. Although the bedrails are prescribed by the medical practitioner, the most current assessment does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #1's individual plan that was last updated on 11/21/25 does not include periodic relief of the device to allow freedom of movement. On 12/4/25 at 10:32 AM, Individual #2's bed contained full bed rails that restricted the movement or function of the individual's body. The agency obtained a prescription for the bedrails on 12/3/25. Although the bedrails are prescribed by the medical practitioner, the most current assessment does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #2's individual plan that was last updated on 10/24/25 does not include periodic relief of the device to allow freedom of movement.A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement.On 12-29-25 The Residential Supervisor contacted Individuals #1 and #2 Primary Care Physician and asked if there was any concern with the individuals using bed wedges instead of Bed Rails. She obtained the orders to have the Wedges replace the bed rails. On 01-04-2026 The wedges were ordered. for both Individual #1 and #2. On 01-05-2026 Residential Director Notified Program Specialist and Supports Coordinator to make the changes to the ISP and Assessment for the bed rails until the Wedges arrive. We will have their ISP's and assessments changed to include the bed rails stating that They are receiving periodic relief from the Bed rails from 6am-8pm Daily unless napping or ill. It will also include that They are checked on every 2 hours during the night, and it will include checking to see if they are indicating that they want relief from the bed rails.  On 01-06-2026 there is a mandatory training at the home This training will include all staff working the homes that utilize bed rails. The training will include safety concerns and how to use wedges and relief from them when indicated. 01/05/2026 Implemented
SIN-00202033 Renewal 03/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The bathroom in the basement of the home did not have an operable window or mechanical ventilation.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. After accessing the situation - the best option was to have an exhaust fan installed in the bathroom - a work order (#2340) was generated on 3/21/2022 to have this completed. Until the completion - we did not utilize that bathroom as the remaining bathroom in the home meets the regulatory requirements. An exhaust fan with a light was installed in the basement bathroom at 106 Schroyers Lane on 3/25/2022. The venting apparatus was run through the basement to the outside of the house. Verifying documentation and photos will be sent via email to Amy Scharpf as directed 03/25/2022 Implemented
6400.110(f)Individual #1's assessment, completed 9/9/21, states Individual #1 has difficulty hearing smoke alarms over using a C-PAP machine while sleeping due to hearing loss in both ears and does not wear hear aids while sleeping. In addition, Individual #1's individual plan dated 3/10/22 indicates Individual #1 is visually impaired with corrective lenses. The smoke detectors in the home are not equipped so that Individual #1 will be alerted in the event of a fire. 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. On 3/21/2022 Greene Arc starting researching for what device would work best for this individual and be interactive with the site's smoke detector system. on 3/22/2022 Greene placed an order for the SafeAwake Safewake Bed Shaker - according to the order form it is set to arrive 3/25/2022 - later received a notice delivery was delayed until 3/28/2022. Upon arrival this device was be placed under the individual's mattress - the individual was made familiar with the device so she understands the need and importance of utilizing it. The device also has a light that comes on when it is activated. Since this individual is only experiencing difficulty hearing the smoke alarms while sleeping and wearing her C-PAP machine this device will be placed in her bedroom - this device is also portable so if the individual goes on vacation or stays overnight with her family - it can accompany her - therefore help keep her safe while she is sleeping in any environment. this individual wears her hearing aids during the day while at home and in the community. An addendum was done on the individual's assessment and sent out to the individual's team members on 3/25/2022 stating "During awake hours with her hearing aids in, she is able to hear the fire alarm but may ignore it if interested in task she is doing - She should be verbally prompted to evacuate" The program specialist also provided this information via email to her supports coordinator to have it added to her ISP. The fire drill form template for the site located at 106 Schroyers Lane was also updated to include a section where it can be documented if the bed shaker device is operable. On 3/30/2022 an asleep fire drill was run at the site utilizing this updated form. Verifying documentation and photos will be sent to [the Department, HSLS] as directed. 03/30/2022 Implemented
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