| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.82(e) | On 1/30/2025, there was no non-slip surface in bathtub. | Bathtubs and showers shall have a nonslip surface or mat. | Immediately there was a non-stick mat applied. Moving forward staff will ensure that after cleaning the mat will be replaced back in the tub immediately. There will be an addition to the chore list to initial that the non-stick mat is in place each shift. Written documentation of safety checks will be kept. |
01/30/2025
| Implemented |
| 6400.141(c)(6) | Individual #1, date of admission 12/8/2024, had a tuberculin evaluation completed on 12/10/24. This was completed after admission. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Admitting staff will ensure that the TB skin testing is on the physical before admission to the facility. Physical paperwork will be confirmed before the day of admission to ensure that the patient has had the proper testing. |
01/30/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, dated 9/6/2024, did not address medical information pertinent to diagnosis and treatment in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Admitting staff will ensure that all medical information pertinent to diagnosis and treatment in case emergency is on the physical before admission to the facility. Physical paperwork will be confirmed before the day of admission to ensure that the patient has had the proper information needed for admission. |
01/30/2025
| Implemented |