Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00218727 Renewal 01/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)Chemicals such as glass cleaner and laundry detergent were stored in a closet along with beverages.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.Supervisors will complete daily rounds in respective homes to ensure that chemicals and food items are not stored together. 03/16/2023 Implemented
6400.64(a)The cabinets and area underneath the kitchen sink were unclean.Clean and sanitary conditions shall be maintained in the home. A housekeeping checklist was developed that managers will ensure is used by all housekeeping staff; Implementation of this checklist will be checked minimally, once/month. 04/30/2023 Implemented
6400.67(a)The window blinds in room 16 are ripped and torn. The lint trap in the dryer is broken and in need of repair.Floors, walls, ceilings and other surfaces shall be in good repair. Last year we implemented a plan to address the environmental citations. As a result of this plan, we had about a 35% decrease in physical plant citations. We will continue with the same plan as indicated below. Three times per year an unannounced walk through/inspection will be conducted in all licensed homes by a Residential Director and/or Assistant Vice President of Residential Program. A plan of correction along with a compliance score sheet will be issued to the building manager who will have 30 days to respond and correct all areas that are not in compliance with regulatory standards. The scores will be used to develop a performance improvement plan for the assigned Residential Manager. Residential Directors will not complete unannounced inspection in their assigned programs. 03/16/2023 Implemented
6400.141(c)(10)Physical dated 2/25/22 stated that individual 1 is not free from communicable diseases. Staff states that was an error and that individual IS free from communicable diseases, however documentation was not provided during review to ascertain the correct health status.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. An addendum was added to the individual's annual physical examination on 1/23/23 stating the individual was free communicable diseases. 03/06/2023 Implemented
6400.142(e)Individual 1's dental exam on 3/22/22 stated a 6 month follow-up appointment was needed, which should have taken place around September 2022. This appointment did not take place until 1/18/23, which is 10 months after the original appointment recall recommendation.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.Starting on 2/17/23, dental agency agreed to upload dental examinations daily into the individual's electronic health record. A member of the individual's treatment team will track the individual's appointments to coordinate dental care. 05/01/2023 Implemented
SIN-00200070 Renewal 01/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(b)Debris outside of the building, on the common grounds was not well maintained or free from unsafe conditions. There are multiple pieces of furniture (dressers/beds, bags, containers, sharp ended objects etc.) on the grounds to be removed The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Debris discarded on 2/24/22. On 3/2/22 Residential Director walked through all common areas in Maplewood and no debris or trash was noted. 03/31/2022 Implemented
6400.144Waist circumference quarterly checks-per the Nurse this is done-Feb, June, Oct-all MAR's provided however, June 2021 had lines going through the dates on the mar-staff states the lines on the mar represent this was due to refusal, however, the refusal is not defined or annotated by staff as a refusal on the June 2021 Mar.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. All residents¿ have a right to refuse treatments/medical care/assessments. Medical staff will document refusals of care in the electronic health record (Carelogic). 03/01/2022 Implemented
6400.196(b)It could not be determined if the physical restraint used on the individual was also used directly on the staff person during training as required to be able to implement or manage the behavior of the individual.If a physical restraint will be used, the staff person who implements or manages the behavior support component of the individual plan shall have experienced the use of the physical restraint directly on the staff person.As part of all SMART (physical restraint) classes, every employee is required to have all restraints applied to them. This is noted in course materials on the skills test and participant handout. Materials are attached and applicable statements are highlighted (pages 1 &2). No additional training is required for this POC as ensuring that individuals experience restraints on self during training is already an established policy that is tracked and adhered to for all appropriate Woods employees. 03/01/2022 Implemented
SIN-00183420 Renewal 02/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)A bottle of Clean 64 cleaning chemicals was found in the closet of Room 02. The room is currently unoccupied, but both the room and its closet were unlocked, presenting a poison hazard for the individuals who live in this property.Poisonous materials shall be kept locked or made inaccessible to individuals. A bottle of Clean 64 cleaning chemicals was removed and kept in a locked secure/ closet on 2/8/2021. 05/31/2021 Implemented
