| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The water temperature in the home was measured at 125.4 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Effective 09/09/2025, the water temperature in the home was adjusted to 118.4 degrees Fahrenheit. |
11/01/2025
| Implemented |
| 6400.112(d) | There was no evacuation time listed on the drill dated 6/9/25, 7/21/25 | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Effective 10/04/2025, the staff member (C. Johnson) responsible for conducting the fire drills on 6/9/25 and 7/21/25, was re-trained on conducting fire drills and how to properly complete the fire drill form. |
10/04/2025
| Implemented |
| 6400.112(e) | There was only one sleep drill during the period between August of 2024 through August of 2025. | A fire drill shall be held during sleeping hours at least every 6 months. | A fire safety spreadsheet was created effective 09/30/2025, which will include dates for fire drills, whether the drill was asleep or awake, and when the next asleep drill is due to be conducted. Agency administrative staff will have all data entered prior to 11/01/2025. The Program Specialist then added a reminder to the shared google calendar for February 2026, to complete the asleep fire drill and will then be responsible for reminding the house supervisor to complete the asleep drill in February 2026. |
11/01/2025
| Implemented |
| 6400.113(a) | Individual #2 received fire safety training on 10/10/24. There was no documented fire safety training in the record for the individual's admission date on 10/10/23. It was impossible to determine annual compliance due to no initial fire safety training in the record. | 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. | A fire safety tracking spreadsheet was created effective 09/30/2025, which will include dates for fire drills and individual fire safety training dates. All dates for all individuals receiving services will be updated prior to 11/01/2025. |
11/01/2025
| Implemented |
| 6400.141(c)(4) | Individual #2's 9/20/24 and 8/21/25 annual physicals did not include hearing exams. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The individual's hearing examination is scheduled for 10/07/2025 at 8:00 am with Dr. Kim, Einstein Medical at Elders Hall. |
10/07/2025
| Implemented |
| 6400.142(a) | Individual #2 had a dental exam completed on 8/25/25. There was no dental exam documentation in the record for 2024. The individual was admitted to the home on 10/10/2023. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual #2 had a dental examination conducted on 8/25/2025. Individual #2's prior dental examination had occurred on 3/18/2024. Form was located after the time of inspection. Individual #2's next dental examination and cleaning is scheduled for 02/06/2026 at 9:00 am at Dental Dreams. |
10/04/2025
| Implemented |
| 6400.181(a) | Individual #2 was admitted to the home on 10/10/23. An annual assessment dated 10/10/24 was present in the record. No initial 60-day assessment as required by regulation was found in the record. | 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. | The annual assessment was completed on 10/10/2024. The most recent annual assessment was completed on 10/03/2025. |
10/03/2025
| Implemented |
| 6400.34(a) | Individual #2 was informed of their individual rights and signed the form in his record on 10/10/24. There was no documentation in the record to show that the individual was informed of individual rights upon admission on 10/10/23 and thus had been informed of rights annually. | 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. | The home informed individual #2 of their individual rights and the process to report a rights violation to the individual on 09/11/2025. Effective 09/30/2025, individual rights dates have been added to the individual appointment tracking spreadsheet to ensure individuals rights are reviewed upon admission and annually thereafter. |
09/30/2025
| Implemented |
| 6400.163(h) | During the medication review for Individual #2, the following medications were stored with actively prescribed medications but not present on the MAR: Mucinex DM Max and Risperidone 2mg. Additionally, Risperidone 2mg was expired per Pharmacy label and should have been discarded after 11/1/2024. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Effective 09/09/2025, the Mucinex DM Max and Risperidone 2 mg were removed from the home and property destroyed in a safe manner according to Federal and State statutes and regulations. |
11/01/2025
| Implemented |
| 6400.165(g) | Individual #2 is prescribed psychotropic medications. There was an 8 month gap where no documentation was in the record to show psychiatrist appointments occurred between the appointments on 8/13/24 and 4/25/25. | 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. | Individual #2 had medication management appointments on the following dates, 9/16/2024, 11/26/2024, 1/21/2025, 2/28/2025, and 3/28/25, however the documentation was not available/present at the time of the inspection. Documentation was located after the inspection and is available for review. Individual #2's next medication management appointment is scheduled for 10/13/2025 at 12:30 pm. |
11/01/2025
| Implemented |