| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The provider agency completed a self-assessment of the home on 5/4/25. The regulations .62a, .62b, .62c, .64e, .68b, and .77b were documented as violations with no summary of corrections made. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. |
06/28/2025
| Implemented |
| 6400.62(c) | On 6/11/25 at 12:13 PM, a plastic water bottle partially filled with a blue liquid substance was in the cabinet under the sink in the ensuite bathroom of the home. Staff interviews revealed that this liquid was toilet cleaner. | Poisonous materials shall be stored in their original, labeled containers. | Poisonous materials shall be stored in their original labeled containers, The blue substance was removed from home. |
06/28/2025
| Implemented |
| 6400.72(b) | On 6/11/25 at 12:17 PM, there were several, one-inch rips in the screen in the window in Individual #1's bedroom. | Screens, windows and doors shall be in good repair. | Screens windows and doors shall be in good repair. Maintenance request was submitted for screen repairs. a letter stating screens will be fixed in July they had to be ordered from property manager. Letter was sent to licensing inspector via email. |
06/28/2025
| Implemented |
| 6400.77(b) | On 6/11/25 at 12:25 PM, there was no thermometer in the home's first aid kit. | 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. | The CEO purchased thermometers for all homes to go in first aid kit. |
06/28/2025
| Implemented |
| 6400.81(k)(2) | On 6/11/25 at 12:19 PM, the bed in Individual #1's bedroom appeared to be two twin bedframes next to one another with one mattress on top. The bed did not appear to be sturdy and comfortably support Individual #1, as it made a loud noise each time Individual #1 moved in the bed. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | The bed now has a new mattress and box spring. Receipt was attached via email sent to licensing inspector. |
06/28/2025
| Implemented |
| 6400.106 | The furnace in the home was inspected and cleaned on 5/10/23, and then again on 9/5/024. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Residential Coordinator has created a tracking sheet of the cleaning inspections annual due date. |
06/28/2025
| Implemented |
| 6400.171 | On 6/11/25 at 12:06 PM, an opened, partially used bottle of ketchup with instructions to "refrigerate after opening" was in the cupboard in the kitchen of the home. At 12:08 PM, there was a container of sour cream with an expiration date of 4/14/25 in the refrigerator of the home. [Repeat Violation- 7/9/24 et al] | Food shall be protected from contamination while being stored, prepared, transported and served.
| Food shall be protected from contamination while being stored prepared transported and served. Instructions on the ketchup bottle states "for best results refrigerate after opening" Ketchup was placed in the refrigerator. Sour cream was removed from home. |
06/28/2025
| Implemented |
| 6400.32(r)(1) | On 6/11/25 at 12:22 PM, there was a turn locking mechanism on the inside with a thumbnail locking mechanism on the outside the door leading to Individual #1's bedroom. Individual #1 has not been provided with a designated mechanism to lock and unlock the door independently. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | An individual has the right to lock the individual's bedroom door. All individuals locks were updated with key and given to individual. Picture was sent via email to licensing inspector. |
06/28/2025
| Implemented |
| 6400.32(r)(5) | On 6/11/25 at 12:22 PM, there was a turn locking mechanism on the inside with a thumbnail locking mechanism on the outside the door leading to Individual #1's bedroom. Staff did not have a designated mechanism to lock and unlock the bedroom door in case of an emergency. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. The locks were replaced with new locks with keys and provided a copy to individual. |
06/28/2025
| Implemented |
| 6400.166(b) | Individual #1's prescribed medications, Differen Gel 0.1%, Doxycycl Hyc and Benzoyl Peroxide Liquid 5% Wash, were not initialed as having been administered at 8 AM on 6/9/25, 6/10/25 and 6/11/25. [Repeat Violation- 7/9/24 et al] | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The responsible staff member was immediately retrained on the correct procedure for documenting medication administration. On 6/13/2025 this staff member was retrained on proper Mar documentation procedures including immediate documentation after administration. The use of acceptable documenting codes and steps to follow when a dose is missed, refused or delayed. Staff reviewed the Medication Administration Policy and signed acknowledgment forms. |
06/13/2025
| Implemented |