Inspection ID

Reason for Inspection

Inspection Date

Inspection Status

SIN-00228928

Unannounced Monitoring

08/02/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.22(d)(1)	The home shall keep an up to date financial and property record for each individual that reflects personal possessions and funds received or deposited in the home. The individual annual assessment dated 11/2/22 reflects he cannot manage money and requires assistance with all purchases. There is no financial record in the home for Individual #1 and purchases have been made throughout the month.	The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home.	The provider has re-trained staff on proper documentation. The provider reviewed previous documentations and updated items as appropriate.	08/05/2023	Implemented
6400.32(r)(5)	Individual #1 has a bedroom lock on his door. At the time of inspection, the staff did not have a key to the lock on the bedroom door.	Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.	Additional keys have been made and currently there are 3 keys to the room. Staff have been directed to have a key on them at all times while on shift, Austin is aware of the location of the second key (he's not interested in keeping his own key), and the third key is kept in the staff office.	08/03/2023	Implemented
6400.52(b)(2)	Staff did not have documentation that reflects they received 24 hours of annual training. Staff did have 8 training certificates that reflect approximately 8 hours of annual training.	The following shall complete 12 hours of training each year: Dietary, housekeeping, maintenance and ancillary staff persons. This provision does not include a person who provides dietary, housekeeping, maintenance or ancillary services, if the person is employed or contracted by the building owner and the licensed facility does not own the building.	Staff #1 had several trainings from myodp at the time of inspection in addition to in-person trainings. Most of myodp training certificates did not include training hours awarded. After inquiries, in additions to in-person trainings, Staff #1 had more than 12 hours of training including the mandatory trainings.	08/04/2023	Implemented
6400.52(c)(1)	Staff #2Orientation did not reflect training in the section of Individual Choice and Supporting Individuals to develop and maintain relationships. Staff #1did not have documentation to reflect that they received training in person centered practices, community integration, individual choice, support individuals develop and maintain relationships.	The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.	On 4/16/2023, staff #2 had training on community integration, individual choice, understanding communication and supporting individuals to develop and maintain relationships. The documentation was not in the employee folder at the time of inspection.	08/04/2023	Implemented
6400.52(c)(3)	Staff did not have documentation to reflect that they received training in individual Rights.	The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.	Staff #1 did not have documentation for Individual rights training at the time of inspection. Documentation was printed on 8/4/2022 for the training that was completed on 4/17/2023.	08/04/2023	Implemented
6400.166(b)	The individual is prescribed several medications that were not in the home at the time of the inspection on 8/2/23. The medications included Desitin Diaper Rash cream to be applied 2 times a day to the penile glans as needed until abrasions resolve, Zovirax ointment to be given 4 times a day, and Bactroban Ointment to be given 2 a day to affected areas. Staff initialed and dated the medication administration record on 8/2/23 at 8am that these medications were administered.	The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.	The medications that were included in this citation had previously been discontinued. Over time, the pharmacy failed to remove the items from the MAR despite the provider's communication to them. As per the time of this documentation, all except one medication remains in the MAR but Leadership is working with the pharmacy to remove the information. The staff who initialed the discontinued medication was retrained on medication administration documentation on 8/5/2023.	08/05/2023	Implemented
6400.169(d)	Staff #2 had his initial mediation administration training on 4/1/23. The training documentation states that staff completed 6 observations on 4/1/23. The documentation provided only reflects that 4 observations were completed on 4/1/23. There should be an accurate record of training containing the person trained, the dates, source, name of trainer and documentation that the course was successfully completed.	A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.	Staff completed 2 medication administration passes on 4/2/2023.	08/02/2023	Implemented

