| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The exterior light located at the side porch exit was inoperable during inspection. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The exterior light located at the side porch exit was replaced during the inspection. |
12/15/2025
| Implemented |
| 6400.70 | Telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center were not posted on or near the home's telephone. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Telephone numbers for the nearest hospital, police department, fire department, ambulance service, and poison control center were posted near the home's telephone on 12/15/2025. |
12/15/2025
| Implemented |
| 6400.72(b) | The bifold closet door in Individual #2's bedroom was off track and missing the piece that keeps the door secured to the overhead sliding railing. | Screens, windows and doors shall be in good repair. | The bifold closet door in Individual #2's bedroom was repaired on 12/15/2025. |
12/15/2025
| Implemented |
| 6400.77(b) | The home's First Aid Kit was not equipped with tweezers. | 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 missing tweezers were purchased and placed on-site in the home's first aid kit on December 15, 2025. The first aid kit was reviewed at that time to confirm it was fully stocked and compliant with required first aid supply standards, and staff were notified of the update to ensure the supplies remain available and accessible for use as needed. |
12/15/2025
| Implemented |
| 6400.80(a) | Snow has not been cleared from the bottom/rear portion of the home's driveway that is accessible to vehicles and used as a parking area. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The snow was removed on 12/15/2025, located at the bottom/rear portion of the home's driveway that is accessible to vehicles and used as a parking area. |
12/15/2025
| Implemented |
| 6400.112(e) | The home became occupied effective 4/14/25, but a sleep drill wasn't conducted until December 2025. | A fire drill shall be held during sleeping hours at least every 6 months. | LVC C Class Realty LLC has a fire drill schedule to ensure that all required fire drills, including those conducted during sleeping hours, are completed promptly and in accordance with regulatory requirements. The schedule is designed to track quarterly fire drills and biannual sleeping-hours drills, verify completion, and support ongoing compliance. |
12/15/2025
| Implemented |
| 6400.141(a) | The physical examinations for Individual #2 were completed on 9/16/24 and 11/4/25 respectively, which exceeds the annual requirement with the allowable 15-day grace period. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Upon discovery, LVC C Class Realty LLC verified that Individual #2's initial physical was completed on 9/16/2024 and the updated annual physical examination was completed on 11/4/2025, exceeding the 15-day grace period. The opportunity was reviewed with Human Resources on 12/15/2025 and HR staff was retrained on the proper intake procedures for participants. The intake checklist was updated to include compliance with preadmission and post admission deadlines for physical examinations. |
01/09/2026
| Implemented |
| 6400.24 | Individual #2 is prescribed controlled substance Clonazepam 1 mg tablet (dispensed at 8am and 8pm). The medication was not being kept in double locked storage. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | On 12/15/2025, upon discovery, LVC C Class Realty purchased a lock box to store individual #2's prescribed controlled substance Clonazepam 1 mg tablet (dispensed at 8 am and 8 pm) in the locked storage cabinet so that the medication is double locked as per applicable Federal and State statutes and regulations and local ordinances. |
12/15/2025
| Implemented |
| 6400.34(a) | The full listing of rights has not been presented to Individual #2 for understanding and acknowledgment. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | LVC C Class Realty LLC has reviewed and updated its Individual Rights Policy to ensure it fully incorporates all requirements outlined in 55 Pa. Code Chapter 6400 related to individual rights. The updated policy clearly defines and protects the rights of individuals receiving services, including dignity, privacy, choice, freedom from abuse and neglect, access to personal property, communication, and participation in decision-making. The policy was reviewed with and signed by Individual #2. |
12/15/2025
| Implemented |