| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(2) | There were ATM Cash withdrawals from individual 2's account on 09/02/25 for $133.00 & $102.00; 10/01/25 for $82.00 & $17.00; 11/03/25 for $142.00; 11/03/25 SQ Café 32 for $77.10, and 12/02/25 for $27.00 & $121.90 had no indication that funds were given directly to the individual. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. | To ensure proper management and monitoring of the individual 2 personal funds, Staff will assist and supervise the individual with all ATM withdrawals and cash transactions. Each withdrawal will be documented, including the date, amount withdrawn, purpose of withdrawal, and staff verification. |
02/09/2026
| Implemented |
| 6400.68(b) | The water temperature in the bathroom was 125.5 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. The hot water temperature was decreased to 115°F within 24 hours after the inspection. | Maintenance staff did adjust and secure the water heater thermostat to prevent temperatures for exceeding the required limit |
02/09/2026
| Implemented |
| 6400.76(a) | The toilet in the upstairs bathroom was not properly secured to the floor and wobbled when pushed. | Furniture and equipment shall be nonhazardous, clean and sturdy. | To ensure the safety of the individual and prevent injury, a stronger and more secure toilet was installed in the bathroom. Maintenance replace the existing toilet with a heavy-duty toilet that is properly anchored and secured the floor in accordance with manufacturer and building safety standards |
01/06/2026
| Not Accepted |
| 6400.110(a) | The basement of the home had a smoke detector however it was inoperable during the inspection. An operable smoke detector was installed in the basement within 24 hours after the inspection. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Staff will conduct routine checks of smoke detectors, including testing functionality and inspection batteries. Batteries will be checked monthly and replaced immediately if low or non-functional. |
12/30/2025
| Implemented |
| 6400.113(a) | There was no record on file to show that Individual 2 received Fire Safety training within the last year. The last record on file was completed on 05/16/2024. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | All individual receive fire safety training when they first move into a home and annually thereafter. Training will cover fire prevention evacuation procedures, use of fire extinguishers, and individual specific evacuation needs. Documentation of completion will be maintained in the provider training records |
01/05/2026
| Not Accepted |
| 6400.141(c)(4) | The 07/29/2025 physical examination for individual 2 did not include a hearing screening, and none was found on file. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The provider will ensure that all annual physical examinations include screening hearing and vision. Physical exam documentation will be reviewed to confirm completeness prior to filing in the individual record |
01/06/2026
| Implemented |
| 6400.141(c)(6) | The 07/29/2025 physical examination and immunization record for Individual 2 did not include Tuberculin testing and results, and none was found on file. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | We will ensure that all employees obtain a per-employment physical examination and tuberculosis screening, and ongoing. Documentation of physical examinations and TB results will be maintained in each employee personnel file. |
01/06/2026
| Implemented |
| 6400.144 | Individual 2 was referred to Occupational Therapy by the PCP on 09/25/2025 for mobility assessment for employment. There were no records on file to support that the referral and assessment were scheduled or completed.
Individual 1 was seen at the Endocrinologist on 07/29/2025 and provided instructions to "return in 4 months (approximately 11/29/25)". There were no records on file to support that a return visit has been scheduled or completed. | 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.
| We will ensure that for any referral made by the PCP a copy of the referral and documentation from the specialist visit is obtained and maintained in the individual medical record. Record will include visit summaries, recommendation and any follow up instructions |
01/06/2026
| Implemented |
| 6400.213(4) | The record for Individual 2 did not include a dental examination. | Each individual's record must include the following information: Dental examinations.
| Moving forward a copy of each individual dental examination will be obtained whenever they visit the dentist and kept in their recored |
01/05/2026
| Implemented |
| 6400.213(5) | The record for Individual 2 did not include a dental hygiene plan. | Each individual's record must include the following information: Dental hygiene plans. | Moving forward a copy of each individual dental hygiene plan will be obtained whenever they visit the dentist and kept in their record |
01/05/2026
| Implemented |
| 6400.213(6) | The record for Individual 2 did not include Assessments as required under §6400.181 (relating to assessments). | Each individual's record must include the following information: Assessments as required under § 6400.181 (relating to assessment).
| Safelift will ensure each individual receives an assessment prior to admission or within 60 days after admission to home. Assessments will be reviewed and updated annually. |
01/06/2026
| Implemented |
| 6400.18(i) | Individual 2 - Incident ID 9687049 with a Discovery Date 09/02/25 and no extension filed.