SIN-00227435

Unannounced Monitoring

07/11/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.64(b)	There may not be evidence of infestation of insects or rodents in the home. At the time of inspection, this licensor noticed what appeared to be wood shavings inside the plexiglass covering of the window in the sunroom. The outside of that window was wood framing. It appears that some insect has made its way through the wood into the window frame and the wood shavings inside the windowsill are a result of that. The window frame is also separated from the side of the window. Insects were not seen at the time, but the damage noted above would suggest that insects are getting into that area and can lead to a larger issue if not addressed.	There may not be evidence of infestation of insects or rodents in the home.	The plexiglass covering the window was removed and the area cleaned. Before returning the plexiglass, the window frame was adjusted and there does not appear to be any further concerns.	07/13/2023	Implemented
6400.67(b)	Floors, walls, ceilings and other surfaces are not free of hazards. At the time of inspection, the basement had large amounts of excess water on the floor creating a hazard. (Repeat Violation 8/25/22, 1/31/23 and 2/27/23)	Floors, walls, ceilings and other surfaces shall be free of hazards.	The basement was cleaned. No potential cause was identified during the inspection but there has not been a repeat of the incident.	07/11/2023	Implemented
6400.171	Food shall be protected from contamination while being stored, prepared, transported, and served. At the time of the inspection, a 4 pack of Yoplait yogurt was in the kitchen cupboard. This food needs refrigeration to be stored properly. The agency did immediately throw this food into the garbage at the time of inspection.	Food shall be protected from contamination while being stored, prepared, transported and served.	The food item on this citation was thrown away and fresh yogurt was later purchased.	07/11/2023	Implemented

SIN-00225942

Unannounced Monitoring

06/07/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.66	The four hardwired ceiling light fixtures in the home's basement could not be operated via their corresponding light switches at the time of inspection. Staff on Site assessed the home's circuit-breaker system, but this did not appear to be the source of the issue. Lighting could not be restored to the area prior to the conclusion of the on-site inspection. In this condition, the basement of the home is not well lit, and, therefore, the chance a person would experience accident or injury is increased.	Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.	Provider replaced the burnt out light bulb in the basement.	06/07/2023	Implemented

SIN-00223250

Unannounced Monitoring

04/20/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.163(h)	Individual #3 is prescribed Serevent Diskus "Inhale 1 puff by mouth 2x daily as needed for SOB/Wheezing." At time of inspection on 4/20/23 two boxes of the Serevent Diskus were stored in the home. One box filled on 4/16/23 was sealed and not in use. The remaining diskus had been filled on 4/20/22 and expired on 4/20/23 according to the pharmacy label. Additional pharmacy label on the open box indicates that "Discard 42 days after opening. Date opened --/--/--. The date opened was not filled in on the pharmacy label as directed nor on the diskus which contained sections of "Pouch Opened" and "Use by" which required dates. Manufacturer instructions contained in the packages indicate that "Discard Serevent Diskus 6 weeks after opening the foil pouch or when the counter reads "0" (after all blisters have been used), whichever comes first." Manufacturer instructions on the side of the box contain the same discard instructions. No open date was recorded on the April 2023 Medication Administration Record (MAR) for Individual #3 nor the diskus or box label as instructed. At time of inspection 29 of 60 blisters remained in the diskus indicating that 31 blisters had been used. The April 2023 MAR's indicated that the medication had not been administered in April. Information required to ensure proper disposal and storage had not been recorded. Proper disposal of the medication did not occur.	Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.	Provider contacted the PCP to clarify the severest Diskus order. This order was scheduled to be returned to the pharmacy on 4/20/23 for disposal.	04/20/2023	Implemented

SIN-00221527

Unannounced Monitoring

03/21/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.34(a)	The home did not maintain clean and sanitary conditions. Upon entering the home, there was an overwhelming smell of rotten eggs. This smell was also observed in the basement of the home. (Repeat violation 5/12/22, 6/21/22, 7/25/22, 8/25/22)	The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.	Provider requested maintenance to investigate strong malodor. Maintenance replaced a piece that appeared stuck open allowing the smell to remain in the drainage system.	03/28/2023	Implemented

