Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232534 Renewal 10/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(a)The current annual assessment for Individual#1 was completed late. The current assessment was completed on 8/25/2023 and the previous assessment was completed on 7/26/2022.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.A spread sheet was developed to track the due dates of annual assessments and other time sensitive documentation. 10/30/2023 Implemented
SIN-00156819 Renewal 06/14/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The written fire drill record for the drill that was conducted on 9/11/18 did not document the exit(s) used.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 was operative.On 9/11/18 all members evacuated to the fire safe area using both left and right front doors. The form was updated. The center director will complete the document and the Activity Director will review to assure all aspects are completed. 06/14/2019 Implemented
2380.89(g)The written fire drill record for the drill that was conducted on 9/11/18 did not document if all participants evacuated to the designated meeting place.Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.On 9/11/18 all members evacuated to the fire safe area using both left and right front doors. The form was updated. The center director will complete the document and the Activity Director will review to assure all aspects are completed. 06/14/2019 Implemented
2380.111(c)(7)The annual physical examination for Individual #1 dated 1/10/19 did not document: assessment of health maintenance needs.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.On 6/18/19, the Center Director spoke with the Doctor's office inquiring if there are any recommendations for health maintenance needs, blood work and medication regimens. There is currently no recommendation for blood work or instruction for health care needs not addressed. All medications are to be taken as prescribed. The Center director updated and initialed the form as addressed with the Dr's office. The Center Director and Center Nurse will both review all physical forms to assure all aspects are completed. Forms will not be accepted if all aspects are not addressed. 06/18/2019 Implemented
2380.111(c)(8)The annual physical examination for Individual #1 dated 1/10/19 did not document: physical limitations.The physical examination shall include: Physical limitations of the individual.On 6/18/19, the Center Director spoke with the Doctor's office inquiring if there are any limitations for activities. There are currently no limitations and activities should occur as tolerated. The Center director updated and initialed the form as addressed with the Dr's office. The Center Director and Center Nurse will both review all physical forms to assure all aspects are completed. Forms will not be accepted if all aspects are not addressed. 06/18/2019 Implemented
2380.111(c)(9)The annual physical examination for Individual #1 dated 1/10/19 did not document: allergies.The physical examination shall include: Allergies or contraindicated medication.On 6/18/19, the Center Director spoke with the Doctor's office inquiring of allergies. The Center Director was informed the individual has seasonal allergies and at this time there are not contraindicated medications. The Center director updated and initialed the form as addressed with the Dr's office. The Center Director and Center Nurse will both review all physical forms to assure all aspects are completed. Forms will not be accepted if all aspects are not addressed. 06/18/2019 Implemented
2380.111(c)(10)The annual physical examination for Individual #1 dated 1/10/19 did not document: information pertinent to diagnosis in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.On 6/18/19, the Center Director spoke with the Doctor's office inquiring medical information pertinent to diagnosis and treatment in case of emergency. In the event of emergency 911 should be called. The Center Director updated and initialed the form as addressed with the Dr's office. The Center Director and Center Nurse will both review all physical forms to assure all aspects are completed. Forms will not be accepted if all aspects are not addressed. 06/18/2019 Implemented
2380.111(c)(11)The annual physical examination for Individual #1 dated 1/10/19 did not document: special diet instructions.The physical examination shall include: Special instructions for an individual's diet.On 6/18/19, the Center Director spoke with the Doctor's office inquiring if there are any special instructions to be followed for the individual's diet. There are currently no instructions related to diet. The Center director updated and initialed the form as addressed with the Dr's office. The Center Director and Center Nurse will both review all physical forms to assure all aspects are completed. Forms will not be accepted if all aspects are not addressed. 06/18/2019 Implemented
SIN-00212586 Renewal 10/04/2022 Compliant - Finalized
SIN-00192169 Renewal 09/20/2021 Compliant - Finalized
SIN-00136555 Initial review 06/14/2018 Compliant - Finalized