6400.62(d)Cleaning chemicals were observed to be stored with food items in a common area closet. Diet Pepsi, Diet Coke, bottled water, and Gatorade were kept in the same closet with hand cream/lotion, bathroom cleaner/bleach, oven cleaner, stainless steel cleaner, and glass cleaner.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.A bottle of Clean 64 cleaning chemicals was removed and kept in a locked secure/ closet on 2/8/2021. 05/31/2021 Implemented
6400.64(a)A black substance consistent with dust or dirt was observed on and around ceiling vents throughout the property, both in bedrooms and common areas.Clean and sanitary conditions shall be maintained in the home. All vents were cleaned on 2/9/21. 05/31/2021 Implemented
6400.67(a)In Room 19 (belonging to individual#1), a crack in the ceiling paint was observed. Unfinished repair work was also observed in the kitchen area, whose ceiling was partially unpainted.Floors, walls, ceilings and other surfaces shall be in good repair. A work order was submitted on 2/15/2021, estimated completion date 4/8/2021. Attachment #6 05/31/2021 Implemented
6400.72(b)The window screen in Room 28 (belonging to individual#2) is damaged. There is a hole in the screen near its right side. Screens, windows and doors shall be in good repair. A work order was submitted on 2/15/2021, estimated completion date 4/8/2021. Attachment #6 05/31/2021 Implemented
6400.76(a)The mirror in individual#3's room (Room 21) is broken. It is missing a large chunk of glass along its left edge. Furniture and equipment shall be nonhazardous, clean and sturdy. Broken mirror was discarded and a new mirror was purchased and hung on 3/23/21. Attachment #6 05/31/2021 Implemented
6400.80(a)The ramp/walkway onto which the right hallway back exit opens was observed to be covered in snow; it had not been shoveled or cleared. 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
6400.113(c)The fire safety training record in individual#1's file does not list the property for which the individual was trained. A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept.Care Coordinator added the missing name, property, date of the training and meeting location information to the Fire Safety certificate on 3/16/2021. Attachment #1 05/31/2021 Implemented
6400.32(d)Throughout the inspection at this location, announcements of open doors could be heard on a frequent basis. These announcements were loud and funneled through the public address system of the building, which made the environment difficult to obtain quiet.An individual shall be treated with dignity and respect.Although we understand the concern around the noise level when doors are opened, these alarms were installed to mitigate the risk of elopement that is present for many of the individuals who reside in Maplewood. We have had individuals elope into the community and commit crimes. We believe that the risk mitigation that is derived from these alarms outweighs the disruption to the environment that the alarms produce. 04/30/2021 Implemented
6400.165(g)Psychotropic medication management visit documentation reviewed for individual#1. Reports from the 8/19/20 and 11/25/20 reviews indicate Adderall maintenance medication therapy should continue, but does not state the dosage.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The current problems have already been corrected by the providers. 03/20/2021 Implemented
6400.181(f)It could not be determined that individual#1'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 2/25/20, but the letter drafted to accompany his assessment was dated 2/12/20.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Care Coordinator, corrected this issue of a late Resident Assessment. The current Resident Assessment was completed & signed on 1/4/2021; the distribution letter is dated 1/13/2021 and the ISP meeting occurred on 2/18/2021. Attachments #3. 03/22/2021 Implemented
SIN-00156313 Renewal 04/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)Individual #16's green recliner is broken with wood sticking up from the bottom of the chair cushion. Furniture and equipment shall be nonhazardous, clean and sturdy. The recliner was removed from the bedroom on 05/7/2019 by the Residenital Manager and replaced with a leather covered chair the same day. A monthly environmental inspection will be completed by the Residential manager,and all concerns will be addressed and forwarded to the Residential Director. 05/10/2019 Implemented
6400.141(b)The initial physical for individual #15 dated 7/23/18 was not signed by the physician.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. Review of mandatory signature after completion of physical examination by a licensed physician, certified nurse practitioner or licensed physician's assistant will be discussed at the next provider meeting scheduled on 7/15/19. 07/15/2019 Implemented
6400.141(c)(14)Individual #15's physical exam dated 7/23/18 did not include Information pertinent to diagnosis and treatment in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Eileen Fox, Systems Analyst, updated the Annual Physical Exam report to include medical information pertinent to diagnosis and treatment in case of emergency under the PE 2 section. PCP is now able to indicate this information was reviewed as indicated. (attachment #1) 07/08/2019 Implemented