Incident ID 9413414 with Discovery Date of 05/09/24 and no timely extension filed.
Incident ID 9382291 with a Discovery Date of 03/15/24 and no extension filed.
Incident ID 9380676 with a Discovery Date 03/13/24a and extension was not filed timely.
Incident ID 9362891 with a Discover Date of 02/12/24 and extension was filed timely. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | Safelift require the Certified Investigator to submit a 30 day extension request whenever an investigation cannot be completed within the initial 30 day timeframe. Extension requests will be submitted in accordance with regulatory requirements and documented in investigation file |
01/06/2026
| Implemented |
| 6400.24 | - The 02/25/2025 criminal background check for Staff 5 noted a "Record." The provider did not complete a case-by-case decision about whether to hire the person and did not have a policy in place to complete reviews.
- The 04/21/2025 criminal background check for Staff 6 noted a "Record." The provider did not complete a case-by-case decision about whether to hire the person and did not have a policy in place to complete reviews.
- The room and board agreement for individual 2 was not completed on the required DP 1077 form.
§ 6100.687(a) states: The provider shall ensure that a room and board residency agreement, on a form specified by the Department, is completed and signed by the individual annually. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | We have a written policy requiring a case by case review of any applicant with a criminal background. The review will consider the nature and severity of the offense, the date of the offense relevance to the position evidence of rehabilitation, and any prohibitive offense of rehabilitation and any prohibitive offenses and supporting rationale will be documented and approved by designated management |
01/06/2026
| Implemented |
| 6400.34(a) | There was no record on file to show that Individual 2 was informed of their Individual Rights within the last year. The last record on file was signed by the individual on 09/16/2023. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | All individuals will review and sign their Individual Rights annually at the beginning of each calendar year. |
01/05/2026
| Not Accepted |
| 6400.163(f) | The home contains refrigerated medications that were not locked and stored in a crisper in the refrigerator for individual 2. The refrigerated medications were placed in a locked box inside the refrigerator's crisper drawer within 24 hours after the inspection. | Prescription medications stored in a refrigerator shall be kept in an area or container that is locked. | The medication could not be used with the required attachment, which was secured in a locked box lock in the cabin. We purchased a separate locked medication container.The medication is stored in a locked container at all times. A photo verifying the correction was submitted within 24 house of the inspection |
12/30/2025
| Implemented |
| 6400.165(g) | Individual 2 is prescribed medications to treat symptoms of psychiatric illness. Medications require review at least every three (3) months; however, during the inspection period, reviews took place only on 05/05/2025 and 07/01/2025. | 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. | Effective immediately Safelift will ensure that any medication prescribed to treat psychiatric symptoms is reviewed by a licensed physician at least every 3 months |
01/06/2026
| Implemented |
| 6400.166(b) | On MAR for individual 2, the 8pm administration of the 12/26/25, administration of the Prescription Munjaro was not signed for as being administered. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Moving forward, the House Director will review Medication Administration Records daily to ensure all medications are properly signed out at time of administration. In addition, staff will complete medication administration training that reviews proper documentation. |
01/05/2026
| Implemented |
| 6400.183(c) | The record for Individual 2 did not include a list of persons who participated in the individual plan meeting. | The list of persons who participated in the individual plan meeting shall be kept. | Moving forward, the agency will retain the email from the SC that lists all individuals who participated in the individual plan meeting |
02/06/2026
| Implemented |