Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00214759 Renewal 11/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There is a substance consistent with mildew or mold under the inoperable sink in the basement.Clean and sanitary conditions shall be maintained in the home. Provider removed cabinet connection under sink, thoroughly cleaned area and placed a new cabinet around sink. Provider made sure there were no leaks from pipes or further mildewed areas. 11/18/2022 Implemented
6400.144The daily medication Bactroban 2% ointment, to be administered at 8 AM, 4 PM, and 8 PM to individual 3 was not present at the time of inspection. The PRN medication Bacitracin, apply to self-inflicted wound areas every 8 hours as needed to individual 3 was not present at the time of inspection, the medication was refilled after the inspection on 11/14/22.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. Provider ordered medication. Medication arrived on site 11/16/2022. PRN medication was not needed during the time of refill. 11/16/2022 Implemented
6400.166(b)Individual 3's daily prescribed medications were not logged as administered for 8 PM on 11/13/22 or 8 AM on 11/14/22.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Provider retrained staff member in Medication Administration on 11/29/2022. 11/29/2022 Implemented
SIN-00131749 Renewal 12/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There were 2 spokes broken on the blind on Individual #1's bedroom window.Floors, walls, ceilings and other surfaces shall be in good repair. The blinds in individual #1¿s bedroom were replaced on 12/12/17. Damages to window coverings at this site and all COMHAR sites will be reported in COMHAR¿s maintenance reporting system by the Assistant Site Manager assigned to the site. The work ticket generated by the report will be assigned to a maintenance mechanic by Maintenance technician. Repair or replacement will be addressed by the assigned maintenance mechanic. Quality assurance will be provided by the Assistant Site Manager with oversight provided via the assigned Site Manager. 12/12/2017 Implemented
6400.141(a)Individual #2's current physical exam was done on 9/7/17 and the previous physical exam was done on 8/19/16An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Staff were retrained on this regulation on 2/1/18 to prevent future discrepancies with timely completion of individual¿s physicals. Site Manager is responsible to assure compliance with the annual requirement for consumers' physicals. Oversight will be completed by nursing and Assistant Residential Directors during chart audits. 02/01/2018 Implemented
SIN-00057025 Renewal 12/09/2013 Compliant - Finalized