Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00290928 Renewal 06/23/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.207(5)(III)On 6/24/2026 at 11:55 AM, Individual #1's bed contained partial bilateral bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for the bed rails on 1/15/2025. Although the bed rails are prescribed by the medical practitioner, Individual #1's most current assessment completed 12/07/2025 does not indicate the need for the device, 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 individual support plan last updated 1/26/2026 does not include 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: 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.On 06-30-26 the Program Specialist for Individual #1, completed an addendum to Individual #1 current assessment to include the Individuals need for the device, if the individual can easily remove the device, or if the device is removed by a staff person immediately upon the request or indication of the Individual. The Program Specialist sent to Individual #1 team members the addendum, signed and dated by the Individual and Program Specialist. 07/08/2026 Implemented
SIN-00251064 Renewal 08/20/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)On 8/21/24 the window air conditioning unit in Individual #1's bedroom was not securely fixed to the window opening. This resulted in a 1.5-to-2-inch gap.Windows, including windows in doors, shall be securely screened when windows or doors are open. On 08-21-2024 the Program Director immediately secured the window air conditioning unit to make it secure in the window opening. 08/21/2024 Implemented
SIN-00196019 Renewal 11/09/2021 Compliant - Finalized
SIN-00159258 Renewal 07/16/2019 Compliant - Finalized