Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00218720 Renewal 01/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit did not have a thermometer at the time of inspection. Staff put a thermometer in the first aid kit as required immediately after discovery. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Nursing staff will continue to check the Emergency Equipment which includes the First Aid kit on weekly basis and document as well as replenish any supplies used. Nurse Manager will review checklist monthly. 03/31/2023 Implemented
6400.32(h)Individual 1 has a right to privacy in his bedroom. His bedroom window did not have curtains. It was suggested to put film on the window to give him privacy.An individual has the right to privacy of person and possessions.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. 03/31/2023 Implemented
6400.32(i)Individual 1 does not have secure access to his belongings (clothing); his clothing's is being stored in the living room closet. His ISP states no furniture can be in his bedroom to prevent injury of himself or others, however, Individual 1's items are not being stored in a safe, secure location accessible only to the individual.An individual has the right of access to and security of the individual's possessions.An individual's right of access to and security of their personal possessions will be reviewed at manager's meeting. 03/16/2023 Implemented
SIN-00199980 Renewal 01/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)Hand sanitizer was located in the kitchen cabinet along with food.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.Sanitizer removed during walk through. All Residential Directors and Residential Managers will be trained in the new procedure in March 2022 and implementation will begin in April of 2022. 03/02/2022 Implemented
6400.64(a)All tubs and shower areas had a dark substance consistent with dirt or mildew. These areas should be cleaned and re-caulked.Clean and sanitary conditions shall be maintained in the home. Maintenance requested sent for recaulking. All Residential Directors and Residential Managers will be trained in the new procedure in March 2022 and implementation will begin in April of 2022. 03/02/2022 Implemented
6400.82(e)The nonslip mat is too small. The nonslip surface or mat must be large enough to cover the entire floor surface of the bathtub or shower. Bathtubs and showers shall have a nonslip surface or mat. Non slip mat replaced with larger one. All Residential Directors and Residential Managers will be trained in the new procedure in March 2022 and implementation will begin in April of 2022. 03/02/2022 Implemented
6400.111(f)The fire extinguishers in the kitchen and supervisor's office were last serviced in January 2021. This needs to be completed annually. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Extinguisher checked and tagged. 03/02/2022 Implemented
6400.141(c)(6)No current TB test results were found in the record for Individual #1 at inspection. Physical exam dated 1/31/22 indicates last TB test conducted in 2019-no month/day provided-however, immunization record lists the date as 4/13/19.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. Individual #1 received a Tuberculin skin test on 1/31/2022. See attachment. A tuberculosis screening will be performed as needed during the individual's Annual Physical exam (APE)to ensure testing is completed every two years. On 3/3/2022, a chart review was conducted by the Manager of QA & UR and confirmed that all remaining residents in this home are fully compliant with TB test results. 03/03/2022 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
6400.213(1)(i)Individual #1 - Demographics-SSN, hair color, eye color, identifying marks not found in content of record-(assessment, ISP, face sheet or physical exam)Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Woods does not print the SSN on any documents as it is considered to be protected health information (PHI) under Federal HIPAA laws.  The SSN is located in the electronic health record on the opening screen once in the individual's record. Director of Records created the form being utilized in this plan and will also be the person disseminating form to future reviewers. She is intimately aware of the form and the dissemination plan and thus, does not require training to execute. More specifically, the Director of Records Services will ensure the technical assistance document is distributed to all in-person reviewers.  Director of Records Services will ensure the screen shot of the "Face Sheet" screen is included for all uploaded charts for virtual reviews. The Chief Performance & Quality Officer will hold Director of Records accountable to POC. Addendum was completed for Resident assessment and updated all information at the ISP meeting held 2/7/22. Director of Care Coordination and Assistant Director of Care coordination. His Care Coordinator was retrained on 2/2/22. 03/01/2022 Implemented
SIN-00183423 Renewal 02/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71Phone in kitchen area does not list emergency numbersTelephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center was placed near the outside line on 2/8/2021. 05/31/2021 Implemented
6400.72(a)No screen in window in fitness area No screens found in individual #'s 2, 3, or 4 bedroom windowsWindows, including windows in doors, shall be securely screened when windows or doors are open. Work order was submitted to maintenance on 2/9/21, estimated completion date is 4/8/2021. 05/31/2021 Implemented
6400.144Prn pazeo eye drops not found in med box @inspection for individual#1-staff stated it was expired and had not been replaced. Requested but no documentation provided of it being replaced.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. Prn pazeo eye drops is currently in med box. 05/31/2021 Implemented
6400.46(b)Staff#1 did not complete an annual fire safety training for the training year of 6/1/19-5/31/20.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Annual fire safety training was completed on 1/20/2021. 05/31/2021 Implemented
SIN-00156331 Renewal 04/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The dining room had one chair with a detached seat cover. Furniture and equipment shall be nonhazardous, clean and sturdy. The chair was removed from the dining room and discarded by the Residenital Manager on 05/3/2019. A monthly environmental inspection will be completed by the Residential manager,and all concerns will be addressed and forwarded to the Residential Director. (attachment #4) 05/03/2019 Implemented
