Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00259081 Renewal 01/13/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Certain areas in the kitchen needed to be cleaned, specifically in the tall cabinet for pans and under the sink.Clean and sanitary conditions shall be maintained in the home. The observed areas were cleaned, attachment. 02/12/2025 Implemented
6400.141(c)(15)There was no mention of dietary needs on the annual physical dated 3/12/24 for Ind. #23.The physical examination shall include:Special instructions for the individual's diet. Individual #23 is scheduled for his annual physical examination on 3/17/25. 02/12/2025 Implemented
6400.144Individual #22 is prescribed 2 PRN Medications that were not present on site. Those medications are as follows: Sore Throat 1.4% Liqd -- Give 2 Sprays every 3 hours as needed for sore throat Tussin 100MG/5LM Syrp -- Give 10 ML at bedtime for coughHealth 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. The pharmacy was called, by the nurse charge and the medication was prioritized for same day delivery. 01/16/2025 Implemented
6400.165(g)There was no psychotropic medication review in Ind. #23's file since 9/21/23.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.A Psychiatric Progress note for 12/27/24 was added. 02/10/2025 Implemented
SIN-00183400 Renewal 02/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71Emergency numbers were not posted by the telephone in individual#2's bedroom.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center was placed near the outside line was placed on 2/8/2021. 05/31/2021 Implemented
6400.80(a)Back door exit was not clear from snow/ice, as you step out of door there was ice immediately outside the entrance. Outside walkways shall be free from ice, snow, obstructions and other hazards. Shovels supplied to Residential Managers to confirm all exits are cleared during the snow season, was supplied on 2/9/2021. 05/31/2021 Implemented
6400.166(a)(13)Individual#1's Levothyroxin was not initialed as being administered on 2/7/21 at 4 pm.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.All nurses and medication trained/certified staff will document that they have read and understand the Woods' Medication Administration Manual. 05/31/2021 Implemented
SIN-00135807 Renewal 02/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71There were no emergency numbers posted by the telephone in the living room.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The Residential Director posted a sign of local emergency numbers (attached pictures). The Residential Manager will confirm the sign is by all phones during the environmental walk conducted monthly. 02/15/2018 Implemented
6400.112(f)The front exit was used in all the fire drills conducted from 11/9/16 - 12/13/17.Alternate exit routes shall be used during fire drills. The Residential Director revisited this issue with fire drill conductors. The Residential Manager will confirm alternate exits are used during fire drills. The Residential Director also will review the forms each month. Forms are sent to Quality Improvement who maintains a database of exits used. 03/17/2018 Implemented
SIN-00219064 Renewal 01/23/2023 Compliant - Finalized
SIN-00156317 Renewal 04/29/2019 Compliant - Finalized
SIN-00091128 Renewal 10/26/2015 Compliant - Finalized
SIN-00063878 Renewal 07/28/2014 Compliant - Finalized