| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | There was a spray container located in the kitchen cabinet that was not labeled or in its original container. Content was unknown. | Poisonous materials shall be stored in their original, labeled containers. | Spray bottle removed from closet and discarded on 2/8/2021. |
05/31/2021
| Implemented |
| 6400.67(a) | The window at the front door of the lobby was boarded up. The window had been broken out by an Individual. (No work order was provided at time of inspection). | Floors, walls, ceilings and other surfaces shall be in good repair. | A work order was submitted 2/3/21 this is an outside contractor may take up to 6 weeks, estimated date of completion is 4/20/2021. |
05/31/2021
| Implemented |
| 6400.67(b) | The electric outlet in Individual#'s 6 and 7 bedroom was damaged. (Work order not provided). | Floors, walls, ceilings and other surfaces shall be free of hazards. | Room 9 not 6 and 7. Work order submitted 2/3/21. Another work order submitted on 3/23/21, completion date should be around 4/6/2021. |
05/31/2021
| Implemented |
| 6400.76(a) | The drop ceiling tile in hallway Wing A was damaged. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Ceiling tile replaced on 2/8/2021. |
05/31/2021
| Implemented |
| 6400.76(a) | The dresser located in Individual #4's bedroom #33 was damaged and in need of repair. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Dresser removed will purchase new dresser, estimated delivery date is 4/6/2021. |
05/31/2021
| Implemented |
| 6400.76(a) | The dresser located in Individual#2's bedroom was missing a knob. (Third drawer right side) | Furniture and equipment shall be nonhazardous, clean and sturdy. | Dresser removed will purchase new dresser, estimated delivery date is 4/6/2021. |
05/31/2021
| Implemented |
| 6400.77(c) | The First Aid Kit did not contain a first aid manual. | A first aid manual shall be kept with the first aid kit. | All nurses and medication trained/certified staff will document that they have read and understand the Woods' Medication Administration Manual which includes First Aid Kit contents. This will be completed by the end of the training year, which is May 31st. |
05/31/2021
| Implemented |
| 6400.80(a) | The outside walkway was not free of snow preventing the exit doors in Rm. #42 from opening. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Shovels supplied to Residential Managers to confirm all exits are cleared during the snow season, was supplied on 2/9/2021. |
05/31/2021
| Implemented |
| 6400.81(k)(3) | The bedding for Individual#2, Rm.#22 did not include linens appropriate for the season. There was no flat sheet present. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | All beds will be equipped with fitted sheet and flat sheets at all times, completed on 2/9/2021. |
05/31/2021
| Implemented |
| 6400.81(k)(6) | There was no personal mirror located in Individual#8's bedroom #34. | In bedrooms, each individual shall have the following: A mirror. | Mirrors were purchased and will be hung, around 3/25/2021. |
05/31/2021
| Implemented |
| 6400.81(k)(6) | There was no personal mirror located in Individual's #6 and 7's bedroom. | In bedrooms, each individual shall have the following: A mirror. | Mirrors were purchased and will be hung. around 3/25/2021. |
05/31/2021
| Implemented |
| 6400.82(e) | There was no mat or nonslip surface in Individual#1's bathroom #19. | Bathtubs and showers shall have a nonslip surface or mat. | All bathrooms were provided with nonslip surface on 2/9/2021. |
05/31/2021
| Implemented |
| 6400.82(f) | The bathroom of Individual#3 did not have individual clean paper or cloth towels. | 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. | All bathrooms will be provided with paper towels at all times. |
05/31/2021
| Implemented |
| 6400.111(a) | The Fire Extinguisher located in the laundry room was not safe and operable, it was overcharged. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | Residential Manager, or designee, will complete fire inspections at least one time per month and document results on the fire drill report. These forms will then be submitted to the Residential Director for review and forwarded to the Compliance and Licensing Department. |
05/31/2021
| Implemented |
| 6400.141(c)(6) | The TB test completed for Individual#9 has insufficient documentation. The documentation was in the form of an excel file with no doctor's name or signature on the documentation. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Mantoux will be planted at the Annual Physical for all Woods' residents beginning in April 2021. |
04/30/2021
| Implemented |
| 6400.141(c)(7) | No current GYN exam for Individual#9 available at time of inspection. Nurse stated that this is due to family not wanting her to attend however this is not stated in the assessment or ISP. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | A note dated 2/24/2021 from Nicole Milici's mother was located in Care Logic as submitted by the Redwood Nurse. The Resident Assessment and ISP have been revised based on the information in this note. Attachments #1. |
02/24/2021
| Implemented |
| 6400.32(d) | The windows located in bedrooms 9,10 and 11 were locked with no access to open them. During the inspection staff could not locate the key.
