Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00279751 Renewal 12/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered, and whether the fire alarm or smoke detector was operative.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Upon review of fire drill documentation, there have been 9 fire drills since 3/17/25 and copies reflect that all drills have the time of the drill accurately recorded. The Residential Director retrained all Managers on fire drill procedures including requirements to be held on different days of the week, different times of the day, using different exits, and the requirement that fire drills are unannounced. Copies attached. Complete 12/17/25. 12/17/2025 Implemented
6400.52(c)(6)Staff #1 was trained in individual service plans, however at the time of the inspection, Staff #1 did not have adequate knowledge of poison safety and sharp safety of the individuals in the home. Staff #1 was unsure who was safe with poisons and sharps.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Staff #1 was retrained on poison safety for all individuals living in the home. Copy attached. Complete 12/22/25. 12/22/2025 Implemented
6400.193(a)At the time of inspection all sharps were locked in the home despite there being no restrictive procedure plans in place for any of the individuals residing in the home identified as unsafe with sharps.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-00263132 Renewal 03/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(a)There shall be a dental exam yearly. Documentation of dental exams were provided for dates on 10.10.23 for Individual #1 and not again until 12/10/24. This exceeds the annual time frame.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 #1 had a dental exam on 6/4/24. The documentation was missing during the on-site inspection. A copy is attached. 04/15/2025 Implemented
6400.166(a)(11)The medication record shall list the diagnosis or purpose for the medication. Individual's March 2025 medication administration record had 2 medications listed which did not list the diagnosis. The medications Divalproex Sod ER 250mg, and 500mg tablets, as well as Sertaline HCL 50mg.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 MARs were corrected by the Director of Nursing and are attached. 04/15/2025 Implemented
SIN-00222526 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions shall be maintained in the home. The upstairs bathroom sink had a brown substance all along the outer rim of the sink.Clean and sanitary conditions shall be maintained in the home. Identified sink was cleaned by staff members on duty. Cleaning was confirmed by center QI staff members. (Attachment: Sterling cleaned sink) 05/01/2023 Implemented
6400.67(a)Other surfaces shall be in good repair. The laundry room heating vent had multiple areas of rust on it.Floors, walls, ceilings and other surfaces shall be in good repair. The center¿s Facilities Maintenance team applied a coat of paint to the heating vent in the laundry room on 03/29/2023. (Attachment- Maintenance: Sterling baseboard 1 & 2) 03/29/2023 Implemented
6400.72(b)Screens shall be in good repair. Individual #3's bedroom window screen had a rip all along the bottom of it and half- way up the left side of the screen. Screens, windows and doors shall be in good repair. The center¿s Facilities Maintenance team repaired individual #3¿s bedroom window screen on 03/29/2023 . (Attachment ¿ Maintenance: Sterling Screen 1 & 2) 03/29/2023 Implemented
6400.166(a)(2)Individual #2's March 2023 Medication Administration Record (MAR) did not include the name of the prescriber Melan Preibe.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The Physicians name added to the current month¿s MAR to ensure current month¿s medication logs identify the correct prescribers. 04/30/2023 Implemented
SIN-00203495 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
SIN-00189710 Renewal 04/20/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)Fire drills were not held during the months of September 2020 and February 2021. An unannounced fire drill shall be held at least once a month. Fire drill records were located after inspection had included. Fire drill record review processes were also review by the center to ensure review practices could meet and ensure regulatory compliance. 05/31/2021 Implemented
6400.112(c)There was no documentation of problems encountered during the fire drill held on 11/17/2020 which was not completed within the home's extended evacuation time of 5 minutes.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Fire drill records review process was reviewed by the center to ensure internal processes would ensure fire drills and fire drill records met regulatory standards. 05/31/2021 Implemented
6400.112(d)The documented evacuation time for the fire drill held on 11/17/2020 was 5 minutes and 30 seconds which exceeded the approved extended evacuation time of 5 minutes.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home.Fire drill records review process was reviewed by the center to ensure internal processes would ensure fire drills and fire drill records met regulatory standards. ((subsequent fire drills have evacuation times within the 5 minute timeframe demonstrating that individuals can safely evacuate the home as per the limit set by the fire safety expert -CH 8/12/2021)) 05/31/2021 Implemented
6400.52(c)(4)Staff #1 was not trained in Recognizing and Reporting Incidents during the annual training year reviewed during the 2020 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Center specific deadline for completion of all 6100-training completion will be moved to the end of November in order to catch future errors or missing trainings. ((Staff #1 was trained on 8/13/2021 in recognizing and reporting incidents -CH 8/13/2021)) 05/31/2021 Implemented
SIN-00152348 Renewal 03/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The metal handrails on either side of the outdoor steps leading from the front door were peeling with sharp edges, and rusted metal was exposed. Floors, walls, ceilings and other surfaces shall be free of hazards.The following action was completed under the direction of the Facilities Manager: Work order submitted on 3/18/19 Handrail repaired/repainted on 3/19/19 ( Attachment G) Residential Manager to notify Facilities Director and submit work order for any repairs needed Operations will continue to utilize QCG tool for compliance 05/03/2019 Implemented
6400.161(e)Milk of Magnesia suspension, with a prescription label for Individual #1, was found in the medication box but was not listed on the Individual's current medication administration record.Discontinued prescription medications shall be disposed of in a safe manner.The following action was completed under the direction of the QM Manager: Medication was removed immediately and returned to Nursing for disposal on 3/18/19 Operations will continue to utilize QCG tool for review of compliance 04/17/2019 Implemented
6400.162(a)The medication Duoneb 2.5-0.5mg./3ml. solution, which is to be administered to Individual #1 twice daily and PRN via a nebulizer, did not have a pharmacy label on the package.The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. The following action was completed under the direction of the Assistant Executive Director: Nursing was notified on 3/18 and missing pharmacy label was ordered and provided on 3/19. Med Techs/Residential Managers/Assistant Managers will check all medication for labels and notify nursing if a medication does not have a label Operations will continue to utilize QCG tool for review of compliance 05/03/2019 Implemented
SIN-00136791 Renewal 03/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Carpet in the second floor hallway and the two 2nd floor bedrooms appeared heavily soiled with multiple dark stains and bleach marks; and was loose or buckling in several places, posing a potential tripping hazard.Clean and sanitary conditions shall be maintained in the home. A work order had been submitted by the Residential Manager on 3/12/18. The carpet was cleaned and stretched to remove the buckling on 5/10/18. Operations will continue to review physical site through use of the QCG and work orders will be placed as needed. 05/10/2018 Implemented
6400.67(a)The door to the 2nd floor bathroom was broken at the bottom, outside of the door; with the outer surface layer cracked and peeling away from the door.Floors, walls, ceilings and other surfaces shall be in good repair. A work order was submitted by the Residential Manager on 3/12/18 for this to be repaired. The bathroom door was fixed on 3/26/18. Operations will continue to review physical site through use of QCG and work orders will be placed as needed. 03/26/2018 Implemented
SIN-00172820 Renewal 03/02/2020 Compliant - Finalized
SIN-00158464 Change in Location Capacity 07/11/2019 Compliant - Finalized
SIN-00130501 Renewal 03/20/2018 Compliant - Finalized
SIN-00130481 Renewal 03/20/2018 Compliant - Finalized
SIN-00111930 Renewal 05/02/2017 Compliant - Finalized
SIN-00091004 Renewal 04/04/2016 Compliant - Finalized
SIN-00070719 Renewal 03/25/2015 Compliant - Finalized
SIN-00044140 Renewal 01/22/2013 Compliant - Finalized