SIN-00220082

Unannounced Monitoring

02/27/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.62(d)	Cleaning supplies were found stored with food. Several bottles of assorted cleaning products were stored with food items such as Nutrigrain cereal bars and snack cups of applesauce in the closet located in the staff office.	Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.	Provider removed all cleaning supplies from closet while licensor on site.	02/27/2023	Implemented
6400.141(c)(4)	Individual #1 had an annual physical examination on 10/24/2022 and a hearing screening was not completed.	The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician.	Provider contacted the PCP who stated that a hearing check was done but not initialed.	02/27/2023	Implemented

SIN-00213658

Unannounced Monitoring

10/18/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.64(f)	A large trash bin alongside the home's detached storage shed was over-full to the point that the lid was fully open, exposing its contents to the penetration of insects or rodents. Two large bags of trash were sitting next to this trash can, also unprotected from such penetrations.	Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.	Provider separated the garbage into garbage bags and brought it out to the curbside for pick up.	10/19/2022	Implemented
6400.72(a)	One of two windows in the home's basement is able to be opened; this window did not have a secure screen.	Windows, including windows in doors, shall be securely screened when windows or doors are open.	Provider replaced screw that locked window shut.	10/19/2022	Implemented
6400.216(a)	Individual #1's confidential records were left unlocked within the home. The home's staff office is connected to the main living area via a doorless archway. An unlocked closet in the staff office contained several binders of the individual's records, including a binder labeled "Individual #1's Medical Binder," which contained the individual's sensitive medical information.	An individual's records shall be kept locked when unattended.	Provider placed a work order to add a lock to the closet door in the office.	10/19/2022	Implemented

SIN-00210743

Unannounced Monitoring

08/25/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.80(b)	The walkway from the front of the home to the entrance at the rear of the home is covered with an overgrowth of weeds that are approximately waist high. (Repeat Violation 7/25/22)	The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.	Provider notified the contractor of overgrown weed. Contractor removed the overgrown weed.	08/18/2022	Implemented
6400.181(a)	The most current annual assessment located in the home for Individual #3 was dated 7/28/2021.	Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home.	Provider re-printed current assessment.	08/18/2022	Implemented
6400.32(r)	The door to individual #3's bedroom and closet has doorknobs with "coin key" style locking mechanisms. A "coin key" or "pin key" lock is not acceptable to comply with this regulation as they do not provide the individual with the necessary level of privacy and security.	An individual has the right to lock the individual's bedroom door.	Provider changed the lock to Individual #3's bedroom.	08/20/2022	Implemented
6400.163(a)	Individual #3 is prescribed the medication Latuda, 80mg. tablet, to be administered by mouth one time daily at 8PM. The medication in the home is in a box from the manufacturer labeled "professional sample" and does not have a pharmacy label.	Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.	Individual #3's Latuda is in prior authorization by the insurance company. Sample medications offered by practitioner, and a script filed in the MAR.	08/18/2022	Implemented

