| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | There is an exposed, live electrical wire hanging from a basement light fixture. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Maintenance Personnel was called and the exposed wiring was corrected the same day. |
02/06/2026
| Implemented |
| 6400.77(b) | The first aid kit did not contain scissors or a thermometer. | 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. | New first aid kits were purchased to be inclusive of all missing items and placed in all homes |
02/07/2026
| Implemented |
| 6400.166(b) | Individual #1 is prescribed Vitamin D3 500IU (125mcg) to be taken daily at 8:00am. On 2/6/26 this medication was administered, however there were no initials on the medication log stating that it was administered. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Program Director reviewed the Medication Administration Record (MAR) and verified the medication administration with the staff member who administered the medication. The MAR was corrected to include the appropriate staff signature verifying administration. All current MARs were reviewed to ensure that medication administrations are properly documented with staff signatures. |
02/11/2026
| Implemented |