| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | The bathroom did not have the required ventilation by window or mechanical device. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Upon notification of the finding, a mechanical exhaust fan was installed in the bathroom to provide proper ventilation. The fan was tested to confirm it operates properly and vents to the outside.
All other bathrooms, kitchens, and living areas in the home were inspected on the same date to confirm each has at least one operable window or working mechanical ventilation. No additional deficiencies were identified.
Responsible person: House Manager |
04/10/2026
| Implemented |
| 6400.68(b) | The bathroom sink and tub registered 128 degrees which exceeded the allowable temperature of 120 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | April 10, 2026 -- Upon notification of the finding, the hot water heater thermostat was adjusted to ensure water temperature does not exceed 120°F. Water temperature was tested three times at the bathroom sink and tub and did not exceed 120°F.
April 10, 2026 -- All other sinks, tubs, and showers in the home were tested on the same date to confirm water temperature did not exceed 120°F. No additional deficiencies were identified.
Responsible person: House Manager |
04/10/2026
| Implemented |
| 6400.70 | The phone in the residence used for emergencies was inoperable during the inspection. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Upon notification of the finding, the inoperable telephone was repaired/replaced. The telephone was tested to confirm it is operable, has an outside line, and is not coin-operated.
All other telephones in the home were tested on the same date to confirm they are operable and accessible to individuals and staff. No additional deficiencies were identified.
Responsible person: House Manager |
04/10/2026
| Implemented |
| 6400.72(b) | The left front room window closest to the door was not able to be locked during the inspection. | Screens, windows and doors shall be in good repair. | Upon notification of the finding, the window lock on the left front room window was repaired/replaced. The window was tested to confirm it locks securely.
All other windows in the home were inspected on the same date to confirm they lock securely and are in good repair. No additional deficiencies were identified.
Responsible person: House Manager |
04/10/2026
| Implemented |
| 6400.77(b) | The first aid kit was missing tweezers and antiseptic. The tweezers were placed in the kit during the inspection, which corrected that deficiency. | 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. | Upon notification of the finding, antiseptic was purchased and added to the first aid kit. The kit was inspected to confirm it contained all required items: antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors, and syrup of Ipecac where applicable.
All other first aid kits maintained at the home were inspected on the same date to confirm a complete, unexpired inventory. No additional deficiencies were identified.
Responsible person: House Manager |
04/10/2026
| Implemented |
| 6400.112(a) | Each of the fire drills at this location occurred on the 27th of each month, which potentially indicated that the drills were announced whereas the requirement is that an unannounced fire drill shall be held at least once a month. It is worthy to note that this practice was noticed at other residences | An unannounced fire drill shall be held at least once a month. | Upon notification of the finding, staff were retrained on the requirement that fire drills must be unannounced and must occur at varying, unpredictable dates and times each month, not on a fixed recurring date. Staff were instructed that only the staff conducting the drill may be told immediately beforehand; individuals and other staff must not have advance notice.
The fire drill schedule was reviewed, and a randomized schedule was established going forward to ensure drills are not held on a predictable, recurring date.
Responsible person: House Manager |
04/10/2026
| Implemented |
| 6400.112(e) | Two fire drills occurred on May 27, 2025 at 2am and the next on December 27, 2025 at 1:30 am, but one is marked and overnight and the other was not. Additionally, the drills exceeded the requirement that a 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. | Upon notification of the finding, an overnight fire drill was conducted during sleeping hours to bring the home back into compliance with the 6-month requirement. Staff were retrained on the requirement that a fire drill must be held during sleeping hours at least every 6 months, and on the importance of accurately and consistently marking fire drill records to indicate whether each drill occurred during sleeping hours.
The home's fire drill log was reviewed and corrected to ensure all overnight drills are accurately and consistently documented as such going forward.
Responsible person: House Manager |
04/10/2026
| Implemented |
| 6400.141(a) | Individual #3's annual physical dated 5/26/25 was completed more than one year from the previous exam held on 5/03/24. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Upon notification of the finding, Individual #3's physician appointment was scheduled/completed to bring the individual back into compliance with the annual physical exam requirement. The updated physical examination was placed in Individual #3's record.
The physical examination due dates for all individuals in the home were reviewed on the same date to confirm no other individual's annual physical was overdue. No additional deficiencies were identified. |
06/04/2026
| Implemented |
| 6400.141(c)(14) | Individual #3's annual physical dated 5/26/25 did not indicate what information is pertinent to diagnosis in case of an emergency. They were two identical forms in the record. One left the area blank and the other had N/A on the line. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Upon notification of the finding, the physician's office was contacted to obtain a corrected physical examination form that properly completes the section addressing medical information pertinent to diagnosis and treatment in case of an emergency. The corrected form was placed in Individual #3's record, and the incomplete/conflicting duplicate forms were removed.
Physical examination forms for all other individuals in the home were reviewed on the same date to confirm the emergency medical information section was properly completed. No additional deficiencies were identified.
Responsible person: House Manager |
04/10/2026
| Implemented |
| 6400.165(g) | Individual #3's record for psychotropic medication reviews over the past year did not always include documentation of the reason for prescribing the medication, the need to continue the medication and 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. | Upon notification of the finding, Individual #3's prescribing physician was contacted to obtain complete documentation for each required quarterly review, including the reason for prescribing the medication, the need to continue the medication, and the necessary dosage. The completed documentation was placed in Individual #3's record.
Psychotropic medication review records for all other individuals in the home were reviewed on the same date to confirm each quarterly review included the required elements. No additional deficiencies were identified.
Responsible person: House Manager |
04/10/2026
| Implemented |