Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00280526 Renewal 02/02/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)(Repeat from renewal inspection 4/21/25) Individual #1's physical dated 1/14/26 does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1 saw the PCP on 2/12/2026, at this appointment an attachment was completed and included with physical exam form with "Medical information pertinent to diagnosis and treatment in case of an emergency", see Attachment #38. The violation was reviewed with the Residential Program Specialist and Residential Coordinator, and they were trained on Regulation 6400.141(c)(14) on 2/18/2026 by the Director of Quality Assurance, see Attachment #39. 03/31/2026 Implemented
6400.142(d)There was no documentation of a dental cleaning for Individual #1 since 4/18/24. The dental appointment form from 4/29/25 appointment does not indicate a cleaning occurred.The dental examination shall include teeth cleaning or checking gums and dentures. The newly assigned Residential Program Specialist contacted the dental clinic where Individual #1 was seen to get more information about the 4/29/2025 appointment to verify if a cleaning occurred and if not as to why. The dentist office verified that a cleaning wasn't completed due to aggression and refusal from Individual #1, as a result they were referred to an oral surgeon for a consult that was scheduled on 1/17/2026 however that appointment was cancelled due to the fact that the individual was admitted in a skilled nursing facility. Individual #1 was seen by the PCP and the release for surgery was completed, see Attachment #43. The Residential Program Specialist reached out to the dental clinic for an update on individual #1's appointment. An email was received stating that the information was being reviewed by the anesthesiologists before making the appointment, see Attachment #44. The violation was reviewed with the Residential Program Specialist and Residential Coordinator, and they were trained on Regulation 142(d) on 2/18/2026 by the Director of Quality Assurance, see Attachment #45. 03/31/2026 Implemented
6400.142(e)On the 4/18/24 dental form it was recommended to remove 4 of Individual #1's teeth that were decayed and broken. There was no evidence that the teeth were removed as recommended. Then again on the 4/29/25 dental exam form removal of all remaining teeth for Individual #1 was recommended (teeth numbered 5, 8, 10, 11, 12, 13, 19, 20, 27, 30, 31). A referral to oral surgery was sent after this appointment with a note that there is a 2-year waiting list. There is no documented action taken to follow up on the recommendation to remove individual #1's teeth between the 4/18/24 appointment and the 4/29/25 appointment.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.The newly assigned Program Specialist reach out to the Individual #1's dentist and was able to verify that 2 referrals were placed after the 4/18/2024 appointment. There is no evidence in the record showing that the Residential Coordinator or Residential Program Specialist followed up on the referrals, neither of them continues to work with the agency. Individual #1 was referred to an oral surgeon for a consult after their 4/29/2025 appointment and was scheduled for 1/17/2026 however that appointment was cancelled due to the fact that the individual was admitted in a skilled nursing facility. Individual #1 was seen by the PCP and the release for surgery was completed, see Attachment #43. The Residential Program Specialist reached out to the dental clinic for an update on individual #1's appointment. An email was received stating that the information was being reviewed by the anesthesiologists before making the appointment, see Attachment #44. The violation was reviewed with the Residential Program Specialist and Residential Coordinator and they were trained on Regulation 142(e) on 2/18/2026 by the Director of Quality Assurance, see Attachment #46. 03/31/2026 Implemented
6400.165(g)The 1/14/26 psychotropic medication review form for individual #1 incorrectly indicated the medication Sertraline 100mg as being taken twice per day. Per the MAR and current order, the dosage is 100mg once per day.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 new Psych Medication Form was filled out with correct medication information for Sertraline 100mg and was faxed to the prescribing doctor for verification, a copy of the form was signed and faxed by the prescribing physician on 2/17/2026, see Attachment #47. The violation was reviewed with the Residential Coordinator, and they were trained on Regulation 6400.165(g) on 2/18/2026 by the Director of Quality Assurance, see Attachment #48. 02/18/2026 Implemented
6400.166(a)(2)The May 2025-January 2026 MARs did not contain each prescriber for each prescribed medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.February 2026 MARs had prescribers added to each prescribed medication and will be done with all MARs moving forward. The violation was reviewed with the Residential Coordinator and they were trained on Regulation 6400.166(a)(2) by Director of Quality Assurance on 2/18/2026, see Attachment #49. All staff in the home will be trained on how to document prescribers on the MARs by a Medication Administration Trainer no later than 3/31/2026, and will be sent as Attachment #50. 02/24/2026 Implemented
6400.166(a)(11)(Repeat from renewal inspection 4/21/25) The February 2026 MAR's do not contain a diagnosis for the following medications: Amoxicillin-Clav 875-125mg, Oflaxin .3% eye drops, and sulfa methoxazole TMP.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The Diagnoses were added to the MARs for Amoxicillin-Clav 875-125mg, Oflaxin .3% eye drops, and sulfa methoxazole TMP, see Attachment #51. The violation was reviewed with the Residential Coordinator and they were trained on Regulation 6400.166(a)(11) by Director of Quality Assurance on 2/18/2026, see Attachment #52. All staff in the home will be trained on how to document diagnoses on the MARs by a Medication Administration Trainer no later than 3/31/2026, and will be sent as Attachment #53. 02/24/2026 Implemented
6400.166(a)(14)Individual #1 was prescribed Polymyxin eye drops 10ml to be given 4 times per day for 10 days. This medication was added to the January 2026 MAR as "Instill 1 drop into the eye in the AM, Noon, evening, and before bed for 7 days for infection" instead of the prescribed 10 days.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Duration of treatment, if applicable.Medication Error IM report #9781523 was file on 2/05/2026. A debriefing was completed on 2/6/2026 with the target following the agency Policy and Procedures for Medication Administration, see Attachment #54. The violation was reviewed with the Residential Coordinator and they were trained on Regulation 6400.167(a)(1) by Director of Quality Assurance on 2/18/2026, see Attachment #55. 02/24/2026 Implemented
6400.167(a)(1)Individual #1 was prescribed Polymyxin eye drops 10ml prescribed as Instill 1 drop into the eye in the AM, Noon, evening, and before bed for 10 days for infection. The medication began being administered 1/14/26 at 6pm and was given until 1/23/26 at 6pm for a total of 9 days. The last dose of the medication should have been on 1/24/26 at 6pm for a total of 10 full days.Medication errors include the following: Failure to administer a medication.Medication Error IM report #9781523 was file on 2/05/2026. A debriefing was completed on2/6/2026 with the target following the agency Policy and Procedures for Medication Administration, see Attachment #54. The violation was reviewed with the Residential Coordinator and they were trained on Regulation 6400.167(a)(1) by Director of Quality Assurance on 2/18/2026, see Attachment #56. 02/24/2026 Implemented