| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The bathroom tub registered 133 degrees which exceeded the allowable temperature of 120 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Upon discovery, staff immediately implemented an interim safety measure by regulating water at the point of use prior to each use to ensure a safe and appropriate temperature for the individual. Water temperatures were checked and documented in a log before each use to ensure health and safety. Prior to the inspection, UFIL INC had already identified concerns with elevated water temperatures and submitted multiple maintenance requests to the apartment complex to address the issue. During the inspection, a temperature reading of 130°F was recorded.
Following the inspection on April 8, 2026, UFIL INC engaged a licensed plumber, and a thermostatic mixing valve was installed on April 9, 2026, which successfully reduced the water temperature to within safe limits. The apartment management team subsequently requested the removal of the device, as installation must be completed through their approved Contractor process. UFIL INC is actively working with the apartment management team to obtain approval to install thermostatic mixing valves at points of use to ensure consistent and safe water temperatures.
In addition, UFIL INC requested that the apartment management team make further adjustments at the source due to the urgency of the situation. The apartment complex indicated that the water temperature at the source has been set to the regulated minimum level for the building. UFIL INC continues to work closely with the apartment management team to bring water temperatures within required limits. Staff will continue to regulate water at the point of use and document water temperatures prior to each use until a permanent solution is approved and implemented. |
04/09/2026
| Implemented |
| 6400.181(a) | Individual 1 was admitted to the CLA on 11/11/25, and the initial assessment was done on 02/20/26 which was more than 60 days after admission. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Upon identification, Individual 1's record was reviewed. The initial assessment has now been completed and is on file. The delay in completion was addressed, and all required components, including the assessment of adaptive behavior and level of skills, have been verified to ensure compliance. At this time, Individual 1's assessment is complete and current, and the home is in compliance with the regulatory requirement. |
04/14/2026
| Implemented |
| 6400.166(a)(4) | Individual 1's medication administration record did not have the Ozempic injection listed by name as required by regulation. The MAR was updated to include the missing information during the inspection. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Upon identification, Individual 1's medication administration record (MAR) was immediately reviewed. The Ozempic injection was added to the MAR by name to ensure accuracy and compliance with regulatory requirements. All medications listed on the MAR were verified against the current prescription orders to ensure completeness. At this time, the MAR accurately reflects all prescribed medications, and the home is in compliance with the regulatory requirement. |
04/08/2026
| Implemented |
| 6400.166(a)(5) | Individual 1's medication administration record did not have the strength of the Ozempic injection listed as required by regulation. The MAR was updated to include the missing information during the inspection. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Upon identification, Individual 1's medication administration record (MAR) was immediately reviewed. The strength of the Ozempic injection was added to the MAR to ensure accuracy and compliance with regulatory requirements. All medications listed on the MAR were verified against current prescription orders to ensure completeness. At this time, the MAR accurately reflects the name and strength of all prescribed medications, and the home is in compliance with the regulatory requirement. |
04/08/2026
| Implemented |
| 6400.166(a)(11) | Individual 1's medication administration record did not consistently include the required diagnosis or purpose for daily maintenance and PRN medications as required by regulation. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Upon identification, Individual 1's medication administration record (MAR) was immediately reviewed. The required diagnosis or purpose for all medications, including daily and PRN medications, was added to the MAR to ensure accuracy and compliance with regulatory requirements. All medications were verified against current physician orders and supporting documentation to ensure completeness.
At this time, the MAR accurately reflects the diagnosis or purpose for each medication, and the home is in compliance with the regulatory requirement. |
04/27/2026
| Implemented |
| 6400.194(b) | The Behavioral Specialist who developed individual 1's behavioral support plan was also the Behavioral Specialist that was included on the human rights team. | The human rights team shall include a professional who has a recognized degree, certification or license relating to behavioral support, who did not develop the behavior support component of the individual plan. | Upon identification, Individual 1's Human Rights Team composition was reviewed. The Behavioral Specialist who developed the Behavioral Support Plan remains involved to provide information and support; however, a separate qualified behavioral professional, who was not involved in the development of the plan, has been added to serve as the independent member of the Human Rights Team in accordance with regulatory requirements.
The roles of each Behavioral Specialist have been clearly defined and documented to ensure compliance. At this time, the Human Rights Team includes a qualified independent behavioral professional, and the team is properly constituted. The home is now in compliance with the regulatory requirement. |
04/10/2026
| Implemented |