Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00269999 Renewal 06/10/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.207(5)(III)On 6/11/2025 at 11:08am, Individual #1's hospital bed was observed with full length, bilateral bedrails. Individual #1 has a diagnosis of spastic diplegia and requires bedrails to prevent them from falling out of bed. The agency obtained a prescription order for the bedrails on 7/9/2024. Although the bed rails are prescribed by a medical practitioner, Individual #1's most current assessment dated 12/10/2024 and support plan last updated 5/21/2025 do 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 support plan last updated 5/21/2025 does not include periodic relief of the device to allow freedom of movement. According to House Supervisor #1, Individual #1 can indicate that they want the bedrails removed by cooing and by pushing themselves up on their elbows while in bed.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.An addendum was added to the assessment including the Pathway of determining the use of a restraint and the manner in which staff are aware of Individual #1's desire to get out of the bed. Staff are trained annually on this Pathway. Attachment - Assessment, and Pathway training 07/25/2025 Implemented
SIN-00209546 Renewal 08/10/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.213(1)(i)The photograph in Individual #1's record was from 2013.Each individual's record must include the following information: (1) Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. (ii) The race, height, weight, color of hair, color of eyes and identifying marks. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. (2) Incident reports relating to the individual. (3) Physical examinations. (4) Dental examinations. (5) Dental hygiene plans. (6) Assessments as required under § 6400.181 (relating to assessment). (7) Individual plan documents as required by this chapter. (8) Copies of psychological evaluations, if applicable.The provider has made an adjustment to the table of contents for the chart, where it clearly indicates this should minimally be completed annually. The entire leadership team was trained on this correction. The training documentation is being emailed to the Licensing supervisor. 08/23/2022 Implemented
SIN-00177299 Renewal 09/29/2020 Compliant - Finalized