| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | There is a locked closet door in the basement that the licensor did not have access to. Staff reported not having a key or knowing where one was. [REPEAT VIOLATION - 7/10/23] | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | The lock on the door in the basement has been replaced with a doorknob with a lock. 05/13/2024 |
05/13/2024
| Implemented |
| 6400.62(a) | The lower kitchen cabinet beneath the sink has a sign on it indicating poisons are within. There is also a child-proof safety lock on the cabinet door. This lock was not engaged during the inspection. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The lock on the cabinet door has been re-locked on 5/10/2024 shortly after the inspector left the site. |
05/10/2024
| Implemented |
| 6400.64(a) | Surfaces in the kitchen, including the floor, counters, appliances, and cabinet fronts, are all sticky and/or grimy, and in need of a thorough cleaning...The second-floor bathroom floor is dirty and grimy, with visible dust/dirt collection around the toilet, behind the door, and along the tub...The third-floor front bedroom's closet has a distinctly pungent smoke smell...The contents of the kitchen cabinets (food, dishware, etc) were haphazardly thrown into them with no real care or attention given to tidiness or order. | Clean and sanitary conditions shall be maintained in the home. | Violation 6400.64(a) was fixed on 5/10/2024. A thorough cleaning was done. |
05/10/2024
| Implemented |
| 6400.64(f) | There were unlidded bins with garbage in them at the front of the property. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | This violation was completed on 5/11/2024. New trash cans were bought including lids. |
05/11/2024
| Implemented |
| 6400.67(a) | One upper kitchen cabinet is broken and hangs loosely by one joint.
One drawer pull is broken on the kitchen island.
Individual 1's bedroom door is non-functional; it is missing its knob, leaving an open hole in the door.
There is a knob missing from the second-floor bathroom vanity. There is broken towel holder on the far wall of the bathroom. | Floors, walls, ceilings and other surfaces shall be in good repair. | The cabinet in the kitchen has been fixed alone with individual 1¿s doorknob, the towel holder and draw pull and vanity knob has been replaced and repaired on 05/14/2024. |
05/14/2024
| Implemented |
| 6400.68(a) | In the second-floor hallway bathroom: the bathtub faucet has low water pressure. The sink faucet also has low water pressure, though it does improve when the knob is fully opened. | A home shall have hot and cold running water under pressure. | The water pressure is working appropriately noted by a plumber. No concerns regarding the water pressure as well. |
05/14/2024
| Implemented |
| 6400.70 | The phone in the second-floor front bedroom did not work as it appeared to not have been properly placed in its charging station. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| The phone has been properly placed in the charging station on 5/10/2024, However another phone has been purchased and operated in a different the event a charging occurs again there is a working phone in the home available to the individual and staff. |
05/10/2024
| Implemented |
| 6400.72(a) | The third-floor bedroom's (empty) windows do not have screens. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | New window screens were ordered on 5/14/24 and will be installed on 5/25/24. |
05/25/2024
| Implemented |
| 6400.72(b) | One of the living room window screens has come loose from its frame, and it is torn in one corner. | Screens, windows and doors shall be in good repair. | Repair of the window screen will be completed on 5/25/24 |
05/25/2024
| Implemented |
| 6400.81(i) | Individual 1's bedroom has no window privacy. There is no one-way cling or blinds in the windows. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | This violation has been extended upon inspection. The actual window needs to be repaired. The same company that will complete the screen repairs will fix the window on 5/25/24 |
05/25/2024
| Implemented |
| 6400.81(k)(3) | Individual 1's bedroom there are two small, stained bed pillows, both without cases. The mattress is bare, without sheets. The mattress itself is also still in the purchase plastic. It appears that when sheets are on the bed, they are put on over the plastic. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | The pillows were replaced, and the bed plastic was removed on 05/10/24. New bedding has been purchased so that when the sheets are being washed, individual 1 can still have a clean- and made-up bed. |
05/10/2024
| Implemented |
| 6400.81(k)(4) | Individual 1's bedroom lacks homelike required equipment and furniture: dresser.
The second-floor front bedroom is formerly the individual's bedroom, per staff statement. That room is now used for staff to sleep in. However, this room still contains the individual's dresser, clothing in the closet, etc. | In bedrooms, each individual shall have the following: A chest of drawers. | The dresser has been moved to individuals 1 bedroom to stay remain in compliance. |
05/14/2024
| Implemented |
| 6400.82(e) | The third-floor bathroom shower stall does not have a non-slip mat. | Bathtubs and showers shall have a nonslip surface or mat. | A new non-slip mat has been added to the third-floor shower on 05/14/2024. |
05/14/2024
| Implemented |
| 6400.82(f) | The third-floor bathroom does not have a hand towel. | 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. | Paper Towels has been added to the third-floor bathroom on 05/14/2024. |
05/14/2024
| Implemented |
| 6400.84(a) | There was a pile of bed linen piled in the corner of the hallway. Staff reported that those were going to be washed and put back on the bed. However, given that there is a linen closet (disorganized but full) with a variety of bedding items contained within, the individual's bed should be able to be remade while the other sheets are being laundered. | Bed linens, towels, washcloths and individual clothing shall be laundered at least weekly. | Individual 1 bedding has been cleaned the same day 05/10/2024. Extra bed lines are now available while current set is being washed |
05/10/2024
| Implemented |
| 6400.111(f) | The fire extinguishers in the basement, kitchen, and second floor are all past due for inspection. Last dated 3/2023.
