| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | On 6/26/2026 at AM, there was a two-inch rip in the screen in the window on the right side of the vacant bedroom of the home. | Screens, windows and doors shall be in good repair. | The rip was repaired by maintenance on July 23rd. A copy of the the repaired screen will be emailed to you today. |
08/06/2025
| Implemented |
| 6400.101 | On 6/26/2025 at 11:23AM, there was a swing bar lock on the inside of the door leading to the front entrance of the home causing an obstructed egress when engaged. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The swing Bar Lock was removed during the inspection on 6/26/25 after the home was notified of the violation. Later that same day, a picture of the unobstructed door was forwarded to the inspector on to substantiate compliance. |
08/06/2025
| Implemented |
| 6400.171 | On 6/26/2025 at 11:36AM, a carton of Friendly Farms Heavy Whipping Cream with an expiration date of 6/9/2025 was on the top shelf of the refrigerator in the kitchen of the home. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The heavy whipping cream has been removed from the refrigerator and discarded. A checklist has been prepared which outlines staff responsibilities during their shift. This will help ensure staff are completing their tasks including checking dates on food for expiration and best used by dates. |
08/06/2025
| Implemented |
| 6400.165(g) | Individual #1, date of admission 9/16/2024, is prescribed medication to treat symptoms of a psychiatric illness. Individual #1 completed psychiatric medication reviews on 2/13/2025 and 3/27/2025. | 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. | Consumer had the required medication psych reviews on the following dates: 10/14/2024, 11/13/2024, 19/19/2024, 2/13/2025, 3/27/2025, 4/24/2025 and 5/23/2025. Documentation of all of the reports was forwarded to the inspector on 6/26/2025 with the exception of the one dated 11/13/2024. That review will be emailed today 7/30/2025. |
06/26/2025
| Implemented |