Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235685 Renewal 12/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions are not maintained in the home. There are multiple items of expired food located in the kitchen cabinet.Clean and sanitary conditions shall be maintained in the home. Expired food items were immediately discarded on 12/7/23. 12/07/2023 Implemented
6400.80(b)The outside of the building and the yard or grounds are not well maintained. The rain gutters along the entire permitter of the home are overflowing with leaves. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The maintenance team cleaned the gutters from leaves and debris at the home on 12/14/23. 12/14/2023 Implemented
6400.151(c)(3)Staff #2's physical examination dated 2/15/23 did not include a signed statement that Staff #1 is free from communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Staff #1 had another physical completed on 1/15/24 which indicated the staff is free from communicable disease. 01/15/2024 Implemented
SIN-00219538 Renewal 12/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Partial dentures belonging to Individual #1 were found in a denture case on the bathroom counter. The denture case holding the partial was dirty with bits of food debris floating in the solution. On the vanity in the same bathroom, a cup held three toothbrushes. The toothbrush heads were touching each other. One of the toothbrushes was caked with dried toothpaste and food debris.Clean and sanitary conditions shall be maintained in the home. Individual's dentures were removed from the case and sanitized. Denture case was sanitized. Individual's toothbrushes were discarded and replaced the day of inspection. 01/13/2023 Implemented
6400.67(b)The lint trap in the clothes dryer located in the home was filled with a baseball-sized wad of lint. Failure to keep the lint trap clean could result in a fire. Floors, walls, ceilings and other surfaces shall be free of hazards.Lint was removed from dryer at the time of inspection. 01/13/2023 Implemented
6400.112(e)A fire drill was conducted during sleeping hours on 4/29/22, then not again until 11/30/22, which exceeds the six-month requirement.A fire drill shall be held during sleeping hours at least every 6 months. Agency Fire Safety Policies were updated to include, updates to the policy itself, update to the fire drill form, creation of a fire drill tracking log and updating fire safety binders for each residence. 01/04/2023 Implemented
SIN-00190466 Unannounced Monitoring 07/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)A spray bottle with an original label of Magic Power Glass Cleaner was bearing a masking tape label that said "Murphy Oil Soap & Water" was found on shelf in the laundry area. Another spray bottle was also found on the shelf in the laundry area with a label that said "Bleach & Water mix 2:1" which was not the original labeled container.Poisonous materials shall be stored in their original, labeled containers. These substances have been removed. 07/21/2021 Implemented
SIN-00181622 Renewal 01/19/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The baseboard heat next to the toilet in the main bathroom was covered with rust. The rust covered the surface up to a length of approximately two feet. Surfaces shall be in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. Since the time of the audit the baseboard heaters next the toilets were cleaned and repaired, in addition all baseboard heaters were observed and all necessary baseboard heaters were repaired. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine physical plant reviews throughout the residence. The physical plant review will consist of all compliant areas involving safety, interior repairs and exterior repairs. Program Management will review this physical plant on a weekly basis, Program Specialist on a monthly basis and the QA Department on a quarterly basis. The training and implementation for this procedure will be conducted by March 15,2021. 03/15/2021 Implemented
6400.181(e)(10)Individual #4's assessment dated 1/13/2021 did not contain a lifetime medical history.The assessment must include the following information: A lifetime medical history. Individual #4 assessment has been updated to include Lifetime Medical History. The Vice President has developed a procedure to monitor the timeliness of the required skills assessment. Assessments will be completed within 30 days of admissions and quarterly reviews thereafter. Program Specialist will be trained to review skills assessment on a quarterly basis and to complete the assessment during the quarter prior the annual review date. The Program Specialist will review that the assessments on file are completed to included but no limited to the Lifetime Medical History. There will be shared calendar to provide oversight to indicate when each individual¿s skills quarterly review and annual assessment will be completed. Training will be done with all Management and Administrative Staff on this procedure and implementation will be in effect by March 15, 2021. 03/15/2021 Implemented
