Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00233503 Renewal 10/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(7)Individual #1 is prescribed Trazodone Tab 100 MG with directions to take two tablets (200 MG) by mouth at bedtime for bipolar disorder. The September 2023 Medication Administration Record has directions to take two tablets (100 MG) by mouth at bedtime for bipolar disorder. This is the incorrect dose of the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.The Health Services Coordinator immediately had the electronic MAR updated to reflect the label on the Trazadone blister pack and ensured accuracy with the most recent prescription. 10/04/2023 Implemented
6400.166(a)(11)Individual #1 is prescribed Fiber Tab 625 MG with directions to take one tablet by mouth twice a day for supplement. The September 2023 Medication Administration Record has directions to take one tablet by mouth twice daily for constipation. Constipation is the incorrect diagnosis or purpose for the medication.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 Health Services Coordinator immediately reviewed the medication label, prescription and Medication Record and updated the Medication Record to reflect supplement as the purpose for prescribing. 10/04/2023 Implemented
6400.166(d)Individual #1 is prescribed Metformin Tab 1000 MG with directions to take one tablet by mouth twice daily with meals for diabetes. The September 2023 Medication Administration Record has directions to take one tablet by mouth twice daily for diabetes, which does not include to take this medication with meals as prescribed.The directions of the prescriber shall be followed.The Health Services Coordinator immediately reviewed the prescription, label and Medication Record and updated the medication record to reflect the correct times of administration. 10/04/2023 Implemented
SIN-00065033 Renewal 09/23/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)Based on interviews, staff are informing individuals in advance of when a fire drill is going to occur. An unannounced fire drill shall be held at least once a month. The Residential Program Supervisors will conduct a staff meeting for all CLA's and will reiterate to all staff that Fire Drills must be unannounced and held at least once a month. It must be held without prior notice to staff persons and individuals, except for the staff person responsible for setting off the alarm and record the results on the drill. The CLA staff meeting will be conducted by 12-1-14. 10/17/2014 Implemented
SIN-00052689 Renewal 08/12/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(e)On 8/12/13, smoke detectors were not interconnected and audible throughout the home. The home has 3 stories.(e) If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Interconnecting talking smoke detectors with alarms were installed on 8-13-2013. Management will assure that every home over one story has interconnecting smoke detectors for future home development. Surveyor visited home after detectors were installed. 09/04/2013 Implemented
SIN-00181162 Renewal 01/06/2021 Compliant - Finalized
SIN-00121703 Renewal 09/19/2017 Compliant - Finalized