SIN-00133739 Renewal 02/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was rust around the bathroom (room #25) sink faucet. The carpet on the floor of bedroom #14 was covered with stains.Clean and sanitary conditions shall be maintained in the home. All carpets in the building were cleaned by Housekeeping (attached picture #4). The Residential Manager will complete a monthly environmental walk to confirm any issues. Any issues found will be reported to the Housekeeper for follow-up. The Residential Director requested with Maintenance to have the faucet replaced. This has been completed (attached picture #5). The Residential Manager will completed monthly environmental walks during these walks any issues will be addressed right away. 06/11/2018 Implemented
6400.67(a)The door panel leading to A hall was cracked/broken. There were knobs missing from the TV stand in the activity room.Floors, walls, ceilings and other surfaces shall be in good repair. The door in hallway A has been repaired (attached picture #2). The Residential Manager will confirm these doors are proper working condition during the monthly environmental walk. Any issues brought up will be addressed at the time of walk. The Residential Director requested that the TV stand missing the knobs be placed in the trash which has been replaced (attached picture #3). The TV stand was discarded. The Residential Manager will confirm furniture is in good standing condition by completing a monthly environmental walk. Any issues found during this walk will be addressed right away. 03/09/2018 Implemented
6400.80(b)There were broken furniture, and leaves gathered outside the back porch. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The broken furniture and leaves on the back porch were discarded (attached picture #1). The Residential Manager will conduct monthly environmental walks and during this time any issues that come up will be addressed right away. 03/01/2018 Implemented
6400.110(a)The smoke detector/fire alarm in the basement was inoperable. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The Residential Director requested for the smoke detector/fire alarm in the basement to be tested. A test was completed (attachment #1) and everything is operate according to computer system. The Residential Manager will confirm working during monthly environmental walk. Any issues found will be address with appropriate departments. 02/23/2018 Implemented
6400.112(i)On 2/12/17 an air horn was set off during the drill. A fire alarm or smoke detector shall be set off during each fire drill.The Residential Director discussed with Supervisor on the correct way to conduct a fire drill. Residential Manager review and Residential Director sign off on the fire drill forms each month. 02/15/2018 Implemented
SIN-00108177 Renewal 02/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was a brown stain identified as feces which was approximately four inches in diameter on the carpet located in room 23. There was a dark stain approximately nine inches in diameter found on the carpet in room 5.Clean and sanitary conditions shall be maintained in the home. The carpet in room 5 and 23 has been cleaned. (see pictures) The Program Supervisor completes an environmental walk thru of the home minimally once per month. Any noted repairs will be submitted to the appropriate department. If repairs cannot be completed, appropriate action will be taken to replace the item. The environmental checklist will then be submitted to the Residential Manager for review. If repairs cannot be completed, appropriate action will be taken to replace the item. The environmental checklist will then be submitted to the Residential Manager for review. If observed at any time, Program Supervisors are to report any issues to the Residential Manager so that immediate action can be taken. 02/15/2017 Implemented
6400.141(c)(14)Individual #1's physical examination, dated 7/12/16, did not document information pertinent to diagnosis in case of an emergency. Individual #2's physical examination, dated 9/15/16, did not document information pertinent to diagnosis in case of an emergency. Individual #3's physical examination, dated 3/31/16, did not document information pertinent to diagnosis in case of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Nursing department revised the physical form to include information pertinent to diagnosis or treatment in case of an emergency. As new physicals are completed, the new form will be utilized. (see attachment) 02/13/2017 Implemented
6400.164(b)Individual #2's MAR did not indicate whether the medication was administered on 2/4/17 at 8pm for Nystop warm compress and Bactroban ointment. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. Nursing completed a Medication Incident report on 2/8/17 at 10 pm along with the corrected MAR. Going forward, the nurse or medication trained staff will complete daily check of the MAR to ensure all medications are initialed for accordingly. If any are missing, the nurse or medication trained staff will complete an Incident report with the missing information and forward it to nursing management. Nursing management will then follow up to ensure completion. (see attachments) 02/08/2017 Implemented
6400.213(1)(i)Individual #1's record did not document identifying marks. Individual #2's record did not document hair color, eye color or identifying marks. Individual #3's record did not document hair color, eye color or identifying marks. Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Individual #1's assessment was updated to include identifying marks. Individual #2 and #3's assessments were updated to include hair color, eye color and identifying marks. (see attachments) This information will be included in all assessments going forward. 03/10/2017 Implemented
