| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | There is an area of visible water damage on the bathroom ceiling in the basement where it is reported that repair was completed but has not been painted. | Floors, walls, ceilings and other surfaces shall be in good repair. | The provider has identified visible water damage on the bathroom ceiling in the basement, where repair was completed but the area has not been painted. To correct this issue, the provider will first conduct an inspection of the affected area within 24 hours to ensure that the repair work is complete and up to standard. After confirming the repair is properly finished, the provider will schedule painting of the ceiling to restore the area, ensuring it meets both safety and aesthetic standards. This work was completed on 03/17/2025. Following the completion of the painting, the area will be regularly monitored to ensure there is no recurrence of water damage. Any future issues will be addressed immediately. Additionally, detailed documentation of the repairs, including dates of completion, will be maintained for future inspections and quality assurance purposes. |
03/17/2025
| Implemented |
| 6400.67(b) | The inside of the oven door is coated in a buildup of significant food splatter and grease. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The provider will address the significant buildup of food splatter and grease on the inside of the oven door by thoroughly cleaning it within the next 24 hours. To prevent future buildup, a regular cleaning schedule will be established, with the oven being cleaned at least once a week. Additionally, staff will be trained on proper kitchen cleaning procedures, including how to maintain the cleanliness of the oven and other appliances. This training will take place within the next two weeks. To ensure ongoing cleanliness, regular checks of the oven and kitchen appliances will be conducted and documented as part of the provider¿s routine maintenance program. |
03/12/2025
| Implemented |
| 6400.72(b) | The pneumatic storm door closer on the bottom of the storm door in the kitchen is broken and detached from the door. It requires repair for the door to operate properly. | Screens, windows and doors shall be in good repair. | The provider will address the broken and detached pneumatic storm door closer by scheduling a repair within the next 48 hours to ensure the door operates properly. A qualified maintenance technician will be contacted to fix the closer and reattach it to the door. To prevent similar issues in the future, the provider will establish a regular inspection and maintenance schedule for all door mechanisms. Any future issues with the storm door or other door hardware will be addressed promptly. Documentation of the repair will be kept on file for accountability and future reference. |
03/17/2025
| Implemented |
| 6400.104 | The letter written to the fire department did not include the exact location of the bedroom of the individual living in the home or whether the individual would need assistance evacuating in the event of a fire. The fire drills for the home indicate that the individual has required verbal direction to evacuate. | 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.
| The provider will immediately resend the letter to the fire department, ensuring that it includes the exact location of the individual¿s bedroom and specifies whether the individual will require assistance evacuating in the event of a fire. The updated letter will be sent within the next 24 hours. Additionally, the provider will review and update all emergency plans to include detailed evacuation instructions, ensuring all necessary information is accurately communicated to the fire department. Staff will be trained to ensure that all future correspondence with emergency services includes complete and accurate information. Documentation of this update will be kept for future reference and compliance. |
03/12/2025
| Implemented |
| 6400.112(h) | On the 10/26/24 and 2/2/25 fire drill forms, it is documented that the individual evacuated to different areas that are not the designated meeting place as per the written fire evacuation procedure for the home. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The provider will review and revise the fire evacuation procedures to ensure that the designated meeting place is clearly communicated and understood by all individuals and staff. The fire drill forms from 10/26/24 and 2/2/25 will be reviewed to identify why the individual evacuated to areas other than the designated meeting place. Staff will be retrained on the proper evacuation procedures and the importance of following the designated meeting place. Additionally, the provider will conduct a fire drill with all individuals to ensure proper evacuation procedures are followed, and that everyone is aware of the correct meeting location. The results of the drill will be documented, and any further discrepancies will be addressed immediately to ensure compliance with safety protocols. |
03/12/2025
| Implemented |
| 6400.171 | There was a container of Daisy sour cream in the refrigerator with an expiration date of 11/25/24. This was thrown out by staff at the time of inspection. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The provider will implement a policy to regularly check expiration dates on all perishable items stored in the refrigerator. Staff will be trained to visually inspect expiration dates on all food items during routine kitchen inspections. Any items found to be expired will be discarded immediately to ensure the safety and well-being of individuals in care. Additionally, a checklist will be created for staff to follow during inspections, ensuring all food items are properly checked and managed. This process will be documented to maintain accountability, and staff will be reminded of the importance of food safety through regular training and monitoring. |
03/11/2025
| Implemented |