Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238872 Renewal 01/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)Neither of Ind. #22-bedroom windows could be opened. Screens, windows and doors shall be in good repair. Window was able to be opened during inspection but was evaluated by maintenance to ensure ease in opening, attachment. 01/23/2024 Implemented
6400.77(b)No thermometer found in first aid kit. 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. Thermometer placed in the First Aid kit. 01/23/2024 Implemented
6400.82(f)No soap found in hall bathroom at inspection.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. Soap placed in bathroom, attachment. 01/23/2024 Implemented
6400.110(g)Smoke detector in living room was not operable when tested. Needs to be replaced. If a smoke detector or fire alarm is inoperative, notification for repair shall be made within 24 hours and repairs completed within 48 hours of the time the detector or alarm was found to be inoperative. Smoke detector replaced, attachment. 01/23/2024 Implemented
6400.112(f)fire drills-front door exit used only on all fire drills beginning January 2023-December 2023. There is another exit in the home.Alternate exit routes shall be used during fire drills. Updated corporate fire drill schedule will be amended to include the use of various exits under unit/shift (highlighted in pink) attachment. 01/24/2024 Implemented
SIN-00219071 Renewal 01/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(a)There was no fire extinguisher located in the basement area. There were 7 steps down to a partial basement.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Monthly fire drills and equipment checks will continue to be made to ensure appropriate equipment is present. 01/27/2023 Implemented
6400.144Sore throat spray to be given 2 sprays every 3 hours as needed was not located on site, not accessible for individual 1 to use if needed. Medication was still notated in the record as an active as needed medication.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. Residential staff will complete cart checks weekly. Residential supervisor will complete random cart checks weekly. Nurse will review cart checks monthly. 03/31/2023 Implemented
6400.165(c)One daily vitamin was not given to individual 1 on 1/3/2023 and Polyeth glyc powder was not administered on 1/5/2023 and 1/24/2023. The morning AM doses were not administered as prescribed. It was notated on the record as medication not available at the time of administration.A prescription medication shall be administered as prescribed.Residential staff will complete cart checks weekly. Residential supervisors will do random cart checks weekly in all homes DSP's administer medications. Nurse will randomly review cart checks monthly. 03/31/2023 Implemented
6400.166(b)Medications Briviact 50mg, Lithium Carb 300mg capsules and Lorezapam were not signed immediately after administration on the 8th and 21st of January for individual 1. The medication record was blank. Pill count was verified that medication was administered but not logged.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Residential supervisor will check for missing signatures weekly. Nurse will do random missing signature checks weekly. Nurse manager will review missing signature checks monthly. 03/31/2023 Implemented