| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | The balcony sliding door handle was shaky and fixed during inspection. | Screens, windows and doors shall be in good repair. | The repair was completed at the time of the inspection. |
10/06/2025
| Implemented |
| 6400.171 | There were boxes of open cereal in the cabinet. | Food shall be protected from contamination while being stored, prepared, transported and served.
| 1. All open food containers have been stored in sealed air tight containers to prevent contamination.
2. Staff was retrained on food storage |
10/06/2025
| Implemented |
| 6400.166(a)(11) | A Med review for individual 1 was done. There is no diagnosis or purpose for medication on the MAR. | 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. | 1. The nurse updated the MAR for individual 1 to include the diagnosis for the medication, verified by the physician's order.
2. All participant's MARs were reviewed to ensure that all medications had a diagnosis for medications prescribed. |
10/06/2025
| Implemented |