6400.141(c)(1)Individual #3's physical exam dated 4/29/19 did not include a review of medical history.The physical examination shall include: A review of previous medical history. The physical exam report contains a listing of all historical medical information located immediately under 'reason for visit.' Eileen Fox, Systems Analyst, will add 'previous medical history reviewed.' Personal Care Provider (PCP) will be able to indicate on report that the medical history was checked. This will be addressed with the PCP at the next provider meeting. Provider meeting is scheduled 7/15/19. 07/15/2019 Implemented
6400.141(c)(3)Individual #3's physical exam dated 4/29/19 did not include a current diphtheria and tetanus, last diphtheria and tetanus was on 7/24/07.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Eileen Fox, Systems Analyst, updated the Annual Physical Exam report to include immunizations, screening tests, and laboratory tests reviewed and recommendations made as needed under the PE 1 section. Primary Care Physician is now able to add his recommendations concerning all three areas in the physical report as indicated. (attachment 2) 07/08/2019 Implemented
6400.141(c)(9)Individual #4 physical exam dated 9/28/18 did not document a prostate exam.The physical examination shall include: A prostate examination for men 40 years of age or older. At Woods, the screening decision to complete a digital exam is at the physicians discretion. This residents Prostate-Specific Antigen (PSA) has been monitored; last PSA was done 10/2017 and reviewed by PCP. PSA 0.2 (< or + 4.0). (attachment 3) 07/08/2019 Implemented
6400.141(c)(10)Individual #3's physical exam dated 4/29/19 did not include if they were free of communicable disease.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. Eileen Fox, Systems Analyst, updated the Annual Physical Exam report to include immunizations, screening tests, and laboratory tests reviewed and recommendations made as needed under the PE 1 section. Primary Care Physician is now able to add his recommendations as indicated. (attachment 2) 07/08/2019 Implemented
6400.141(c)(11)Individual #3's physical exam dated 4/29/19 did not include health maintenance needs.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Eileen Fox, Systems Analyst, updated the Annual Physical Exam report to include assessment of health maintenance needs, medication regimen, and the need for blood work at recommended intervals under the PE 2 section. Personal Care Provider is now able to document his assessment of these three areas in the physical report as indicated. (attachment 2) 07/08/2019 Implemented
6400.141(c)(12)Individual #3's physical exam dated 4/29/19 did not include a review of physical limitations.The physical examination shall include: Physical limitations of the individual. Eileen Fox, Systems Analyst, updated the Annual Physical Exam form to include physical limitations under the PE 1 section. Primary Care Physician is now able to add physical limitations as indicated. (attachment 1) 07/08/2019 Implemented
6400.141(c)(15)Individual #3's physical exam dated 4/29/19 did not include diet instructions.The physical examination shall include: Special instructions for the individual's diet.Eileen Fox, Systems Analyst, will add diet instructions under the Nutrition, Weight, and Body Image Evaluation section in the Review of Systems on the physical exam. After this addition, Primary Care Physician (PCP) will add any diet instructions as indicated to the physical report. This will be addressed with the PCP at the next provider meeting. Provider meeting is scheduled 7/15/19. 07/15/2019 Implemented
SIN-00134250 Renewal 02/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The strobe lights in #3,#8,#16 and #20 were inoperable.Floors, walls, ceilings and other surfaces shall be in good repair. The light bulbs in the strobes have been replaced (attachment #2). The Residential Manager is responsible for confirming the strobes are working during the fire equipment checks monthly. Any issues will be addressed with appropriate department. 02/23/2018 Implemented
6400.70The Telephones in the common area do not dial to outside lines.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. Woods uses an operator type system on campus within the common living areas. If an emergency arises the staff are trained to dial "6" the emgenecyline and the operator contacts the emergency personnel needed. The phones in the common living areas dial to the switchboard operator and not to an outside line (attachment #1). 02/16/2018 Implemented
SIN-00108170 Renewal 02/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The bottom right side of the bathroom door frame located between room 7 and 8 was rusted and corroded.Floors, walls, ceilings and other surfaces shall be in good repair. A request has been submitted to Maintenance to repair on 3/21/17. 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 observed at any time, Program Supervisors are to report any issues to the Residential Manager so that immediate action can be taken. (see attachment) 04/30/2017 Implemented
6400.164(a)Individual #1's MAR did not list the time that Systane Solution, Aveeno lotion, and Miconazorb Pow AF 2% was given for the evening. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. The MAR for Individual #1 was corrected to include the time of 8pm instead of 3-11pm. (see attachment) A medication incident report was also completed on 3/29/17 at 10pm for this incident. Going forward, the nurse or medication trained staff will complete daily checks of the MAR to ensure all medications are addressed accordingly. If there is any discrepancy, the nurse or medication trained staff will make the needed corrected and/or report it to nursing management to ensure appropriate follow up is completed. (see attachment) 04/01/2017 Implemented
SIN-00092407 Initial review 03/28/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The kitchen cabinet was found unlocked and had products labelled keep out of reach of children such as: Joy dishwasher soap and Dial hand moisturizer lotion. Many of the individuals residing in this home are unable to handle poisons.Poisonous materials shall be kept locked or made inaccessible to individuals. A lock has been installed on the kitchen cabinet doors by the Woods Maintenance Department. Monthly area inspections will be completed by the Residential Manager. Issues will be documented and forwarded to maintenance. 03/28/2016 Implemented
6400.64(a)The carpet in bedroom # 2 has a large red stain near the bed.Clean and sanitary conditions shall be maintained in the home. The carpet in bedroom #2 was ordered on 04/18/2016 and will be replaced by the Woods Maintenance Department upon delivery. Monthly environmental inspections will be completed by the Residential Manager. Issues will be documented and forwarded to maintenance. 04/28/2016 Implemented