Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00236059 Renewal 12/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.211(b)(3)211b3- Individual #1's Emergency Information sheet does not identify who can provide Emergency Medical Consent.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. This regulation is important because it ensures that all parties have access to critical information in the case of an emergency. This violation occurred due to a misperception that "Next of Kin" was synonymous with emergency conesent. The Face sheet for Individual #1 was updated on 12/18/23 to reflect the proper terminology. All facesheets will be evaluated for proper semantics by 12/22/23 and will be updated, if necessary. This process will be monitored by the program specialist coordinator. 12/22/2023 Implemented
SIN-00217230 Unannounced Monitoring 01/09/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)REPEAT FROM 3/29/21 - In the laundry room there was a purple unmarked bottle, which staff stated contained water. There was also a pink unmarked bottle with "stain remover" written on it, and therefore it was not in its original labeled container. There was also another unmarked bottle located in the first bathroom.Poisonous materials shall be stored in their original, labeled containers. This noncompliance was rectified immediately upon communication of its identification. All homes will be assessed for current compliance with this regulation by 6/1/23. All staff working in this home will be retrained in this regulation by 6/5/23. Documentation of this training will be kept. Issue Identified - REPEAT FROM 3/29/21 - In the laundry room there was a purple unmarked bottle, which staff stated contained water. There was also a pink unmarked bottle with "stain remover" written on it, and therefore it was not in its original labeled container. There was also another unmarked bottle located in the first bathroom. Correction Required - Poisonous materials shall be stored in their original, labeled containers. This regulation is important because it minimizes the possibility that either staff or individuals are harmed by exposure to or consumption of poisonous materials. During the monitoring from ODP in January 2023, the inspector found 2 unmarked containers which contained water (according to the staff present) and stain remover (according to the writing on the bottle). Both bottles were immediately thrown into the garbage. No further actions were needed. To prevent this from happening again, the staff that work in this home were trained on the importance of this regulation and completing the Regulation Shift checklist correctly. All staff in the Residential Department have been retrained in the importance of this regulation. Additionally, per the settlement agreement signed 5/15/23, a house visit checklist has been developed for use by Lead Management Staff or Program Specialists on a biweekly basis. This tool includes assessing compliance with the content of this regulation and documentation of its completion will be kept in an accessible digital format. All staff using this tool will be trained on its implementation by 6/1/23. 06/05/2023 Implemented
6400.171At the time of the inspection, there was a box of mashed potatoes that was not stored properly in the pantry; the tab was left open.Food shall be protected from contamination while being stored, prepared, transported and served. This noncompliance was rectified immediately upon communication of its identification. All homes will be assessed for current compliance with this regulation by 6/1/23. All staff working in this home will be retrained in this regulation by 6/5/23. Documentation of this training will be kept. Issue identified - At the time of the inspection, there was a box of mashed potatoes that was not stored properly in the pantry; the tab was left open. Correction required - Food shall be protected from contamination while being stored, prepared, transported and served. This regulation is important because it can prevent individuals from getting sick when eating food that has been contaminated, prepared, transported or served incorrectly. It also can prevent insects or rodents from getting into the food. At the time of the inspection on 1/9/23, the ODP monitor found a box of mashed potatoes that was open, however it was not kept in a sealed bag or container. The potatoes were in a cardboard box with an opening on the side. Once this flap is opened the box cannot be re-sealed and should be placed in a resealable bag or container. The staff that work in the home incorrectly thought that closing this cardboard flap was sufficient when storing it in the pantry. The Associate Directors do weekly checks of each home and one of the questions in this checklist is "food is protected from contamination while being stored, prepared, transported, and served". The check immediately prior to this inspection showed that all food was stored properly, so it seems that since that check a staff incorrectly put the mashed potatoes in the pantry. The issue was immediately rectified following the inspection and all the staff that work in that home were retrained in regulation #171 and the importance of it. To prevent this occurrence from happening again, all staff in the Residential Department have been retrained in regulation #171. Additionally, per the settlement agreement, a house visit checklist has been developed for use by Lead Management Staff or Program Specialists on a biweekly basis. This tool includes assessing compliance with the content of this regulation and documentation of its completion will be kept in an accessible digital format. All staff using this tool will be trained on its implementation by 6/1/23. 06/05/2023 Implemented