6400.241(a)There were approximately six bowls of Jell-O and a Lactaid drink found uncovered in the refrigerator in the kitchen. Food shall be stored in covered containers. The items were thrown away on the day of the walk through inspection. The Program Supervisor completes an environmental walk thru of the home minimally once per month. Any noted food items left uncovered will be immediately throw away. If observed at any time, staff, including housekeepers and residential counselors, are to throw away any observed uncovered food items. Housekeeping staff are also in the residential homes on a daily basis to complete household duties. 02/08/2017 Implemented
SIN-00091121 Renewal 10/26/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The window blinds in rooms 14 and 15 were found broken. The kitchen counter was found cracked by the sink.Floors, walls, ceilings and other surfaces shall be in good repair. The blinds in rooms 14 and 15 were removed and curtains are currently in place. CMI later came out to Woods to repair the countertop. (See attachment B) Management staff will conduct monthly environmental inspection of each of their residences and notify/report any findings to the appropriate department. Housekeeping staff also report any needed repairs to the immediate supervisor upon discovery as needed. 12/04/2015 Implemented
6400.110(f)The strob light in room 21 was found inoperable. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. Note: There is no strobe light present in room #21. The strobe light in room #16 was inoperable and was repaired the same day as the walk through inspection. (See attachment with completed status). Management staff will continue to complete monthly fire equipment checks to ensure equipment is properly working. Any issues found will be reported to the appropriate management staff for follow up and correction. 10/30/2015 Implemented
SIN-00063872 Renewal 07/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.161(a)Individual #1's Sildenafil Citrate 20mg was removed from its original container by the physician.  Prescription and nonprescription medications shall be kept in their original containers, except for medications of individuals who self-administer medications and keep the medications in personal daily or weekly dispensing containers.The Health Services Administrator, requested on 10/29/14, that Nursing contact the mail order pharmacy to explain the DPW citation and to request that they send three bottles of 30 pills as opposed to one bottle with 90 pills, which would then be divided and relabeled by the prescribing Physician. Maggie Brosz, Nurse Manager, contacted the CVS Specialty that sends the pills via mail order and they have agreed to switch the order to three bottles of 30 tablets to meet the DPW regulation. (See attachment A) Going forward, if a similar incident occurs, the Nursing department will contact the mail order pharmacy and explain to them the DPW regulation and the need to package the pills the way they are needed prior to the pills being sent to Woods. 10/29/2014 Implemented
6400.241(a)There were Tostitos and pretzels found uncovered. Food shall be stored in covered containers. The Residential Manager, threw out the open bags of Tostitos and pretzels during the BHSL walk through inspection and reminded the housekeeper that all Tostitos and pretzel bags must be clipped once they are opened. Environmental reviews are done on a monthly basis by the management staff and will ensure that all Tostitos and pretzel bags are clipped if opened. [All staff that handle or come into contact with food in the home will be trained in this regulation within 30 days of receipt of this plan of correction. LAC 1/26/15] 08/04/2014 Implemented
SIN-00044229 Unannounced Monitoring 12/18/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)Individual # 1 was left unattended on a bus with the bus driver during a community trip on 12/09/2012.(a) An individual may not be neglected, abused, mistreated or subjected to corporal punishment. The target staff in this incident did not follow the procedure accurately as stated in the 'Client/Staff Trip Accountability Policy.' Target staff was retrained on the policy and procedures on 12/19/2012. 12/19/2012 Implemented
6400.45(e)Individual #1's ISP identifies that constant supervision is required at all times. On 12/9/12, Individual #1 remained on the bus during the community outing, unsupervised by trained staff.(e) An individual may not be left unsupervised solely for the convenience of the residential home or the direct service worker. In this incident, the individual was not left unsupervised for the convenience of the residential counselor; the individual was overlooked while sleeping on the bus, while the staff was focused on the other individuals exiting the bus. It was determined as a result of the investigation that the target staff did not follow the policy and procedures regarding trip accountability; the target staff was returned to work upon completion of the investigation, on 12/13/2012, and given disciplinary action for not following the policy. The Recreational Drivers were trained on 12/11/2012 on the expectation of accompanying their group of staff/individuals into the establishment, to park the vehicle as close as possible to the establishment, and if they are unable to park close to the establishment cell phones must be available. Individual #1 will not be left unsupervised at any time and the agency will follow the individual's ISP at all times. The program director will monitor staffing requirements of this individual and all individuals living in this home on a weekly basis. 12/13/2012 Implemented