Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00279752 Renewal 12/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66There is no light at the top of the basement steps causing the area to be dimly lit unless a light in the hallway outside of the basement door is turned on.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A light was installed at the top of the basement stairs. Photo attached. Complete 12/10/25. 12/10/2025 Implemented
6400.80(a)The stairs out of the office from the upstairs were not free from ice and snow and need to be cleared of ice and snow. Outside walkways shall be free from ice, snow, obstructions and other hazards. The area was cleaned and ice-melt was applied. 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 no procedure plans in place with regard to sharp safety.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-00263134 Renewal 03/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Poisonous material shall be stored in their original labeled containers. At the time of the inspection there was a sanitizer bottle under the sink that had "bleach" written on the bottle in a black marker.Poisonous materials shall be stored in their original, labeled containers. The poisonous material that was not in its original container was thrown away by the inspector. We will review the regulation regarding Poisonous materials shall be stored in their original, labeled containers with all staff in the home. 05/15/2025 Implemented
6400.112(g)Fire drills hall be held on different days of the week and at different times of the day. Documentation for the sleep drills held on 9.16.24 and 6.20.24 were both conducted at 4:39am. In addition, the sleep drill on 12.27.24 was conducted at 4:40am. These are not different times of the night. Sleep drills are being conducted at the same time. Fire drills shall be held on different days of the week and at different times of the day and night. An unannounced fire drill was held at the location on 3/27/25 at 11:20pm. Copy attached. 03/27/2025 Implemented
6400.141(c)(10)Individual physical dated 3.20.24 does not reflect if the individual is free from communicable diseases. That area was not filled out. Specific precautions shall be taken if an individual has a communicable disease to prevent the spread.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. The annual Physical was corrected via consultation with physician. A copy is attached. 04/11/2025 Implemented
6400.144A mammogram was completed on 6.4.23 with a follow up to occur in one year. The following mammogram was not completed until 9.27.24 which exceeds the annual time frame.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. Individual #1 is scheduled for an annual mammogram on 9/30/25. 04/15/2025 Implemented
SIN-00242468 Renewal 04/02/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)Poisonous materials are not kept separate from food. There were multiple cleaning supplies on a shelf in the basement with gallon bottles of apple juice and Kool aid.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.Food and cleaning supplies were separated. (Attachment 16a-c: Before & after comparison) 04/03/2024 Implemented
6400.64(a)Clean and sanitary conditions are not maintained in the home. There were two boxes of expired granola bars in the cabinet in the kitchen.Clean and sanitary conditions shall be maintained in the home. Boxes of granola bars were removed during ODP physical site walkthrough on 04/02/2024. 04/02/2024 Implemented
6400.80(b)The chain link fence in the front of the house had a hole approximately the diameter of a gallon bucket. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.On 4/26/2024 the chain link fence in front of the Residence was repaired. (Attachment 13: Fence repair) 04/26/2024 Implemented
SIN-00203497 Renewal 04/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The 3 to 6 months completion window for the agencies self-assessments prior to the expiration date of the agency's certificate of compliance was 9/30/21 to 12/31/21, and the self- assessment was dated 2/1/22. This exceeds the requirement.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. 2022-2023 self-assessment was completed on 02/01/2022. 01/01/2023 Implemented
6400.67(a)Located on the ceiling next to the attic access had what appeared to be water damage on the ceiling approximately the size of a softball. The outlet cover was missing from light switch in the upstairs office on the left at the top of the steps. Surfaces shall be in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. The center has identified a contractor to replace the programs roof and is awaiting a start date for the repairs to begin. Light switch cover was replaced on the date the issue was identified. 06/13/2022 Implemented
6400.141(c)(9)Individual #2 did not have a prostate exam performed. Their physical exam dated 2/28/22 noted "not performed" in this section. This exceeds the requirement.The physical examination shall include: A prostate examination for men 40 years of age or older. Canter nursing Department will reschedule individual 2's prostate exam by 07/12/2022 07/12/2022 Implemented
6400.142(a)Individual #3 has not had a dental exam.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. Individual received dental exam with IV sedation on 04/14/2022. 04/14/2022 Implemented
SIN-00172828 Renewal 03/02/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The top step on the outside exit stairway from the 2nd floor was wobbly & becoming detached, which poses as a falling hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.The facilities maintenance team repaired the fire escape at Stuart House on 3/3/2020 to ensure safe usage of the fire escape (Attachment #2). 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-00111932 Renewal 05/03/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)There was a stairway potentially used as an exit leading from the basement up to bilco doors and the outside that had nine steps and no handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Type your correction here: Handrails were installed on 5/19. All exits/stairs will be checked as part of the Internal Group Home Review Process by 2 staff members. (please see attachment # 4) 05/19/2017 Implemented
6400.186(b)Individual #1 did not sign the 02/29/17 ISP review signature sheet. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. The clinical director will remind all program specialists at the next clinical meeting of the need to obtain the individuals¿ signature at the time of the ISP. Individual #1¿s signature was obtained. (please see attachment #3). 05/10/2017 Implemented
SIN-00091006 Renewal 04/04/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(e)Individual #5 has a baby monitor in his bedroom which staff utilize to monitor his activities when Individual #5 is in the bedroom.An individual has the right to privacy in bedrooms, bathrooms and during personal care. The use of the baby monitor has been removed effective immediately. Supervision checks will continue by staff every 15 minutes when Jon is in his room Due to current medical concerns. The treatment team will discuss, and if agreed upon, will develop a restrictive plan for the use of the monitor by May 20, 2016. Please see attachment #8. The correct interpretation of the use of baby monitors with regard to reg 195(b) and this being restrictive will be reviewed at the next Clinical Meeting, Manager¿s Meeting and Quality Management Meeting. To be completed by May 31, 2016. 05/31/2016 Implemented
SIN-00222528 Renewal 03/28/2023 Compliant - Finalized
SIN-00189712 Renewal 04/20/2021 Compliant - Finalized
SIN-00152350 Renewal 03/18/2019 Compliant - Finalized
SIN-00130503 Renewal 03/20/2018 Compliant - Finalized
SIN-00136800 Renewal 03/20/2018 Compliant - Finalized
SIN-00070721 Renewal 04/01/2015 Compliant - Finalized