| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | Both bathroom sink cabinets were locked and could not be opened and inspected. | 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. | Locks were removed and replaced with new workable locks on both bathroom sink cabinets. |
11/20/2024
| Implemented |
| 6400.65 | The upstairs bathroom did not have a fan and the skylight had a window covering the screen that prevented ventilation from the outside. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| A facility work order has been placed for this issue and the work order will be completed by 1/1/2025. |
01/01/2025
| Implemented |
| 6400.216(a) | All individuals' progress notes and ISPs were not locked when unattended. | An individual's records shall be kept locked when unattended.
| Individual Progress notes and ISP were moved to the locked medicine cabinet. |
11/19/2024
| Implemented |