The windows in the TV/leisure room was locked and unable to be opened. During the inspection staff could not locate the key.
Food located in the kitchen was observed as expired, Syrup expired 11/24/2020 and fruit that was in the refrigerator had expired on 2/6/2021. | An individual shall be treated with dignity and respect. | That label is not an expiration date but rather the date the fruit was packed in the FNC. Fruit was on the menu for Sunday, 2/7 (see attached menu) so it was packed on either 2/6 or 2/7 and sent to the homes. Staff are trained to discard any unused food after serving the meal in the home. |
03/21/2021
| Implemented |
| 6400.32(i) | Bedroom #36 belonging to Individual#5 had no furniture such as a chest of drawers or mirror. (Ind. needs to have the furniture returned) | An individual has the right of access to and security of the individual's possessions. | Dresser was placed in Jennifer's room. Jennifer has a history of destroying her bedroom furniture. This is noted in her assessment. If Jennifer should exhibit this behavior in the future a program will be written in her ISP. |
03/09/2021
| Implemented |
| 6400.181(f) | The assessment for Individual#9 was sent to the team on 7/10/2020 and her meeting was held on 7/15/2020. This is 5 days prior to the meeting and the assessment should be sent at least 30 days prior to the meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | It is important to note that Nicole was admitted to Woods on 6/16/2020 and as required by NJ CSOC, her initial ISP meeting had to occur within 30 days of admission, which occurred on 7/14/2021. This means the Resident Assessment could not be completed or distributed 30 days prior to the ISP meeting because Nicole was not even residing at Woods. The next Resident Assessment will be completed and reviewed in June 2021, 6 weeks prior to the ISP meeting to ensure distribution at least 30 days prior to the next ISP meeting, which is scheduled for 7/14/2021 by whomever is the Care Coordinator or designee at that time. |
07/14/2021
| Implemented |
| 6400.181(f) | It could not be determined if individual#10's yearly assessment was shared with the planning team at least 30 days prior to the ISP. Documentation reviewed indicates the ISP meeting was on 10/22/20, and the letter accompanying the assessment was dated 9/29/20. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The next Resident Assessment will be completed in June 2021 to ensure distribution no less than 30 days prior to the next ISP meeting, which is scheduled for 7/14/2021 by whomever is the Care Coordinator or designee at that time. |
06/01/2021
| Implemented |
| 6400.193(b)(1) | Ukeru pads are described in individual#10's record as a safety measure. This terminology is used in theISP and the agency behavioral support plan, as well as in incident reports that were generated after ukeru pad use. The usage of ukeru pads, however, requires an individual to engage in behavior they otherwise would not, given freedom of choice. Their use is not requested or sought out by the individual---they are a staff measure used when behaviors or incidents become hazardous, but they are not treated like restrictive techniques in documentation: for example, ukeru pad incident descriptions reviewed do not consistently show attempts at de-escalation or redirection in the way that incidents that were reviewed relating to hand holding or supine floor holds do. Ukeru pad usage and incidents must be elevated in practice and documentation to the level of other restrictive procedures. | For each incident requiring restrictive procedures: Every attempt shall be made to anticipate and de-escalate the behavior using methods of intervention less intrusive than restrictive procedures. | Ukeru pad use is a safety technique that protects both staff and individuals from harm without any restrictive components. |
03/23/2021
| Implemented |
| 6400.196(a) | It could not be determined that staff members#'s1 and 2 were trained to provide the restrictive behavior support components of individual#10's plan that were implemented on incidents dated 5/16/20 and 8/14/20. | A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used. | The restrictive components of the plan is the restraint. Both Famatta Kawah and Hawa Karbah were trained in SMART (implementation of restraints). |
03/23/2021
| Implemented |
| 6400.196(c) | It could not be determined that records of restrictive procedure training for staff members #1 and 2 were kept, as documentation was not provided at time of inspection. | Documentation of the training provided, including the staff persons trained, dates of training, description of training and training source, shall be kept. | The ISP training for member #2 was completed on 1/28/2021 & member #1 training was conducted on 10/3/2019 & 1/22/2020. Woods has revised their training plans to create a structured design related to training course completion dates. |
04/30/2021
| Implemented |
| 6400.213(2) | It could not be determined that records of all incident reports relating to individual#10 were kept. Psychotropic medication maintenance reports that were reviewed made reference to seven incidences of ukeru pad usage throughout 2020, but five incident reports were observed in the record. | Each individual's record must include the following information: Incident reports relating to the individual. | With all staff using and entering incidents into Care Logic should improve this process and make sure this doesn't happen again. |
04/25/2021
| Implemented |