SIN-00209281

Unannounced Monitoring

07/25/2022

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.80(a)	Access to the only entry/exit door of the home is through the lawn. There was no walkway to the only door of the home. Entrance to the home is through the yard. A rainspout was observed that would drain rainwater directly over the grassy walkway causing unsafe conditions dependent upon the weather, freezing in colder months and muddy wet areas during periods of rain.	Outside walkways shall be free from ice, snow, obstructions and other hazards.	A work order was place with a contractor and work will begin at the yard in the week of 8/14/2022.	08/16/2022	Implemented
6400.80(b)	The exterior lawn of the home was not well maintained, in good repair or free from unsafe conditions. Weeds were observed growing approximately two feet tall along the outside of the fence facing the alley. The lawn and patio area were littered with dead leaves. At the time of initial inspection, the provider's van was parked in a grassy area to the right of the home. There were two large, indented areas in excess of 12 inches long and four inches deep in the area used to access the van which presented a tripping hazard. The back stairs to another access/egress of the property were partially covered with overgrown vegetation. A rainspout extended across the patio with drainage directly into the van parking area. This rainspout, as well as a loose, individual paver approximately two inches high and the crumbling surface of the cement patio presented tripping hazards.	The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.	The lawn was mowed.	08/16/2022	Not Implemented
6400.141(c)(4)	Individual #3 had an annual eye exam on 6/21/19 with a recommendation to be evaluated again in two years. Evaluation was completed on 7/16/22. This exceeds the established two-year time frame as well as the fifteen-day grace period allowed.	The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician.	Individual #3's eye appointment had been scheduled on the next available date (7/16/2022). The provider called the doctor's office to schedule the next exam in order to get an earlier date.	08/16/2022	Implemented
6400.144	Individual #3 was treated for a boil on 5/3/22. Doctor's report indicated that a follow-up was to occur on 5/18/22. There was no documentation to illustrate that the follow up had been completed as recommended. Individual #3 was treated for a left elbow abrasion on 4/28/22. The doctor's report indicated that a follow up should be completed in two weeks. There was no documentation to support that follow-up occurred as recommended. Individual #3 attended a podiatry appointment on 8/3/21 with the next appointment documented to occur on 10/19/21. There was no documentation to support that this visit occurred. The next podiatry appointment documented occurred on 6/9/22. (Repeat Violation 6/21/22, 5/12/22, 3/11/22, 1/25/22)	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.	Individual #3's PCP was contacted and individual was advised to visit his PCP on the next scheduled routine visit or go to the emergency room if symptoms return. AB's podiatrist makes home visits. The team failed to have the appointment forms completed upon the end of the visits. The podiatrist was requested to fill out the forms.	08/16/2022	Implemented
6400.165(c)	Individual #3 is prescribed Azelastine 0.1% 2 sprays in each nostril at 8am. This medication was last filled on 4/20/2022 with a 30-day supply in the bottle. The medication is being documented on the Medication Administration Record (MAR) as being administered as prescribed. This bottle was still in use approximately eight weeks after refill and is documented as being administered as prescribed. (Repeat Violation 5/12/22, 4/8/22, 3/11/22, 1/25/22)	A prescription medication shall be administered as prescribed.	Staff involved have been addressed and retrained on medication administration.	08/16/2022	Implemented
6400.166(b)	The initials of the person administering the medication were not entered at the time medication was administered on the Medication Administration Records (MAR) for Individual #3 on the July 2022 MARs. Buspirone was not initialed as being administered on 7/24/22 for the pm dose. Risperdal was not initialed at the time of administration on 7/25/22 at 8AM. Child Allegra was not initialed at the time of administration on 7/25 at 8am. Initials shall be recorded in the medication record at the time the medication is administered. (Repeat violation 5/12/22, 4/8/22, 1/25/22)	The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.	Staff involved have been addressed and retrained on proper documentation.	08/16/2022	Implemented
6400.213(1)(i)	At time of inspection a dated photograph of Individual #3 was located in their medication administration binder. The picture was dated 3/10/20. A picture is considered current and compliance with regulation is to be noted when the picture is one that is taken annually or if there is a significant change in the individual's appearance.	Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.	A new photo was taken for the books.	08/16/2022	Not Implemented

