Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00224038 Renewal 04/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)There was an unmarked container of soap in the bathroom with the label peeled off.Poisonous materials shall be stored in their original, labeled containers. Clearly labeled soap and sanitizer will be at the home in original containers. This was changed in an attempt to make the bathroom decorative and homely but does not follow with our regulations. 05/01/2023 Implemented
6400.77(b)There was no Tape located in the 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. A full first aid kit is essential and must be on site to ensure the health and safety of individuals in the home. While there was a first aid kit, items were missing. Immediately after inspection surgical tape was purchased and added to the kit. 05/01/2023 Implemented
6400.111(f)The fire extinguisher in kitchen was last inspected in December of 2018 and was no longer fully charged. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Upon inspection a work order was placed to remove the additional fire extinguisher. We had a working up to date fire extinguisher in the same kitchen, however in the event of a fire, by having 2, a staff could have accidentally taken the wrong extinguisher. This becomes a safety issue and so it was corrected immediately upon inspection. 05/01/2023 Implemented
6400.141(c)(14)Individual 2's 11/15/22 physical does not contain information pertinent to diagnosis in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. While a physical was completed timely, information that is important and required by regulation was not obtained and reviewed by the physician. Immediately after inspection, our nurse went to the doctor¿s to address the areas that were not previously signed off or noted by the physician. 05/01/2023 Implemented
6400.165(g)Individual 2's file has no records of a psychotropic medication reviews between 12/28/21 and 5/16/22.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.Its essential to have psychotropic medication checked every 90 days. In the event a doctor¿s office is delayed, or an appointment is cancelled, it¿s important that we have this cancellation clearly documented and that we have the medications reviewed promptly. 05/01/2023 Implemented
SIN-00203989 Renewal 04/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)In December of 2021 Individual #1 was dispersed $1000. Of that $1000 there is $215.73 which is not accounted for in the provided documentation.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. We were in the process of switching banks and issuing debit cards when some issues with ledgers occurred and our process changed. Moving forward we are doing everything electronically, so all ledgers will have an electronic record that ties back to their bank account for a clear and legible audit trail. 05/18/2022 Implemented
6400.67(a)The cabinet door under the bathroom sink was damaged.Floors, walls, ceilings and other surfaces shall be in good repair. A work order was placed to replace the cabinet door 05/04/2022 Implemented
6400.67(b)The electrical Outlet in individual #1's room was exposed and damaged. Floors, walls, ceilings and other surfaces shall be free of hazards.The electrical outlet was immediately covered and a work order was put in for repair. 05/04/2022 Implemented
6400.112(e)The fire drills for 742 Woodbrook Road location did not have an overnight fire drill on record from 4/20/21 to 3/24/22A fire drill shall be held during sleeping hours at least every 6 months. An overnight fire drill was completed. 05/13/2022 Implemented
6400.141(a)According to the documentation found within Individual #1's Record, the individual's latest physical examination occurred on 05/24/2021; however, a record of the prior appointment was unavailable in the record. As such, there is no documentation that the individual received a physical examination annually as required.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Please see attached documentation, also an upcoming physical is scheduled. 05/13/2022 Implemented
6400.142(a)According to the documentation found within Individual #1's Record, the individual's latest dental examination occurred on 02/23/2022; however, a record of the prior appointment was unavailable in the record. As such, there was no documentation that the individual received a dental examination annually as required.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. This individual needed several clearances from other physicians and family sign off to complete this appointment. Merakey is in the process of getting all needed appointments completed and consents signed. 05/13/2022 Implemented
6400.144According to the documentation found within Individual #1's Record, the individual's latest vision examination occurred on 05/06/2021 and the individual's latest hearing examination occurred on 03/22/2022; however, records of the prior appointments were unavailable in the record. As such, there was no documentation that the individual received a vision or hearing examination annually as required.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. It is essential that appointments be scheduled routinely and as prescribed to ensure the health and safety of the individuals we support. When resident refuses or there is a delay from the medical provider in seeing our resident, it is important that we are providing clear documentation on the events that are occurring. Also, the individual has an upcoming physical appointment, and this will be reviewed to ensure it is documented properly on the physical. In addition, the management team is meeting on 5/13/22 to review how documentation should look prior to any medical appointment and what the physician should complete on the required paperwork 05/13/2022 Implemented
