| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual #2's Individual Record was missing a financial record for the month of February 2025. As such, there was no record of disbursements made to or for the individual during that month. | The home shall keep an up-to-date financial and property record for each individual that includes the following:
(2) Disbursements made to or for the individual. | The supervisor checked the financial records stored for each individual at the corporate office and confirmed that a ledger does in fact exist. |
12/22/2025
| Implemented |
| 6400.71 | At the time of inspection, a cordless phone was lying on the kitchen island, off of its base located in the living room. While emergency telephone numbers were posted next to the cordless phone's base, the phone was not near its base at the time of inspection. Emergency telephone numbers were not posted on or by this telephone. | 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.
| 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 (6400.71). At the time of inspection, a cordless phone was lying on the kitchen island, off of its base located in the living room. While emergency telephone numbers were posted next to the cordless phone's base, the phone was not near its base at the time of inspection. Emergency telephone numbers were not posted on or by this telephone. The supervisor call the home on 12/19/25 in an effort to confirm that the phone was placed on the base. The phone, in fact still was not on its base. The Supervisor directed staff to place the phone on the base in the living room area. |
12/19/2025
| Implemented |
| 6400.72(b) | The screen door on the home's rear sliding door had a hole in its screen that was approximately 2 inches by 4 inches. | Screens, windows and doors shall be in good repair. | Screens, windows and doors shall be in good repair (6400.72 (b). During the annual ODP inspection at LVHS, the screen door on the home's rear sliding door had a hole in its screen that was approximately 2 inches by 4 inches. The supervisor contacted maintenance at the leasing office and stipulated that the screen door be replaced immediately. The screen was replaced on December 22, 2025. |
12/22/2025
| Implemented |
| 6400.141(c)(8) | Per Individual #2's Individual Record, the individual's two most recent mammograms occurred on 03/24/2022 and 05/13/2024---more than two years apart. This individual did not receive a mammogram at least every 2 years as required. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | According to 6400.141 (c) (8) The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. In an annual inspection on December 18, 2025, per Individual #2's Individual Record, the individual's two most recent mammograms occurred on 03/24/2022 and 05/13/2024---more than two years apart. This individual did not receive a mammogram at least biannually as required. The supervisor has scheduled a mammogram for Individual #2 on 2/17/26 |
01/13/2026
| Implemented |
| 6400.141(c)(11) | Individual #2's Physical Examination, dated 08/18/2025, did not include a medication regimen for the individual. There was an area of the physical form designated for this information; however, it was left blank with a note to "See Attached." As there were no additional documents attached to the physical form, it could not be established that an assessment of the individual's medication regimen occurred during the Physical Examination. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | (6400.141 (c) (11) states that he physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen, and the need for blood work at recommended intervals. ODP Site inspection conducted on December 18, 2025 revealed a violation. Individual #2's Physical Examination, dated 08/18/2025, did not include a medication regimen for the individual. There was an area of the physical form designated for this information; however, it was left blank with a note to "See Attached." As there were no additional documents attached to the physical form, it could not be established that an assessment of the individual's medication regimen occurred during the Physical Examination. On January 6, 2026, the supervisor contacted the PCP's office of Individual #2 and requested a copy of the medication regimen located on the discharge summary for the 8/18/25 visit. This information was added to individual #2's file. |
01/06/2026
| Implemented |
| 6400.142(a) | Individual #2's two most recent dental examinations and cleanings occurred on 09/04/2024 and 11/10/2025---more than one year apart. This individual did not receive a dental examination and cleaning annually as required. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | According to 6400.142 (a) an individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. In the December 18, 2025 inspection with ODP, individual #2's two most recent dental examinations and cleanings occurred on 09/04/2024 and 11/10/2025---more than one year apart. This individual did not receive a dental examination and cleaning annually as required. The supervisor has scheduled a dental examination for Individual #2 on 5/11/26 |
01/14/2026
| Implemented |
| 6400.142(g) | Per the Individual Record, Individual #2's two most recent Dental Hygiene Plans were written on 09/04/2024 and 11/10/2025---more than one year apart. This individual's Dental Hygiene Plan was not rewritten annually as required. | A dental hygiene plan shall be rewritten at least annually. | 6400.142 (g) states that a dental hygiene plan shall be rewritten at least annually. In the ODP site visit on December 18, 2025, LVHS received a violation of this requirement. Per the Individual Record, Individual #2's two most recent Dental Hygiene Plans were written on 09/04/2024 and 11/10/2025---more than one year apart. This individual's Dental Hygiene Plan was not rewritten annually as required. On January 6, 2026, the supervisor contacted the dental office and requested that a dental plan be completed. The plan has been placed in the individual's record. |
01/06/2026
| Implemented |
| 6400.144 | Per Individual #2's December 2025 Medication Administration Record (MAR), the individual was prescribed Methocarbamol 500mg Tablet with instructions to "Take one tablet by mouth 3 times daily as needed for muscle spasms." At the time of inspection, this prescription medication could not be located within the individual's home. As such, the provider failed to arrange pharmaceutical services for the individual. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided (6400.144). P er Individual #2's December 2025 Medication Administration Record (MAR), the individual was prescribed Methocarbamol 500mg Tablet with instructions to "Take one tablet by mouth 3 times daily as needed for muscle spasms." At the time of inspection, this prescription medication could not be located within the individual's home. As such, the provider failed to arrange pharmaceutical services for the individual. On December 18, 2025, the supervisor drove to Hartzel's Pharmacy to get the medication, but they did not have it in stock. On December 19, 2025, the Pharmacy delivered the medication to the individual's home and the medication was administered. |
12/19/2025
| Implemented |
| 6400.163(a) | Per Individual #2's December 2025 Medication Administration Record (MAR), the individual was prescribed Secura Protective 10% Cream, Sunscreen SPF 30 Lotion, and PEDIFIX Visco-Gel Bunion Pads. The pharmacy-issued labels on the containers of these prescription medications were worn off to the point of being completely illegible. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy (6400.163 (a).