SIN-00208709

Unannounced Monitoring

06/21/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.62(a)	Individual #1's current Individual Support Plan (ISP) dated 6/16/2022 states that the individual requires supervision around dangerous substances. At the time of the inspection, a bag of rock salt was found in the entryway to the home. The label on the rock salt stated that it was hazardous to consume.	Poisonous materials shall be kept locked or made inaccessible to individuals.	Staff were retrained on the individual's ISP.	08/16/2022	Implemented
6400.62(d)	There was a package of multi-colored craft paints found stored in a kitchen cabinet next to food items such as Gatorade, and pineapple snack cups. A chemical fire extinguisher was stored in a cabinet next to a container of cereal.	Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.	The craft paints were removed from the kitchen cabinets.	08/16/2022	Implemented
6400.72(a)	A window located in the basement did not have a window screen. The window was capable of being opened and, therefore, needs to be securely screened.	Windows, including windows in doors, shall be securely screened when windows or doors are open.	A new screen was installed.	08/16/2022	Implemented
6400.82(f)	There was no soap for handwashing in the bathroom.	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.	Hand soap was placed in the bathroom.	08/16/2022	Implemented
6400.171	There was a bottle of liquid corn oil found in a lower kitchen cabinet. The bottle did not have a cap or cover, leaving the contents exposed to potential contamination.	Food shall be protected from contamination while being stored, prepared, transported and served.	The bottle of corn oil was disposed of.	08/16/2022	Implemented
6400.163(d)	The medications were found to be unlocked at the time of the inspection. Medications are stored in a file cabinet with a key lock in the office of the home. The office does not have a door. When licensing inspectors arrived at the home, the file cabinet was not locked.	Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.	The Provider reviewed with staff the proper storage of medications. Staff on shift were met with and the incident reviewed.	08/16/2022	Implemented
6400.163(h)	The topical medication bactroban ointment had been discontinued prior to June 2022 (the month of inspection) but was still in the drawer with the individual's current medications.	Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.	The bactroban ointment was removed from the home and disposed of as per protocol.	08/16/2022	Implemented
6400.166(a)(13)	The names and initials of staff who administer medications in the home were not recorded in the Medication Administration Record.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.	Staff added their names and initials to the back of the MAR. Documentation training was reviewed with staff.	08/16/2022	Implemented
6400.182(c)	The current annual assessment dated 7/23/2021 and Individual Support Plan (ISP) dated 6/16/2022 contain conflicting information regarding Individual #1's ability to safely use and/or avoid poisonous substances. The home has a responsibility in the development and revision of the Individual's plan to ensure that the information contained in the plan is accurate and reflects the individual's needs and abilities.	The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.	The conflict between the ISP and the Annual Assessment was resolved.	08/16/2022	Implemented

SIN-00205220

Unannounced Monitoring

05/12/2022

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.64(a)	There was water pooling in the basement. Clean and Sanitary conditions shall be maintained in the home. (Repeat violation 1/25/22 and 3/11/22)	Clean and sanitary conditions shall be maintained in the home.	Maintenance order was placed to a contractor and the water pooling was resolved.	08/16/2022	Implemented
6400.71	Emergency phone numbers were not located by the landline which was located in the office of this residence. (Repeat Violation 4/8/22).	Telephone 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.	An updated emergency phone list was printed and posted by the landline.	08/16/2022	Implemented
6400.72(a)	The bathroom window did not have a screen. Windows shall be securing screened when windows are open.	Windows, including windows in doors, shall be securely screened when windows or doors are open.	A screen for the bathroom window has been installed.	08/16/2022	Implemented
6400.72(b)	Individual #2's bedroom screen was torn. Screens shall be in good repair.	Screens, windows and doors shall be in good repair.	The bedroom window screen has been replaced	08/16/2022	Implemented
6400.82(e)	The bathroom tub did not have a non-slip mat or surface.	Bathtubs and showers shall have a nonslip surface or mat.	A new non-slip mat was purchased to replace an old one that had been removed from the bathroom.	08/16/2022	Implemented
6400.82(f)	At the time of inspection there were no paper or cloth towels in the bathroom. (Repeat violation 3/11/22)	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.	A new paper towel roll was placed in the bathroom.	08/16/2022	Implemented
6400.111(f)	At the time of inspection there was two fire extinguishers under the sink. One was inspected and fully operational. However, the second was an old extinguisher that was not inspected and unsure if it was ready for use. Staff report it was an old extinguisher and should be removed. Any extinguisher in the home that is accessible in the event of an emergency or fire needs to be inspected yearly	A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher.	The old fire extinguisher was removed from the home.	08/16/2022	Implemented
6400.166(a)(11)	Individual #2 was prescribed Doxycycline Hyclate 100mg which was to be taken by mouth 2x a day at 8am and 8pm for 10 days beginning on 4/25/2022. This medication did not have a diagnosis or purpose for the medication on the Medication Administration Record.	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 team was reminded to ensure that medication labels and MAR include the reason for the prescription and to consult with the pharmacy if the information is missing.	08/16/2022	Implemented
6400.186	At the time of inspection there was a knife with a red handle located in the kitchen drawer. All sharps should be locked in this home. (Repeat Violation 1/25/22)	The home shall implement the individual plan, including revisions.	The knife was removed from the drawer and locked away.	08/16/2022	Not Implemented

