Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00279749 Renewal 12/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Health services are not planned for or arranged. Individual #1 is prescribed Lorazepam Pro Re Nata for anxiety. There was not a written protocol available with the medication administration records that includes when and who should determine if the medication is to be administered.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 PRN Protocol was placed in the MAR binder while the inspector was present. Copy attached. Complete 12/11/25 12/17/2025 Implemented
SIN-00263142 Renewal 03/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)At the time of inspection, the only shower on the first floor of the home next to the Individual's bedrooms was reported to be nonfunctioning with no plan to repair. Surfaces in the home shall be in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. The maintenance department is removing the non-working shower and making the tub accessible for use. 05/09/2025 Implemented
SIN-00242464 Renewal 04/02/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(b)Prescription orders are not kept current. Individual #1's medication's included Nystatin Powder, apply to affected area by topical route 2 times per day. Staff reported the medication was changed to "as needed" on 3/28/24 and provided documentation from the nursing staff to show the change in order. This medication is not entered as "as needed" on the Medication Record and the label on the medication did not reflect it should be taken "as needed".A prescription order shall be kept current.Nystatin Powder updated pharmacy label was acquired on 04/03/2024 and placed on the medication container by the center¿s QM Director. (Attachment: 10 Updated label, Nystatin) 04/03/2024 Implemented
SIN-00222519 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The bathroom located on the lower level of the home did not have hand soap available.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. 6400.82(f) The bathroom located on the lower level of the home did not have hand soap available. Facilities maintenance team has installed a hand soap dispenser in the identified bathroom to ensure soap is available. Attachment: Hand soap dispenser installation 05/01/2023 Implemented
SIN-00203484 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-00190155 Renewal 04/20/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)All fire drills held during the months of April 2020 through March 2021 utilized the same exit -- the front door.Alternate exit routes shall be used during fire drills. 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
6400.165(c)Prescription medications shall be administered as prescribed. The medication administration record (MAR) and pharmacy label for the medication Acetaminophen 500mg tabs state that the medication is to be administered "Two tabs (1000mg) by mouth every 6 hours for temperature greater than 100.5 degrees" to individual #1 on a pro re nata (PRN) basis. On 4/13/2021 and 4/14/2021, staff administered the acetaminophen for knee pain, a use that is not included on the MAR or pharmacy label.A prescription medication shall be administered as prescribed.Nursing department contacted individual¿s PCP regarding the PRN medication. PCP amended the directions for the acetaminophen order (Attachment #4) and PrimeCare Pharmacy delivered updated prescription label 05/03/2021 Implemented
SIN-00172833 Renewal 03/02/2020 Compliant - Finalized