6400.32(r)At time of inspection there were no locks on the bedroom door of Individual #1 or Individual #5. During inspection, Individual #1 responded "Yes" when asked if he wanted a lock on his bedroom door. Door locks shall be provided.An individual has the right to lock the individual's bedroom door.Since the time of the survey, Individual #1 has been given a key to lock his bedroom door. Individual #1 key to obtain a key will be reviewed to monitor if he still wants a key, needs supports and that he is aware of his rights to lock his bedroom door. A Key Assessment will be completed by the Behavior Specialist. The completed the assessment will share with the team and forwarded to Service Coordinator. Moving forward, all individuals (including Individual #1) will be assessed including new admissions. Staff, Behavior Specialist, Management and Administration will be trained on this procedure by March 15, 2021. 03/15/2021 Implemented
SIN-00139344 Renewal 08/14/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Self-assessments are not being done for each home. 1 self-assessment is being used for all 7 homes on this license.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. To prevent this from happening in the future, a single self-assessment will be used for each home 3 to 6 months prior to the expiration date of the COC, 9/2/2019. ((Staff responsible for completion of the self-assessment will be trained in the regulation and EIhab's procedure -CH 9/20/18)) 09/10/2018 Implemented
SIN-00082694 Renewal 10/22/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.161(e)The following 2 expired medications prescribed to individual #1 were found in the locked medication box: 1. Systane Drops prescribed on 8/20/14 with an expiration date of 8/20/2015 (instructions - instill 1 to 2 drops in both eyes 4 times a day as needed); and 2. Ondansetron Tab 4mg. Generic for Zofran prescribed on 10/6/2015 (instructions - take 1 tablet by mouth every 4 hours as needed for nausea/vomiting) prescribed by Dr. Smarse. Discontinued prescription medications shall be disposed of in a safe manner.Meds were destroyed or returned to pharmacy at the time of licensing. To prevent this from happening in the future, all residential staff were retrained on the Medication Policy and Procedure #500 (attachment #6) on 11/10/2015. Training documents #8 will be forwarded. In addition, there will be an additional level of oversight added by a recently hired RN who will provide medication room inspections at least monthly. 11/10/2015 Implemented
6400.167(b)Individual #1 is prescribed Polyeth Glyc powder 3350 by Dr. Kevin Carey to be given at 8am. Administration instructions are to use once daily 17gm in 8oz water or juice. However, on the MAR this medication is written twice and is initialed as being given twice at 8am from 10/1 to 10/16/15. This medication was not given after 10/16/15 because the individual was hospitalized. During this physical inspection, staff #2 was unsure if the medication was given twice or once each day. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.The medication administration record was immediately corrected at the time of licensing. To prevent this from happening in the future, Medication policy #507 focusing on the medication Administration Record was developed specifically describing the checks and balances that must occur daily (See attachment # 5). All residential staff will be trained on the new policy and procedures on 11/10/2015 (see attachment #8). In addition, there will be an additional level of oversight added by a recently hired RN who will provide medication administration reviews at least monthly. 11/10/2015 Implemented
6400.181(e)(6)Individual #1's Annual assessment states that he is safe with poisons. However, according to staff #1 and #2, individual #1 has been using household poisons to kill his pet fish which demonstrates the inability to use poisonous materials safely. The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. POC: Individuals assessment has been updated to reflect he does not have the ability to use poisons safely Poisons, with the exclusion of soap has been secured. All residential staff will be trained on the change in the assessment and securing poisons on 11/10/2015. The house manager will provide oversight to all 6400 homes to monitor for compliance at least weekly. Training documents #8 attached. 11/10/2015 Implemented
SIN-00191675 Unannounced Monitoring 08/06/2021 Compliant - Finalized
SIN-00124565 Renewal 11/14/2017 Compliant - Finalized
SIN-00100811 Renewal 11/21/2016 Compliant - Finalized
SIN-00070636 Initial review 09/02/2014 Compliant - Finalized