SIN-00204066

Unannounced Monitoring

04/08/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.71	Emergency telephone numbers were not posted on or near the telephone in the living area of the home.	Telephone 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.	Provider posted up the emergency phone list.	04/08/2022	Implemented
6400.165(e)	The topical medication Elocon 0.1% cream, to be applied to rash once daily at 8am, was listed on the Medication Administration Record (MAR) as a current medication, but the MAR was not signed by staff as having been administered from 4/01/2022 to 4/08/2022. The medication itself was not available in the home, and the staff in the home stated that they thought it had been discontinued. A written order from the prescriber is required to stop a medication, and the individual's medication record shall be updated as soon as written notice of the change is received.	Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.	Elocon 0.1% was prescribed to be used once daily until the rash resolves. The rash resolved and individual #1 no longer needs the cream. The doctor was contacted to send a discontinue script to the pharmacy.	04/15/2022	Implemented

SIN-00202016

Unannounced Monitoring

03/11/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.68(a)	The water temperature in the bathtub of the home was 96.4 degrees. The water in the bathroom sink did not have appropriate pressure. The water in the sink did not flow from the faucet with an appropriate flow. The sink had very little water pressure.	A home shall have hot and cold running water under pressure.	The water temperature was adjusted and the water pressure adjusted.	03/12/2022	Implemented
6400.165(c)	Individual #7 is prescribed Azelastine 0.1% 2 sprays in each nostril at 8am. This medication was last filled on 2/8/2022 with a 30-day supply in the bottle. The medication is being documented on the Medication Administration Record (MAR) as being administered as prescribed. This medication contained a full bottle five weeks after refill and is documented as being administered as prescribed. (Repeat Violation 9/22/21, 12/14/21 and 1/25/22)	A prescription medication shall be administered as prescribed.	Individual #7's staff were met with about Azelastine 0.1% and retrained on proper administration of nasal spray.	04/01/2022	Implemented

SIN-00199348

Unannounced Monitoring

01/25/2022

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.68(b)	The hot water temperature was measured at 127.1 degrees Fahrenheit in the bathtub in the hall bathroom.	Hot water temperatures in bathtubs and showers may not exceed 120°F.	The water temperature was adjusted to 116¿.	01/26/2022	Implemented
6400.141(a)	Individual #1 had a late physical examination. The Individual's current physical examination was completed on 10/14/2021; the prior physical examination was completed on 9/09/2020.	An individual shall have a physical examination within 12 months prior to admission and annually thereafter.	Individual #1 will be scheduled in advance. The doctor's office allows appointments to be scheduled up to 90 days in advance.	01/28/2022	Implemented
6400.165(c)	Individual #1 is prescribed Azelastine 0.1%, 2 sprays into each nostril at 8am. This medication was last filled on 9/17/2021 with a thirty day supply in the bottle. The medication is being documented on the Medication Administration Record (MAR) as being administered as prescribed. This medication is not being administered as prescribed, however, as it has not needed to be refilled since 9/17/2021.	A prescription medication shall be administered as prescribed.	Medication administration training was reviewed with staff. ((Juli Community Services will contact the physician to notify them of the medication errors and to see if there are any new orders/recommendations. -CHn3/8/2022))	02/28/2022	Not Implemented
6400.165(g)	Individual #1 is prescribed medications to treat the symptoms of a psychiatric illness. the Individual's medications are reviewed every three months but there is no documentation of the reason for prescribing the medication, the need to continue the medication or the necessary 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.	Individual #1 will have quarterly medication review completed and documented during the next scheduled appointment. ((Juli Community Services will contact the physician to notify them of the medication errors and to see if there are any new orders/recommendations. -CHn3/8/2022))	01/31/2022	Implemented

SIN-00218419

Unannounced Monitoring

01/31/2023

Compliant - Finalized

SIN-00216603

Unannounced Monitoring

12/22/2022

Compliant - Finalized