Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00266083 Renewal 05/07/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.70On 5/8/2025 at 11:50AM, the telephone was in the locked staff office on the first floor of the home.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. The telephone base and handset was moved from the staff office area to the dining room of the home, which is a central location of the main living area, on 5/9/2025 to be equally accessible to the individuals and staff persons. 06/20/2025 Implemented
6400.207(5)(III)On 5/8/2025 at 11:45AM, Individual #1 had dual side bed rails that restricts the movement or function of their body. The provider agency did not have physician's orders for the bedrails and the Individual's assessment did not address usage of bedrails. [Repeat Violation, 5/8/2024]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.Individual #1¿s bed is an adjustable bed that had come equipped with bed rails as well when it was purchased. It was discussed with the individual that if she needed/wished to keep the bedrails that we would update her Initial and Annual Assessment and also get an order from her doctor for the bed rails. The individual stated, via a signed statement, that she does not wish to have the bedrails as she does not use them, she only uses the part of the bed that raises her head while she sleeps as she needs to sleep with her head elevated due to her sleep apnea and oxygen issues. The bed rails were removed from her bed and also removed from the facility on 5/14/2025. 06/20/2025 Implemented
SIN-00190717 Renewal 07/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)Individual #1's July 2021 Medication Administration Record does not include the purpose for the following medications: Aripiprazole, Clonazepam, Levothyroxine, Midodrine, Mupirocin, and Perphenazine.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.Individual #1's MAR was updated on 8/9/2021 to include the diagnosis and purpose for each medication. 08/31/2021 Implemented
SIN-00225872 Renewal 06/06/2023 Compliant - Finalized
SIN-00133821 Renewal 04/25/2018 Compliant - Finalized
SIN-00114964 Renewal 05/22/2017 Compliant - Finalized
SIN-00077787 Renewal 07/02/2015 Compliant - Finalized
SIN-00043383 Renewal 11/26/2012 Compliant - Finalized