6400.166(a)(2)The October 2022 MAR for individual #1 did not list the information of the prescribing dr. for medications azithromycin and prednisone.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The LPN overseeing this program was notified of the issue and it was resolved through communication with the physician and the pharmacy. All homes will be assessed for current compliance with this regulation by 6/1/23. All staff working in this home will be retrained in this regulation by 6/5/23. Documentation of this training will be kept. Issue Identified - The October 2022 MAR for individual #1 did not list the information of the prescribing dr. for medications azithromycin and prednisone. Correction Required - A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. This regulation is important to maintain records of what physician prescribes each medication as there are multiple physicians involved in the care and prescribing of medication for one individual. It is important for staff to know the prescribing physician, so they know who to contact in case unwanted effects are observed, clarifications are needed, or refills need requested. The October 2022 MAR for individual #1 did not list the information of the prescribing physician for medications azithromycin and prednisone. Due to the pharmacy interface between the agency's eMAR and pharmacy, medications typically come through the pharmacy with the physician's name already pre-populated. These medications were filled at a local pharmacy and had to be entered into the eMAR system manually. There was an oversight on the part of the LPN entering the medication manually when it came to entering the prescribing physician's name. LPNs currently conduct weekly house visits and complete a checklist that includes the question "Are all medications labeled correctly?" Additionally, by 6/1/23, every program has been given an appointment reminders card for all staff to use, that includes a list of information that is required for the prescription and medication labels. 06/05/2023 Implemented
6400.166(a)(11)REPEAT from 11/1/21 - The October 2022 MAR for individual #1 reads "azithromycin 250mg tablet" however, there was no diagnosis or reason for the medication given. This was also the case for a temporary PRN Medication: "prednisone 20mg tablet"; the Mar did not list a diagnosis or reason for the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The LPN overseeing this program was notified of the issue and it was resolved through communication with the physician and the pharmacy. All homes will be assessed for current compliance with this regulation by 6/1/23. All staff working in this home will be retrained in this regulation by 6/5/23. Documentation of this training will be kept. Issue Identified - REPEAT from 11/1/21 - The October 2022 MAR for individual #1 reads "azithromycin 250mg tablet" however, there was no diagnosis or reason for the medication given. This was also the case for a temporary PRN Medication: "prednisone 20mg tablet"; the Mar did not list a diagnosis or reason for the medication. Correction Required - A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. The diagnosis must be included for each medication because the same medications may be used to treat different conditions. Staff members need to know what the medication is being used to treat so that they are able to observe the individual for desired or unwanted effects, or no effect and communicate that information accurately to the prescribing physician. The October 2022 MAR for individual #1 did not list the diagnosis for azithromycin or prednisone. Due to the pharmacy interface between the agency's eMAR and pharmacy, medications typically come through the pharmacy with the diagnosis already pre-populated. These medications were filled at a local pharmacy and had to be entered into the eMAR system manually. There was an oversight on the part of the LPN entering the medication manually when it came to entering the diagnosis. The LPN overseeing this program was notified of the issue and it was resolved through communication with the physician and the pharmacy. All homes will be assessed for current compliance with this regulation by 6/1/23. All staff working in this home will be retrained in this regulation by 6/5/23. Documentation of this training will be kept. LPNs currently conduct weekly house visits and complete a checklist that includes the question "Are all medications labeled correctly?" Additionally, by 6/1/23, every program has been given an appointment reminders card for all staff to use, that includes a list of information that is required for the prescription and medication labels. 06/05/2023 Implemented
SIN-00211280 Unannounced Monitoring 09/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66During this inspection, the outside light from the basement exit was inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. On 9/13/22, the light fixture was replaced with one that uses a standard lightbulb. By 10/31/22, all homes will be reviewed to ensure that there are spare bulbs for any fixture that is atypical. 10/31/2022 Implemented
SIN-00198632 Unannounced Monitoring 01/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(a)During the 1/11/22 inspection, ice and snow was found directly outside the front egress of the home, on the cement pathway creating a hazard. Outside walkways shall be free from ice, snow, obstructions and other hazards. At the date of the inspection, the ice and snow was cleared from the front egress of the home. All homes will be assessed for current compliance with this regulation by 2/15/22. All staff working in this home will be re-trained in this regulation by the Associate Director before 3/1/22. Documentation of this training will be kept. 03/01/2022 Implemented
