| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | On 1/8/2025, at 11:58AM, there was no mechanical ventilation in the bathroom next to the kitchen on the first floor of the home. The only window in the bathroom was covered by an air conditioning unit with a board above it. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Maintenance removed the A/C from the bathroom window on 1/9/2025. The window is now operable with a screen. |
01/09/2025
| Implemented |
| 6400.80(b) | On 1/8/2025, at 11:51AM, a five foot by two-inch wooden board with nails protruding from it was lying on the porch leading from the back exit of the home. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The nails were removed from the board before being placed in the trash receptacle outside of the home on 1/8/2025. |
01/08/2025
| Implemented |
| 6400.111(e) | On 1/8/2025, at 12:15PM, the only fire extinguisher on the second floor of the home was locked and inaccessible in the staff office. | A fire extinguisher shall be accessible to staff persons and individuals. | The fire extinguisher was placed in the room opposite the office on 1/8/2025 which does not have a lock on the door allowing accessibility. |
01/08/2025
| Implemented |
| 6400.32(r)(1) | On 1/8/2025, at 12:10PM, a doorknob with a turn lock on the inside and a thumbnail mechanism on the outside was on Individual #1's bedroom door. Individual #1 has not been provided with a designated mechanism to lock and unlock the door independently. On 1/8/2025, at 12:11PM, a doorknob with a turn lock on the inside and a thumbnail mechanism on the outside was on Individual #2's bedroom door. Individual #2 has not been provided with a designated mechanism to lock and unlock the door independently | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | Both individuals at the location had signed consents declining door locks on their bedroom doors. The doorknobs were replaced with non-locking knobs on 1/9/2025. |
01/09/2025
| Implemented |
| 6400.166(b) | Individual #1's prescribed dose of Zonisamide was not initialed as administered at 8PM on 1/7/2025 on Individual #1's January 2025 Medication Administration Record. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Program Manager was able to be determined through a review of the medication inventory sheet and the blister pack of the medication that the medication was given. The missed documentation was corrected on 1/8/2025 by the person who had administered the medication. |
01/08/2025
| Implemented |