Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00236198 Renewal 12/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(13)Individual #2 PRN acetaminophen has been administered without being signed for on their MAR. The medication was dispensed from the pharmacy on 12/2/23 and one pill is missing from the blister pack, but their December MAR has no signatures for the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.The community House manager was retrained in lesson 7 & 8 (medication administration and documentation) of the ODP medication administration requirement for those who are qualified by a medication trainer to administer medications to the individuals on 1/18/24. See Attachment #7 03/01/2024 Implemented
SIN-00197287 Renewal 12/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)There was a bottle of spray cleaner located in the kitchen cabinet without the original label. The label used was agency made.Poisonous materials shall be stored in their original, labeled containers. -Spray Cleaner located in the kitchen cabinet without the original label was discarded by Community Home Manager 12/27/2021 Implemented
6400.144The Bayer Contour tester used to measure blood sugar did not have recorded results for the directed 8pm blood sugar tests on December 3rd and December 6th of 2021. Blood sugar levels for individual#1 were documented on the record but it is unknown if the Bayer device was used as prescribed by the staff measuring it.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. -Provider Nurse investigated providing conclusion that the blood sugar was taken and the Bayer device was used as prescribed, but staff failed to document accordingly or as trained. -Documentation in Comment Section of the MAR was completed (by Residential Director) to reflect documentation concerns (need) -Documentation since Citation Discovery has occurred (by DSP Staff administering medication) (need) -Incident Report Completed by Residential Director (need) 12/27/2021 Implemented
SIN-00130335 Renewal 01/16/2018 Compliant - Finalized