Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00259105 Renewal 01/13/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(15)There was no mention of dietary needs on the annual physical dated 2/27/24 for Ind. #24.The physical examination shall include:Special instructions for the individual's diet. Individual #24 is scheduled for annual physical examination on 3/3/25. 02/12/2025 Implemented
SIN-00238513 Renewal 01/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65Mechanical ventilation does not work in hall bathroom across from. Office/room 13Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Maintenance notified 1/23/24 and corrected the following day 1/24/24. 04/30/2024 Implemented
6400.144Oxygen 2 liter via nasal cannula tank was not on-site (PRN order). I requested the nurse to send us the picture that the tank was ascertained. (Not provided)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. The O2 was present in the home, but the reviewer requested it be placed in individual¿s bedroom. The O2 was placed in the individual¿s bedroom on 1/23/24 at the time of the inspection. CRNP reviewed O2 PRN order and discontinued it on 1/23/24. 01/23/2024 Implemented
SIN-00218722 Renewal 01/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(13)Individual 1's annual physical exam dated 1/20/22 did not indicate allergies.The physical examination shall include: Allergies or contraindicated medications.An addendum was added to Renee¿s annual physical examination on 1/27/23 noting her allergies. 03/10/2023 Implemented
SIN-00199979 Renewal 01/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)In bedroom #3- Individual #2 In bedroom #4- Individual #3 In bedroom #5- Individual #4 The individual's dressers were missing knobs, preventing the drawers to be open properly. In bedroom #4 the bathroom fan was missing the cover.Floors, walls, ceilings and other surfaces shall be in good repair. All items have been replaced. All Residential Directors and Residential Managers will be trained in the new procedure in March 2022 and implementation will begin in April of 2022. 03/02/2022 Implemented
6400.110(a)There was no smoke detector in the attic. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Fan cover installed. All Residential Directors and Residential Managers will be trained in the new procedure in March 2022 and implementation will begin in April of 2022. 03/02/2022 Implemented
6400.144Individual #5's 12/1/21 audiology appointment documentation contains a note from the doctor indicating the individual should see their physician to have the cerumen removed from both ear canals prior to them becoming impacted, and if it cannot be done on Woods' campus, an Ear, Nose, and Throat consultation was recommended. Documentation was not provided to indicate that this has occurred.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. Specific order will be written for follow up apt by the medical center through scheduling nurse. 02/08/2022 Implemented
6400.163(h)Medication (NYSTATIN/TRIAM OIL) for Individual #1 was in the medication box and not listed on the Medication Administration Report (MAR), the medication was discontinued and was not destroyed in a safe manner.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.An assigned MTS will perform medication cart checks on a monthly basis to ensure any expired or discontinued meds are appropriately removed from the cart. The certified Med Trainer will educate the MCS/MTS during ODP Med Admin training classes. 03/01/2022 Implemented
SIN-00156333 Renewal 04/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The home has individuals who are not capable of handling poisons. Dial microbial handwashing lotion was found on the kitchen counter. The label states to call poison control if ingested.Poisonous materials shall be kept locked or made inaccessible to individuals. Dial soap was remove- POC- All poisons will be locked up at all times. 07/08/2019 Implemented
6400.67(a)In room #2 the lockset was stuck in the open position at the bathroom entrance. The bedroom door leading to the bathroom had exposed wood splinters at its base. The left hallway door exit had dirt and cobwebs on the outside. The mechanical room closet had a hole in the ceiling covered with cardboard.Floors, walls, ceilings and other surfaces shall be in good repair. "Splintered bottom of door in room #2 reported to maintenance - door was repaired. POC- all doors will be checked every month. (attachment #5) Room #2 lockset repaired. POC- all doorknobs will be inspected monthly for proper functioning. (attachment #6) Left hallway exit area cleaned by housekeeping. Ceiling tile to be installed by maintenance. Hole in ceiling of mechanical room - ceiling tile replaced. Left hall door exit area was cleaned- POC- Housekeeping to clean weekly." 07/08/2019 Implemented
6400.67(b)The laundry room has a set of small lockers of which one unit is rusted. In room #15, the ceiling exhaust was filled with dust. Floors, walls, ceilings and other surfaces shall be free of hazards."Maintence removed the lockers - POC new lockers will be purchased. House keeper cleaned Ceiling vent- POC- this has been added to the housekeeper daily checklist." (attachment 4) 07/08/2019 Implemented
6400.76(a)Room #4 has a chest of drawers missing 3 knobs. The hallway on the right has an exit door with its closure leaking fluid. Furniture and equipment shall be nonhazardous, clean and sturdy. 3 New knobs were replaced in room #4 POC- Dressers have been added to the monthly environmental form. The closure was addressed new door was installed on 6/26/19. (attachment 3) 06/26/2019 Implemented
6400.142(a)Individual #2's previous dental exam was completed on 11/20/17 and the current dental exam was done on 12/7/18 which were more than a year from each other.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Dental report on chart dated 7/10/2018, eight months after the November 2017 exam. 7/10/18 report states this was a recall visit; severe enamel erosion noted. Dental report attached. (attachment 2) 07/08/2019 Implemented