6400.166(b)Nizoral Shampoo prescribed to individual #1 to be applied once every three days was not logged on April 4th immediately after administration, the log was left blank.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.This was a documentation error as this individual regularly gets his hair washed with this product, and staff confirmed that they completed this task but failed to initial. Management will increase med audits to ensure documentation mistakes or errors do not occur. This is especially important with topicals and liquids that can be less easily verified, and so should be checked more frequently for documentation omissions. 05/04/2022 Implemented
SIN-00187193 Renewal 04/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The house's first aid kit was missing medical tape at time of inspection. 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. Medical tape was added to the first aid kit. Ensuring all items of the first aid kit are imperative in the event first aid is needed. At no point should the kit go without an item for an extended period of time. 04/23/2021 Implemented
6400.111(f)Three fire extinguishers were observed to have out of date inspections. Two were located in the kitchen area and the third was in the staff office. The last inspection for all three was in February 2020. 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 fire extinguishers are currently up to date with their inspection with a date of April 2021. We understand the importance of fire extinguishers being inspected on a consistent basis. To ensure the safety of our individuals we will ensure that the fire extinguishers are inspected per regulation guidelines. This home did have Covid in February of 2021, which blocked visitors from entering to inspect the extinguishers. When noted during licensing that these had expired, we addressed this the same week. 04/25/2021 Implemented
SIN-00114616 Renewal 05/23/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was mildew found at the base of the shower stallClean and sanitary conditions shall be maintained in the home. Clean and sanitary conditions are necessary and required in each home. There was mildew found in the shower of the 742 Woodbrook site. This was immediately addressed to ensure clean and sanitary conditions. 05/30/2017 Implemented
6400.104There was no documentation notifying the local fire department of indivduals who need assistance while evacuating.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. There was a notification to the fire department; however the notification did not include the exact location of the bedrooms in the event of an actual fire. Both individuals in this home are fully ambulatory and able to evacuate independently, however the notification has been updated to include more information about the residents in the home and the location of their respective bedrooms. Please see attachment for updated notification. 08/17/2017 Implemented
6400.112(e)A sleep drill was held on 06/15/2016 and there was no documentation of a sleep drill in December 2016A fire drill shall be held during sleeping hours at least every 6 months. A fire drill shall be held during sleeping hours at least every 6 months. The provider failed to do this and had a lapse in sleep drills. It is essential that the provider practice drills during multiple hours to ensure that the individuals know how to react in the event a fire were to occur in the overnight hours. Please see attached sleep drills addressing this issue. 08/17/2017 Implemented
6400.151(c)(3)Staff # 1 physical examination dated 04/21/2016 did not document if staff was free from communicable disease or if specific precautions need to be taken. 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. A physical exam should 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. The doctor did not check off during staff Adomma James physical that she is free of communicable disease. The provider did not note at the time of the physical that this indicator was missing, and so will audit for this specific item moving forward when employee physicals are returned. 08/17/2017 Implemented
SIN-00089222 Renewal 01/14/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(3)Individual #1's Physical dated 1/14/15 had diphtheria and tetanus on 5/3/04 that was more than 10 years.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. This was corrected during licensing. Steven Fields DPT vaccine was expired and was past the 10 year mark. Steven was immediately taken to his Primary Care Physician where he received the vaccine on 1/15/16 @ 10:00am. It is important that all vaccines be up to date and in compliance to ensure the health and safety of the individuals we support. An audit was completed of all medical books to ensure that vaccines were current. Moving forward medical audits will always check for Diphtheria/Tetanus vaccine along with the TB test. 01/15/2016 Implemented
SIN-00161362 Renewal 08/13/2019 Compliant - Finalized
SIN-00138784 Renewal 06/18/2018 Compliant - Finalized
SIN-00043223 Initial review 09/27/2012 Compliant - Finalized