Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00294602 Renewal 08/25/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(a)Individual #1 had a dental examination on 1/7/2025 and then again on 2/10/2026.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. LPN will ensure that dental exam is scheduled and completed annually. LPN will review the individual care needs and ensure that the next exam is scheduled within the required time frame. Documentation of completed dental exam will be maintained in the medical record. 09/04/2026 Implemented
6400.142(d)Individual #1's dental examination completed on 2/10/2026 did not indicate a teeth cleaning; therefore, compliance could not be measured.The dental examination shall include teeth cleaning or checking gums and dentures. The individual's dental cleaning could not be completed at the time of the dental examination. The dentist determined that the cleaning must be completed under sedation. LPN will coordinate with the dentist and appropriate medical providers to schedule the individual for the dental cleaning under sedation. Once completed, documentation of the dental cleaning will be obtained and maintained in the individual's medical record. 09/04/2026 Implemented
6400.166(a)(11)On 8/26/2026 at 9:47AM, Individual #1's August 2026 Medication Administration Record did not include diagnosis or purpose for Guaifenesin Liquid 100mg/5ml and Triamcinolone Cream 0.1%.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.On 8/26/2026, the diagnosis/purpose for Guaifenesin Liquid 100 mg/5 mL and Triamcinolone Cream 0.1% was added to the individual's MAR. The MAR was reviewed to ensure the required information was documented for both medications. 08/26/2026 Implemented
6400.207(5)(I)On 8/26/2026 at 9:36AM, Individual #1's bed was equipped with bed rails. Individual #1 was prescribed a hospital bed with bed rails on 11/20/2025. Individual #1's Individual Plan, last updated 7/30/2026, does not address a 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: Post-surgical or wound care.On 9/1/2026, the SC was notified by email of the need to add language to the individual's Plan regarding periodic relief of the bed rails. The Individual Plan will be updated to specify that staff will provide periodic relief of the bed rails every two hours while in bed to allow the individual freedom of movement. 09/01/2026 Implemented
SIN-00252972 Renewal 09/25/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)On 9/26/2024 at 10:32am, a 15-ounce bottle of Weiman Glass Cook Top cleaner, a 1-gallon bottle of Isopropyl Alcohol Antiseptic 75% Topical Solution, and a 32-fluid ounce bottle of Expert Grill Odorless Lighter fluid, each with instructions to contact a physician or Poison Control center if ingested, were present in the unlocked cabinet under the kitchen sink. Individual #1 is not assessed to independently use and avoid poisonous substances.Poisonous materials shall be kept locked or made inaccessible to individuals. The issue was corrected during the inspection. All poisonous materials will be stored in a locked cabinet located in the laundry room. 09/26/2024 Implemented
6400.101On 9/26/2024 at approximately 10:40am, the egress located at the rear of the garage was observed with a drop measuring approximately sixteen inches in height. A ramp is available at the home to make this door accessible; however, the ramp was not observed at the exit at the time of the inspection. This door is used as a fire escape; however, individual #2 would be unable to utilize this exit in the event of an emergency due to their physical limitations.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Maintenance installed ramp onto the egress located at the rear of the garage to improve accessibility. 09/30/2024 Implemented
6400.181(e)(11)Individual #1's annual assessment, completed 7/24/2024, did not include a copy of the individual's psychological evaluation.The assessment must include the following information: Psychological evaluations, if applicable. Psychological evaluation obtained during inspection and placed in individuals file. 09/26/2024 Implemented
SIN-00213417 Renewal 10/19/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)During the inspection conducted on 10/19/2022, the window in individual #1's bedroom, adjacent to the head of the bed, did not contain a screen.Windows, including windows in doors, shall be securely screened when windows or doors are open. Window screens were ordered on 10/25/22 and installed on 10/27/22. 10/27/2022 Implemented
6400.77(b)During the inspection conducted on 10/19/2022, the first aid kit did not contain tweezers. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Tweezer were replaced in the first aid kit at this location on 10/24/2022. 10/25/2022 Implemented
6400.81(k)(6)During the inspection conducted on 10/19/2022, no mirror was present in individual #1's bedroom.In bedrooms, each individual shall have the following: A mirror. A mirror was purchased on 10/25/22 and put in the individual bedroom. 10/25/2022 Implemented
SIN-00196577 Renewal 11/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Furnace inspections completed on 1/18/2021, 4/22/2021, 7/06/2021, and 10/12/2021 were not completed by a professional furnace cleaning company.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. We previously had our maintenance manager completing the furnace inspections for all homes. The Residential Director contacted and scheduled to have Central Heating and Plumbing inspecting the furnaces at all locations on 12-15-2021 and 12-16-2021. 12/16/2021 Implemented
SIN-00101885 Renewal 09/29/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(b)Zinc Oxide cream, apply 4 times daily at 8:00AM, 12:00PM, 4:00PM and 8:00PM prescribed for Individual #1 was not initialed as administered on 9/14/16 at 4:00PM and on 9/24/16 at 12:00PM. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. The staff member who failed to initial the MAR for the Zinc Oxide cream was retrained on medication administration by Jocelyn Miller, Medication Administration Trainer. The training included Documentation Practice 1 and included completing a Medication Administration Record. This documentation will be sent to you for review.[Immediately and at least weekly, designated staff person shall review all individuals' medication administration records (MAR) to ensure all individuals' are administered medications as prescribed and documented as required. If medications are not logged as required, staff person responsible shall be retrained on medication administration training by a certified medication administration trainer. Documentation of MAR reviews and trainings shall be kept. (AS 11/1/16)] 10/30/2016 Implemented
SIN-00160622 Renewal 08/12/2019 Compliant - Finalized
SIN-00140804 Renewal 08/28/2018 Compliant - Finalized