6400.240(b)The kitchen dishwater was found inoperative. A mechanical dishwasher shall use hot water temperatures exceeding 140°F in the wash cycle and 180°F in the final rinse cycle or shall be of a chemical sanitizing type approved by the National Sanitation Foundation. The dishwashwer was repaired on 5/1/2019. POC- the dishwasher was reported to maintenance on 4/28/19 as per protocol. A part was needed to complete the repair.See attached procedures. (attachment 1) 05/01/2019 Implemented
SIN-00134252 Renewal 02/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There were dust on the perimeter floor between the laundry room and the kitchen. There were some mildew between the tub and the wall in the bathroom next to room #5.Clean and sanitary conditions shall be maintained in the home. As part of Housekeeping's daily responsibility is to remove dust. The Residential Manager will conduct monthly environmental reviews and issues found will be address any housekeeping concerns to the Housekeeping staff. The Residential Director requested to have mildew removed by Housekeeping. This was completed (attached picture #5). Environmental walk through are done monthly by Residential Director/Residential Manager and other needed repairs are reported as they occur. Forms are submitted to the Residential Director at the end of each month to verify that repairs have occurred. 06/12/2018 Implemented
6400.67(a)The Knob on the closet door in room #3 was smashed. There were stains on the carpet in room #18. There were 5 knobs missing on the chest drawer in bedroom #5. The light in the bathroom next room #16 and #18.Floors, walls, ceilings and other surfaces shall be in good repair. The closet knobs have been replaced by Maintenance on 6/12/18 (attached picture #1). Environmental walk through are done monthly by Residential Director/Residential Manager and other needed repairs are reported as they occur. Forms are submitted to the Residential Director at the end of each month to verify that repairs have occurred. Housekeeping was notified and removed the stain (attached picture #2). Environmental walk through are done monthly by Residential Director/Residential Manager. Any stains found will be reported to Housekeeping to address. Forms are submitted to the Residential Director at the end of each month to verify that repairs have occurred. The dresser has been removed and replaced (attached picture #3). Environmental walk through are done monthly by Residential Director/Residential Manager and other needed repairs are reported as they occur. Forms are submitted to the Residential Director at the end of each month to verify that repairs have occurred. Lights are working in the bathrooms (attached picture #4). If light are reported to be out; Housekeeper or staff will report it on the Maintenance repair sheet which is hung in the building. 06/13/2018 Implemented
6400.141(c)(7)Individual #1 was admitted on 2/14/17 and a GYN test was not completed until 2/13/18.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. On 2/13/18 Physician signed an order stating GYN not indicated (attachment #1). GYN test due date will be placed on an excel spreadsheet by the Nursing Manager (attachment #2). This information will be posted in each nursing station. Once EMR is operational, each due date will be flagged and timely alerts will be generated for nursing to implement and/or follow-up. Each nurse covering each residence will be responsible to assess the spreadsheet monthly and follow-up appropriately. Nursing Manager will have oversight to ensure timely completion. 07/01/2018 Implemented
SIN-00108171 Renewal 02/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The cabinet to the right of the kitchen sink had comet disinfecting cleaner and two bottles of Joy dish detergent.Poisonous materials shall be kept locked or made inaccessible to individuals.They were immediately locked up. All poisonous materials will be locked at all times. If observed at any time, staff, including housekeepers and counselors are to remove and lock up any chemicals immediately upon discovery. 02/10/2017 Implemented
6400.64(a)The top shelf of a cabinet in the kitchen had scattered coffee grounds.Clean and sanitary conditions shall be maintained in the home. The coffee grinds were cleaned up in the cabinet. Going forward cabinets will be cleaned daily as part of the housekeeping routine. 02/10/2017 Implemented
6400.141(c)(14)Individual #1's annual physical examination, dated 3/9/16, did not document information pertinent to diagnoses and treatment in case of an emergency. Individual #2's annual physical examination, dated 11/30/16, did not document information pertinent to diagnoses and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Nursing department revised the physical form to include information pertinent to diagnosis or treatment in case of an emergency. As new physicals are completed, the new form will be utilized. (see attachment) 02/13/2017 Implemented
6400.213(1)(i)Individual #1's record did not document hair color, and identifying marks. Individual #2's record did not document hair color, eye color or identifying marks. Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (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. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Individual #1 and Individual #2's assessment were updated to include hair color, eye color and identifying marks. (see attachments) This information will be included in all residential assessments going forward. 04/03/2017 Implemented
SIN-00183422 Renewal 02/08/2021 Compliant - Finalized
SIN-00092406 Initial review 03/28/2016 Compliant - Finalized