Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00279757 Renewal 12/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)The fire extinguisher located next the sink in the kitchen was not a 2A-10BC extinguisher as required. An unannounced fire drill shall be held at least once a month. The fire extinguisher that was in the kitchen that did not meet regulation requirements was removed and replaced. Photo attached. Complete 12/10/25. 12/10/2025 Implemented
6400.193(a)At the time of inspection all sharps were locked in the home despite there being only one individual in the home with a restrictive procedure plan in place with regard to sharp safety. Individuals who did not have a restrictive procedure plan in place did not have access to sharp items.A restrictive procedure may not be used as retribution, for the convenience of staff persons, as a substitute for the program or in a way that interferes with the individual's developmental program.The Program Specialist will complete a review of the annual assessment and ISP for each individual receiving residential services to ensure that the ISP contains information on poisons, sharps, and safety needs which accurately reflect the unique needs of each individual. Changes, if needed, will be communicated to the Supports Coordinator. The Clinical Director and Clinical Program Administrator will support the Program Specialist in completing these reviews/revisions by target date. Staff will be trained on updated ISPs. Due 3/11/26 03/11/2026 Implemented
SIN-00263138 Renewal 03/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There was no record of a fire drill being completed in December of 2024. An unannounced fire drill shall be held at least once a month. The staff did not complete the fire drill in December 2024. Fire drills were held monthly in January 2025, February 2025, and March 2025. Copies of the fire drill documentation are attached. 03/16/2025 Implemented
SIN-00242460 Renewal 04/02/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.34(a)Documentation showed that Individual #1 had a review of their Individual Rights on 1/1/23 then again on 3/13/24. This exceeds the annual time frame.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Annual documentation procedures have been reviewed with expectation that Residential Managers and assigned clinical team members began and complete all individual annual packets by 01/31/2024. If an individual has a POA or guardian, packets will be mailed to the proper parties for review and signature. Implemented
6400.165(c)Individual #1 is prescribed Polyethylene Glycol "Mis 17g powder in 8 ounces of water or juice and take by mouth once daily." The bottle in use at the home contained 14, 17g doses and was found to be approximately ¼ full. The label indicated that it was filled on 3/12/24 with a handwritten date of 3/18 indicating when the bottle had been started. If administered as prescribed the bottle would have been empty on 4/1/24. The medication was not being administered as prescribed.A prescription medication shall be administered as prescribed.It was noted after internal review that Individual 1 did not receive the medication while on home visits, leading to the amount of powder still left in the bottle. Individual 1 was on LOA from03/22/2024 through 03/25/2024. (Attachment11: Individual LOA Documentation) 04/30/2024 Implemented
6400.186At time of inspection Individual #2 was quite active in the home requiring frequent redirection away from the refrigerator. The staff on duty was moving with Individual #2 throughout the home but momentarily stepped away into the living room, Individual #2 went to the refrigerator and was redirected by the licensing representative, staff then reentered the kitchen area. As outlined in the Individual Support Plan (ISP ) for Individual #2, "[Individual #2] needs line-of-sight supervision due to health and safety, and behavioral concerns. She should be kept within arm's lenght in crowds or around food.' Individual #2 was briefly left out of line of sight and around food. The supervision level outlined in the ISP was not implemented.The home shall implement the individual plan, including revisions.After identification of the concern, the center conducted a team meeting to address the needs of the individual. Due to the individual's food-seeking concerns, the center installed refrigerator alarms and motion sensors in the home to enhance technological supports for the individual. The center also conducted a needs assessment for the individual's return to day programming. Since the meeting a staff member to provide 1:1 service for day programming has been identified. 05/28/2024 Implemented
SIN-00222532 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit did not contain tape. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The missing medical tape was immediately placed in the home¿s first-aid kit. 04/30/2023 Implemented
