Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00233354 Renewal 10/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65On 10/04/2, at 10:40 AM, the mechanical ventilation in the bathroom was not operational, and there was no window present for ventilation.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Landlord notified of vent in bathroom not functioning correctly. He went to the home on 10/30/2023 and will be replacing the vent. 10/30/2023 Implemented
SIN-00196579 Renewal 11/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Furnace inspections completed on 1/18/2021, 4/22/2021, 7/06/2021, and 10/12/2021 were not completed by a professional furnace cleaning company.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. We previously had our maintenance manager completing the furnace inspections for all homes. The Residential Director contacted and scheduled to have Central Heating and Plumbing inspecting the furnaces at all locations on 12-15-2021 and 12-16-2021. 12/16/2021 Implemented
6400.163(h)Individual #1, date of admission 3/12/2021, had the following medication discontinued on 8/29/2021: Biofreeze (4%) - Apply to the affected area up to 4 times per day as needed. This medication remained with Individual #1's current medications. This medication was not destroyed in a safe manner according to Federal and State statutes and regulations.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.On 11-17-2021, the Residential Director removed the topical medication from the home and destroyed of it in the proper and safe manner. Please note none of this medication was administered after the discontinued date. 12/10/2021 Implemented
6400.166(a)(7)Individual #1, admission date 3/12/2021, is prescribed the following medication: Fluticasone Propionate 50 micrograms (mcg)/Act - Instill 2 sprays into each nostril everyday as needed. The November 2021 Medication Administration Record for Individual #1 has the medication dosage listed as follows: Fluticasone Propionate Nasal Spray 50 milligrams (mg) - Instill 2 sprays into each nostril daily.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.On 11-17-2021, the Residential Director corrected the dose label on the MAR. Please note that the individual received the correct dosage of medication when administered. However, the staff wrote 50mg instead of 50mcg. 12/10/2021 Implemented
6400.166(d)Individual #1, admission date 3/12/2021, is prescribed the following medication: Polyeth Glyc Pow 3350 NF - Drink one-half capful (8.5 GM) mixed in water on Monday, Wednesday and Friday. May increase to one capful (17 GM) every day if no bowel movement in two days. The November 2021 Medication Administration Record for Individual #1 has the following directions listed: Polyeth Glyc Pow 3350 NF - Mix half capsule in 8 oz. of liquid and drink Monday, Wednesday and Friday. Individual #1, admission date 3/12/2021, is prescribed the following medication: HM Gas Relief 125 MG Softgel - Take one capsule by mouth before meals. The November 2021 Medication Record for Individual #1 has the following directions listed: HM Gas Relief 125 MG Softgel - Take one capsule by mouth three times daily with meals.The directions of the prescriber shall be followed.On 11-17-2021 the Residential Director corrected the MAR to read exactly how the prescriber ordered. 12/10/2021 Implemented
SIN-00121650 Renewal 09/20/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)The assessment for Individual #1 was completed on 7/15/16 and then again 8/10/17. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Once the new program specialist found out the assessment was not completed on time a new assessment was completed on 8-10-17. A checks and balance checklist was created by the residential director. The Program Specialist will review the checklist at the beginning of each month to ensure they are completing all documentation required per 6400 ensuring compliance. Residential Director will review and check all programing documentation quarterly for 1 year to ensure the new program specialist understand all requirements of the job. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure all individuals' assessments are completed, timely. Documentation of all audits by the program specialist and Residential Director shall be kept.(AS 10/10/17)] 10/04/2017 Implemented
SIN-00101887 Renewal 09/29/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)At approximately 2:15 PM, the smoke detector in the basement of the home was inoperable when tested. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. 180 Wick Avenue is a vacant home. There are no individuals living in the home and no staff supporting the home at the present time. When inspecting the unoccupied home, the smoke detector in the basement did not operate properly. The smoke detector was immediately replaced by maintenance. The smoke detector was installed before the self inspection and was working at that time. Due to the fact that there was no one in the home, the smoke detector had not been tested since the self inspection. We will continue to follow our inoperable fire alarm policy as we have in the past. A copy of the inoperable fire alarm policy will be sent for review. [Once the home becomes occupied, at least weekly for at least 2 months and then continuing monthly as required, a designated staff person shall check all smoke detectors in the homes to ensure all are operable and implement inoperable smoke detector policy and procedures if found to be inoperable. Documentation of all checks shall be kept. (AS 11/1/16)] 10/30/2016 Implemented
SIN-00180018 Renewal 12/01/2020 Compliant - Finalized
SIN-00140806 Renewal 08/28/2018 Compliant - Finalized