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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 4/30/2025 at 10:13AM, the hot water temperature measured 131.9°F at the sink in the kitchen of the home. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | How we plan to correct the non-compliance:
What happened / Why did it happen:
On April 30, 2025, at 10:13 AM, the hot water temperature at the kitchen sink in the home measured 131.9°F, exceeding the regulatory limit of 120°F. This posed a significant risk of burns to individuals and violated safety requirements. The issue occurred because the water heater was set too high and there was no system in place to routinely monitor hot water temperatures.
What specific change was made to fix the problem:
On May 2, 2025, the Facility Compliance Manager adjusted the water heater to its lowest safe setting. A follow-up measurement confirmed the water temperature at the kitchen sink was reduced to 112°F, safely below the 120°F threshold. The water heater was labeled with the approved setting and access was restricted to authorized personnel only.
Who made the change and when:
The Facility Compliance Manager completed the adjustment and verified the corrected temperature on May 2, 2025.
How was the issue corrected:
The water temperature is now within compliant range. The heater is labeled and locked to prevent unauthorized adjustments, and a monitoring system has been implemented. |
05/02/2025
| Implemented |
| 6400.68(b) | On 4/30/2025 at 10:55AM, the hot water temperature measured 128.1°F at the bathtub in the only bathroom in the home. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | How we plan to correct the non-compliance:
What happened / Why did it happen:
On April 30, 2025, at 10:55 AM, the hot water temperature at the bathtub in the home¿s only bathroom measured 128.1°F, exceeding the maximum allowable limit of 120°F as outlined in § 6400.68(b). This posed a significant scalding risk to the individuals residing in the home. The violation occurred due to the water heater being set too high, coupled with the absence of a consistent monitoring system to verify water temperature at point-of-use locations.
What specific change was made to fix the problem:
On May 2, 2025, the Facility Compliance Manager adjusted the water heater to its lowest effective setting. A calibrated thermometer was used to re-check the temperature at the bathtub, confirming a new safe range of 110°F¿112°F. The water heater was labeled with the approved setting and secured to restrict unauthorized access.
Who made the change and when:
The Facility Compliance Manager performed the adjustment and verified the new temperature reading on May 2, 2025.
How was the issue corrected:
The water temperature at the bathtub is now compliant and safe. The adjustment was logged, and the water heater was marked with a compliance label. Staff were informed of the correction and reminded of heat risk awareness protocols. |
05/02/2025
| Implemented |
| 6400.70 | On 4/30/2025 at 10:30AM, the cellular telephone provided by the home was on the end table next to the couch in the living room of the home and was not fully charged and required a passcode to operate; therefore, not easily accessible to Individual #1. There is no landline telephone service in the home. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| How we plan to correct the non-compliance:
What happened / Why did it happen:
On April 30, 2025, at 10:30 AM, the home only had a cellular phone, which was found on an end table in the living room. The phone was not fully charged and required a passcode to operate. This made it inaccessible to Individual #1, violating § 6400.70, which requires an operable, non-coin-operated telephone with an outside line that is easily accessible to individuals and staff. There was no landline telephone service in place at the time of the inspection.
What specific change was made to fix the problem:
On May 1, 2025, a landline telephone with an outside line was installed in the living room of the home. The phone is plugged in, operable at all times, and does not require a passcode. Emergency phone numbers for the police, fire department, hospital, ambulance, and poison control were printed and clearly posted both on the base of the phone and on a label on the back of the handset for quick reference.
Who made the change and when:
The Facility Compliance Manager installed and verified the operability of the landline phone on May 1, 2025.
How was the issue corrected:
The cell phone was removed from the home to eliminate confusion and noncompliant practices. The landline was tested and confirmed to provide immediate access to emergency services and outgoing communication. |
05/23/2025
| Implemented |
| 6400.71 | On 4/30/2025 at 10:30AM, the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the the cellular telephone in the home. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| How we plan to correct the non-compliance:
What happened / Why did it happen:
On April 30, 2025, at 10:30 AM, the only telephone in the home was a cellular phone, and it did not have the required emergency phone numbers (police, fire department, hospital, ambulance, and poison control) posted on or near it. This violated § 6400.71, which mandates that these numbers must be visibly posted on or by the telephone to ensure access in case of emergency. The oversight occurred due to reliance on a personal-use cell phone, which is not compliant with 6400 standards.
What specific change was made to fix the problem:
On May 1, 2025, a landline telephone was installed in the living room of the home. A list of emergency numbers¿including the nearest hospital, local police and fire departments, ambulance service, and poison control center¿was printed in large, legible font and posted directly on the wall above the phone and also taped to the back of the phone handset.
Who made the change and when:
The Facility Compliance Manager installed the phone and posted the emergency numbers on May 1, 2025.
How was the issue corrected:
The non-compliant cell phone was removed, and a compliant landline with posted emergency numbers is now in place and accessible to all staff and individuals. |
05/23/2025
| Implemented |
| 6400.77(b) | On 4/30/2025 at 10:23AM, the home's first aid kit did not contain 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. | How we plan to correct the non-compliance:
What happened / Why did it happen:
On April 30, 2025, at 10:23 AM, the home¿s first aid kit did not contain a thermometer, as required by § 6400.77(b). This occurred due to lack of a standardized contents checklist and inconsistent restocking procedures following use or inspection.
What specific change was made to fix the problem:
On May 1, 2025, a new standardized first aid kit was delivered and placed in the home. All required items were verified, including:
Thermometer
First aid manual
Antiseptic
Adhesive bandages (assorted sizes)
Sterile gauze pads
Tape
Scissors
Tweezers
(Syrup of Ipecac if applicable, based on individual profiles)
Who made the change and when:
The Facility Compliance Manager distributed and verified contents of the new first aid kits in all homes on May 1, 2025.
How was the issue corrected:
The thermometer and manual were added, and the full contents were cross-checked against a standardized list. The complete kit is now stored in a designated, clearly labeled area in the home. |
05/16/2025
| Implemented |
| 6400.77(c) | On 4/30/2025 at 10:23AM, a first aid manual was not kept with the the home's first aid kit. | A first aid manual shall be kept with the first aid kit. | Provider¿s Plan of Correction
What Happened / Why It Happened:
On April 30, 2025, at 10:23 AM, the home¿s first aid kit was found without a first aid manual, which is a violation of § 6400.77(c). This occurred due to incomplete restocking during a previous kit replacement and the omission was not identified during routine checks.
Corrective Action Taken:
On May 1, 2025, the home was issued a new, fully stocked first aid kit, which included the required first aid manual.
The Facility Compliance Manager confirmed the manual was included and placed directly inside the kit for accessibility.
All other homes were reviewed and provided with updated first aid kits to ensure compliance. |
05/02/2025
| Implemented |
| 6400.104 | The letter to the local fire department, dated 3/31/2025, did not include exact locations of the bedrooms of the individuals who need assistance evacuating in the event of an actual fire. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Provider¿s Plan of Correction
What Happened / Why It Happened:
The letter sent to the local fire department on March 31, 2025, did not include the exact bedroom locations of individuals who require assistance evacuating in the event of a fire, which is a violation of § 6400.104.
This occurred due to the use of an outdated template that lacked the required specificity and had not been updated to reflect current regulatory expectations.
Corrective Action Taken:
On May 1, 2025, a new letter template was created to include:
The full address of the home
The number of individuals residing in the home
A list of any individuals who require evacuation assistance
The exact bedroom location of each individual requiring assistance
Updated letters were completed and sent to the local fire department for each licensed home.
Copies of the letters were filed both at the home and the administrative office. |
05/02/2025
| Implemented |
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