SIN-00189707 Renewal 04/20/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At the time of inspection there was a purple and white spray bottle of cleaning solution located in an unlocked cabinet in the dining room. Individuals in the home are not able to safely identify and avoid poisonous substances and all poisons are to be locked. This was corrected at the time of inspection.Poisonous materials shall be kept locked or made inaccessible to individuals. All staff members reviewed procedures regarding the locking of chemicals in the homes. 05/31/2021 Implemented
SIN-00172823 Renewal 03/02/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The 5 steps leading up through the Bilco doors in the basement. There is no handrail at this exit. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The facilities maintenance team installed a handrail for the stairwell leading out of Skyview¿s Bilco door on 3/3/2020 (Attachment #3). On-going the facility will conduct monthly quality audits (Attachment #1) on the home to assist in identifying the needs of the homes. The audit tool will consist of not only physical site needs, but also ensuring all homes are in compliance with ODP regulations. All audits will be completed by individuals well versed in ODP regulations, Devereux policies & procedures, and local township requirements. All audits will be collected by the facilities Quality Improvement Manager for review and secure document storage. All needs identified during the audits will immediately be disseminated to the proper department by the individual completing the audit in accordance with Devereux policy. 03/03/2020 Implemented
SIN-00152340 Renewal 03/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There were cobwebs in the kitchen. There was visible filth on the stairs to the second floor and at the top of the stairs. A chair in the kitchen had black stains on the upholstery.Clean and sanitary conditions shall be maintained in the home. The following were completed under the direction of the Facilities Manager: Beams were cleaned on 3/18/19. Work order submitted on 3/18/ 19 for the beams be to be primed and repainted. ( Attachment A) Top of stairs were cleaned 3/18/18 - a brush to get in the creases of the stairs so that will be purchased this week. (Attachment B) Residential Manager to notify Facilities Director /submit work order for any repairs needed. Operations will continue to utilize Quality Compliance Guide (QCG )tool for review of compliance. 05/03/2019 Implemented
SIN-00136795 Renewal 03/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)In the locked closet upstairs, there were many dead insects (wasps, beetles/roaches) on the floor.There may not be evidence of infestation of insects or rodents in the home. Closet was cleaned out by staff on 3/22/18. Exterminator visited site on 4/6/18 and treatment was applied for ladybugs. Quality review checklist was revised to add opening all doorways to check for cleanliness. 04/06/2018 Implemented
SIN-00091009 Renewal 04/04/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(b)The stairs to the second story fire escape were ice and snow covered making them very slick and causing a hazard. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The current shift responsibilities will be revised to include that during inclement weather, a designated staff on each shift will be responsible to clear all exits, walkways and fire escapes of ice, snow or hazardous conditions. This task may be divided among multiple staff. The current shift responsibilities will be revised to include that during inclement weather, the designated shift leader on each shift will be responsible to ensure that all exits, walkways and fire escapes will be safe and clear of ice, snow or hazardous conditions. If for any reason staff cannot clear all exits, walkways and fire escapes of ice, snow or hazardous conditions during the shift, they will notify maintenance and their manager immediately for assistance. Staff who fail to follow the above procedures without valid cause will be addressed through progressive disciplinary action. The shift responsibilities will be changed by August 1, 2016. Staff will be trained on the revised shift responsibilities during August IDT meetings by August 31, 2016. Attachment #1 shift responsibilities will be forwarded once revised 08/31/2016 Implemented
SIN-00066271 Unannounced Monitoring 07/17/2014 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16At approximately 6:00pm on 7/15/14, Individual #1 vomited and began complaining of stomach pain. At approximately 8:00pm, Staff #1 called the on-call nurse to ask if medications should be given or held until 9:00pm due to Individual #1 vomiting earlier that evening. The nurse gave instructions to give medications at 9:00pm and report back to her if vomiting continued or Individual #1¿s condition worsened. The nurse was not contacted again that evening. Individual #1 was still complaining of stomach pain at 9:00pm and refused medications. At approximately 10:30pm, Staff #3, the on-call supervisor was called and informed that Individual #1 was displaying physical aggression, verbal aggression, and self-injurious behaviors. Ativan 1mg PRN was administered. At approximately 11:00pm, Individual #1 was still complaining of stomach pain and asked to be taken to the hospital. Staff #1 instructed the other staff in the home to continue observing and offering liquids to Individual #1. Staff #2 went with Individual #1 to her bedroom. Individual #1 continued to become increasingly aggressive and self-injurious while complaining of stomach pain. At approximately 1:45am, a second dose of Ativan 1mg PRN was administered. Staff #2 remained in the bedroom with Individual #1 who continued to complain of stomach pain until 5:00am when she lay down on the floor and began to calm. At approximately 7:00am, Individual #1 was found to have passed away in her bedroom. Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.Improve communication provided between nursing and staff and procedures for securing treatment. 1. Director of nursing will train/provide guidance to all nurses regarding asking pertinent questions to obtain all necessary information from staff when calls are received to assess the root of problems and obtain appropriate medical care. This training will also include the below mentioned additional procedures. Attachment A 2. A follow up call will be made by the nurse to check on the status of an individual after giving directives to a staff. The nurse will ask to speak directly to the staff caring for the individual, rather than relaying information through a staff that is not assigned to or working directly with the individual at that time. 3. All PRN laxatives will need approval from a nurse before being administered. 4. All staff will be trained on these new procedures by their direct supervisors at their next staff meeting. All new staff will be trained on these procedures during their new hiring mentoring ongoing. Attachment B to be forwarded after 9/1/14 Change the culture so that staff are comfortable making an independent decision to call 911 without direction from nursing, managers, supervisors, or co-workers. 1. The Assistant Executive Director will revise/update the Emergency Medical Procedure to include additional criteria for calling 911, responsibilities, as well as directives and expectations. Attachment C to be forwarded after 9/1/14 2. The Development Director will create eye catching posters to serve as reminders for calling 911 and these will be posted in all program areas. Attachment D to be forwarded after 9/1/14 3. During the next year, all meeting facilitators, will be asked to review the 911 protocol as well as document in their minutes. This will be reviewed with meeting facilitators by the Assistant Executive Director at Manager Meetings, Leadership Meetings and Quality Review Meetings. 09/01/2014 Not Implemented
6400.199(b)Individual #1 has an order for Ativan 1mg to be administered by mouth every 3 hours as needed up to 3 times daily for anxiety which is displayed by verbal aggression, uncontrollable crying, repeated attempts of physical aggression towards staff and peers, and self-injurious behaviors. Authorization to administer the medication must be received from the CEO or their designee. On 7/15/14, Individual #1 received a dose of Ativan 1mg at approximately 10:30pm and received another dose of Ativan 1mg at approximately 1:45am on 7/16/14. Though Individual #1 did display verbal aggression, physical aggression, and self-injurious behaviors, it was not relayed to the CEO's designee, Staff #3, that Individual #1 had been complaining of stomach pain repeatedly starting at 6:00pm and lasting through the evening nor was it relayed that Individual #1 had asked to be taken to the hospital. Full information of Individual #1's status was not given to properly authorize administration of the Ativan. Administration of a chemical restraint is prohibited except for the administration of drugs ordered by a licensed physician on an emergency basis. Improve procedures and communication for PRN administration and approval. 1. The clinical director will revise the current PRN procedure and documentation to include medically related questions that will be asked by the person approving a PRN in order to ascertain a more holistic view of the client¿s current functioning level and condition. Attachment E and F to be forwarded after 9/1/14 2. All staff who are currently delegated by the Executive Director to approve PRNs will be trained by the Clinical Director in asking the new additional questions before approving a PRN. Attachment G to be forwarded after 9/1/14 3. The Clinical Director will change the documentation form of PRN approval from DSP completing to the person approving the PRN to complete it. See attachment F 4. All staff will be trained on these new procedures by clinical team members at their next staff meeting. New staff will be trained during new hire mentoring. Attachment G to be forwarded after 9/1/14 09/01/2014 Not Implemented
SIN-00130507 Renewal 03/20/2018 Compliant - Finalized
SIN-00130485 Renewal 03/20/2018 Compliant - Finalized
SIN-00111938 Renewal 05/02/2017 Compliant - Finalized
SIN-00070728 Renewal 03/24/2015 Compliant - Finalized
SIN-00068564 Renewal 09/16/2014 Compliant - Finalized
SIN-00052094 Change in Location Capacity 08/02/2013 Compliant - Finalized
SIN-00044129 Renewal 01/22/2013 Compliant - Finalized