SIN-00190741 Unannounced Monitoring 07/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(c)A smoke detector was not located in a common area, within 15 feet of Individuals' #1 and #2's bedroom door.The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. A smoke detector will be placed in the common area within 15 feet of both individuals' bedroom door immediately. All homes will be checked by 8/13/21 to ensure there is a smoke detector in the common area within 15 feet of all individuals' bedroom doors. 08/13/2021 Implemented
SIN-00187231 Unannounced Monitoring 04/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(c)(6)Individual #1's choking protocol was developed 7/2/20. The following staff worked in the home prior to receiving training on the choking protocols: Staff person #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.All staff must be trained in an individual's specific dietary needs before working in a home to ensure the health and safety of all individuals. All staff who are currently not trained will be trained by 5/11/21 or will not work with that individual until training is complete. Beginning immediately, ALL staff will be trained in individual dietary needs prior to their first shift in a new home or where a new protocol is implemented. If new dietary restrictions or choking protocols are recommended by a medical professional, the agency nurse will review orders and the program specialist will update all required documents within 24 hours of receipt. Staff will be trained on updates/changes prior to working their first shift with individual. 05/11/2021 Implemented
SIN-00185549 Unannounced Monitoring 03/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individuals residing in the home are assessed to be unsafe around poisonous materials. During the 3/29/2021 inspection of the home, a pump-style bottle of hand sanitizer that contained a label that stated to contact poison control center if ingested, was unlocked and accessible sitting on the kitchen counter.Poisonous materials shall be kept locked or made inaccessible to individuals. Individuals will be assessed of their ability to avoid poisonous substances at least annually, and again throughout the year if any concerns arise. Poisonous materials will be locked immediately. Every staff shift change will ensure poisonous materials are locked or made inaccessible to individuals. Continual monitoring by staff will occur throughout the day to ensure poisonous materials are inaccessible. 04/16/2021 Implemented
SIN-00151260 Unannounced Monitoring 03/06/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There was cracked drywall approximately 3 inches in length above the closet in PR's bedroom. and there was a protruding screw from the bottom of the lazy susan cabinet in the kitchen preventing it from turning appropriately.Floors, walls, ceilings and other surfaces shall be in good repair. Reference previous POC issued by the department. 04/05/2019 Implemented
6400.67(b)The mirrors in both the bathrooms had metal brackets sticking out from both sides of the mirror preventing a potential hazard if an individual were to fall against the mirror. Floors, walls, ceilings and other surfaces shall be free of hazards.Reference previous POC issued by the department. 04/05/2019 Implemented
6400.80(a)There was an accumulation of ice on the front porch. Outside walkways shall be free from ice, snow, obstructions and other hazards. Reference previous POC issued by the department. 04/05/2019 Implemented
SIN-00146272 Unannounced Monitoring 12/04/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The bathroom on the left side of the house did not contain soap.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. Agency will correct the immediate issue. Agency will review the issue for violation and correct. Then agency will train all staff on the violation. Program specialist will review monthly and supervisor will review quarterly and complete tracking form. 12/05/2018 Implemented
SIN-00106595 Renewal 11/30/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The basement main door to the outside would not open fully. The bottom of the door was blocked by the floor. Screens, windows and doors shall be in good repair. The Shadowfax maintenance man sanded down the concrete so the door easily opens. See attached picture of completed citation. Moving forward, besides maintenance checking repairs in each home, the manager of the home will complete a weekly home visit and will check that all doors and windows open and close appropriately and complete the attached home visit report. 12/22/2016 Implemented
6400.74The stairs leading to the basement had non skid surface only on top four stairs. The remaining stairs did not have non-skid surface. Interior stairs and outside steps shall have a nonskid surface. The explanation for regulation 74 states that this regulation does not apply for stairs and steps that are never accessible to individuals. In this particular home, no individuals use this basement but we also do not have documentation of such. Furthermore the explanation of this regulation states that the surface should be assessed and if the surface will be slippery when wet that there must be a non-skid surface applied. As these are unfinished interior steps that are never wet, we did not think this regulation applied. Shadowfax maintenance applied non skids to each step. See attached picture. Moving forward, this will be checked by Shadowfax management on weekly home visits and the attached form will be completed to prevent being cited on this in the future. 12/22/2016 Implemented
SIN-00202698 Unannounced Monitoring 03/31/2022 Compliant - Finalized
SIN-00195609 Unannounced Monitoring 11/01/2021 Compliant - Finalized
SIN-00173221 Unannounced Monitoring 05/26/2020 Compliant - Finalized
SIN-00170982 Unannounced Monitoring 02/06/2020 Compliant - Finalized
SIN-00164219 Unannounced Monitoring 10/10/2019 Compliant - Finalized