The basement fire extinguisher does not have an inspection tag. | 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 were all approved by a fire safety expert on 6/21/24 |
06/21/2024
| Implemented |
| 6400.144 | (Doxazosin 1mg tab: The medication wasn't found in the med box)...(Metoprolol 25mg succ ER tab: The medication wasn't found in the med box)...(Imipramine 25mg tab: The medication wasn't found in the med box).. | 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.
| The following medications have been reviewed and upon reviewing the following medications have been discontinued: Doxazosin 1mg, Metoprolol 25 mg, The medication Imipramine has been located and placed back in the lock box. |
05/22/2024
| Implemented |
| 6400.216(a) | For individual 1: in a kitchen upper cabinet, there was a lockbox that appeared to contain purchase receipts. This box was unlocked and open, the receipts were thrown into the box and cabinet, haphazardly. [REPEAT VIOLATION - 7/10/23] | An individual's records shall be kept locked when unattended.
| This lockbox has been discarded and is no longer used. |
05/14/2024
| Implemented |
| 6400.32(r) | Individual 1's bedroom door does not have a knob. There is a hole where the knob is meant to be. | An individual has the right to lock the individual's bedroom door. | Individual 1¿s doorknob has been replaced on 5/13/2024. |
05/13/2024
| Implemented |
| 6400.163(g) | For individual 1, the medication review revealed the following:
Benztropine 1mg tab; take one and a half at bedtime: the blister pack for today (10th) is broken with the whole tab missing and the half tab still within.
As the licensor moved the blister packs, a single half tab of a pill fell out; which medication could not be determined. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | The whole tablet of Benztropine 1mg has been replaced by the pharmacy on 05/10/2024. |
05/22/2024
| Implemented |
| 6400.166(a)(13) | The medication review for individual 1 revealed the following:
(Benztropine 1mg tab- The blister pack shows this medication as administered, but the MAR is not initialed for doses on 5/2-6, 8, & 9)..
(Melatonin 3mg tab (take one at bedtime): the blister pack indicates the medication was administered, while the MAR is not initialed for doses on 5/2-6, 8, & 9)..
(Clonazepam 1mg tab (take one at bedtime): the blister pack indicates the medication was administered, while the MAR is not initialed for doses on 5/2-6, 8, & 9)..
(Quetiapine 300mg tab (take one at bedtime): the blister pack indicates the medication was administered, while the MAR is not initialed for doses on 5/2-6, 8, & 9)..
(Risperidone 4mg tab (take one at bedtime): the blister pack indicates the medication was administered, while the MAR is not initialed for doses on 5/2-6, 8, & 9)..
(Docusate 100mg cap (take twice daily): for the 8PM dose, the blister pack indicates the medication was administered, while the MAR hasn't been initiated since 5/2)..
(Doxazosin 1mg tab (take one daily, 8AM dose): MAR shows that it wasn't initialed on 5/1 or 5/2. For dates 5/3-10, the MAR is initialed)..
(Metoprolol 25mg succ ER tab (take ½ tab by mouth once daily, 8AM dose): MAR shows that it wasn't initialed on 5/1 or 5/2. For dated 5/3-10, the MAR is initialed)..
(Imipramine 25mg tab (3 tabs by mouth at bedtime, 8PM dose): MAR shows that it was initialed on 5/1 and 5/7. For dates 5/2-6, 8, & 9 not initialed). | 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. | The M.A.R has been reviewed to update the response to each medication. The agency went back to the schedule of who worked those days that were not initialed, within our review we were able to identify what occurred and update the MAR. The outcome is all the medication has been administered to Individual 1 at the date and time appropriately staff did not properly initial. To follow up with the medication violations all staff have been re-trained on proper storage, appropriate signage and sanitary maintenance of medications on 05/22/2024. |
05/22/2024
| Implemented |
| 6400.186 | Individual 1's BSP and assessment state the necessity to keep decorative items away and secured due to the individual's potential for outbursts that can be destructive and harmful to them. This restriction included fire extinguishers. However, during the site visit, the inspector found fire extinguishers hanging on the walls of the second and third floors, and the basement. | The home shall implement the individual plan, including revisions. | The fire extinguishers have been taken down from all walls and placed in closets or in discrete places. Signage has been put up to let DSP know where they are in case of emergency. |
06/27/2024
| Implemented |