Per Individual #2's December 2025 Medication Administration Record (MAR), the individual was prescribed Secura Protective 10% Cream, Sunscreen SPF 30 Lotion, and PEDIFIX Visco-Gel Bunion Pads. The pharmacy-issued labels on the containers of these prescription medications were worn off to the point of being completely illegible. On December 23, the supervisor drove to the Pharmacy to obtain a new medication label for the cream for Individual # 2 and placed it on the medicated cream. |
12/23/2025
| Implemented |
| 6400.165(g) | Individual #2 is prescribed psychotropic medications to treat the symptoms of psychiatric illness. Individual #2 sees a psychiatrist for routine psychotropic medication management, and attended appointments on 11/20/2024, 03/06/2025, 06/23/2025, and 09/16/2025. The documentation corresponding to the medication reviews on 11/20/2024 and 09/16/2025 were each missing the following required information: the names of the psychotropic medications prescribed for the individual, the reason for prescribing each medication, the necessary dosage of each medication, and the need to continue each medication. | 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. | 16. (6400.165 (g) requires that 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 documenting the reason for prescribing the medication, the need to continue the medication, and the necessary dosage. Individual #2 is prescribed psychotropic medications to treat the symptoms of psychiatric illness. Individual #2 sees a psychiatrist for routine psychotropic medication management, and attended appointments on 11/20/2024, 03/06/2025, 06/23/2025, and 09/16/2025. The documentation corresponding to the medication reviews on 11/20/2024 and 09/16/2025 were each missing the following required information: the names of the psychotropic medications prescribed for the individual, the reason for prescribing each medication, the necessary dosage of each medication, and the need to continue each medication. The supervisor has since scheduled a meeting with the psychiatrist to obtain the information required for the 3 month checks. The supervisor has made an appointment for 3/17/26. |
01/13/2026
| Implemented |
| 6400.166(a)(11) | Per Individual #2's December 2025 Medication Administration Record (MAR), the individual was prescribed Cephalexin 500mg Capsule with instructions to "Take one capsule by mouth four times daily for 7 days." Both the medication's pharmacy label and the MAR entry for this prescription medication lacked a diagnosis or purpose for the medication. | 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. | 17. 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 (6400.166 (a) (11). Per Individual #2's December 2025 Medication Administration Record (MAR), the individual was prescribed Cephalexin 500mg Capsule with instructions to "Take one capsule by mouth four times daily for 7 days." Both the medication's pharmacy label and the MAR entry for this prescription medication lacked a diagnosis or purpose for the medication. On December 19, 2025, the supervisory augmented the MAR to include a diagnosis and purpose for the medication. |
12/19/2025
| Implemented |
| 6400.166(d) | Per Individual #2's December 2025 Medication Administration Record (MAR), the individual was prescribed Acetaminophen 325mg Tablet with instructions to "Take one tablet by mouth every 4 hours as needed for fever or mild pain (Pain Score 1-3)." This prescription medication's pharmacy-issued label had instructions that did not match the instructions on the MAR---it read, "Take one tablet by mouth every four hours as needed for fever." As these administration instructions differed, it could not be determined if the prescriber's instructions were being followed. | The directions of the prescriber shall be followed. | 6400.166 (d) indicates that the directions of the prescriber shall be followed. Per Individual #2's December 2025 Medication Administration Record (MAR), the individual was prescribed Acetaminophen 325mg Tablet with instructions to "Take one tablet by mouth every 4 hours as needed for fever or mild pain (Pain Score 1-3)." This prescription medication's pharmacy-issued label had instructions that did not match the instructions on the MAR---it read, "Take one tablet by mouth every four hours as needed for fever." As these administration instructions differed, it could not be determined if the prescriber's instructions were being followed. On December 22, 2025, the supervisor contacted the PCP's office to clarify and request a written order in order to make changes with the medication. Once the received the MAR was corrected to match the doctor's order and the medication bottle. Staff were all alerted to notice the change and administer accordingly. |
12/22/2025
| Implemented |
| 6400.181(f) | Per a sign-in sheet in the Individual Record, Individual #2's most recent Individual Plan Meeting occurred on 07/22/2025. There was no evidence that Individual #2's most recent Individual Assessment, dated 06/23/2025 was sent to members of the Individual Plan Team by the Program Specialist at least 30 calendar days prior to the Individual Plan Meeting as required. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | 19. The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting (6400.181 (f). A violation was discovered in the ODP annual site inspection on December 18, 2025. Per a sign-in sheet in the Individual Record, Individual #2's most recent Individual Plan Meeting occurred on 07/22/2025. There was no evidence that Individual #2's most recent Individual Assessment, dated 06/23/2025 was sent to members of the Individual Plan Team by the Program Specialist at least 30 calendar days prior to the Individual Plan Meeting as required. The PS immediately sent a copy of the assessment to the team (December 23, 2025). |
12/23/2025
| Implemented |