| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(f) | The fire extinguisher under the sink did not have an inspection tag with a date to determine when the extinguisher was inspected. The fire extinguisher shall be inspected and approved annually. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The uncharged fire extinguisher under the kitchen sink was removed |
07/30/2025
| Implemented |
| 6400.141(c)(6) | Individual #1 had a physical exam completed on 11.4.24, is within the 12 months prior to admission, however the TB test was completed on 10.10.23 which is outside the year prior to 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. | A current TB test for Individual #1 was completed, and the results were placed in their medical file to ensure it is within one year prior to admission. |
08/15/2025
| Implemented |
| 6400.141(c)(13) | Individual #1 physical exam was completed on 11.4.24, which is within the 12 months prior to admission. However the physical does not list allergies or contraindicated medications. The area of the physical states "see attached" however there is nothing attached to the physical. | The physical examination shall include: Allergies or contraindicated medications. | The physician¿s office was contacted to obtain the missing allergy and contraindicated medication information for Individual #1, and the updated documentation was attached to the physical in the medical file. |
08/15/2025
| Implemented |
| 6400.171 | Food shall be stored properly to protect from contamination. At the time of the inspection there was a great value spaghetti sauce that opened on 7.25.25 and was used. The jar was then placed back into the cupboard rather than the refrigerator. Once opened this food shall be refrigerated as it can grow bacteria if not properly stored. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The opened jar of spaghetti sauce was discarded immediately, and staff were reminded that once opened, such items must be refrigerated to prevent bacterial growth. |
07/31/2024
| Implemented |
| 6400.181(a) | An initial assessment shall be completed within 60 days after admission to the residential home and updated annually thereafter. Individual #1 was admitted to LVCC on 5.8.25 and as of today's date 7.29.25 there has not been an initial assessment completed by LVCC. The annual assessment in the individual record was completed by the previous agency and dated 10.07.24. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | An initial assessment for Individual #1 was completed immediately, dated, and placed in their record |
08/05/2025
| Implemented |
| 6400.195(a) | Individual #1's Individual Support Plan (ISP) dated 7.1.25 states under the general health and safety risk section that Individual #1 is not safe around knives and reports there is a restrictive procedure plan (RPP) in place. At the time of the inspection, the knives and sharps were locked in a cabinet in the home. However, the RPP dated June 2025 does not reflect that knives are locked under the current restrictions. The plan is being implemented without the proper behavioral plan in place. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | The Restrictive Procedure Plan (RPP) for Individual #1 was updated to include the current restriction of locking knives and sharps, ensuring the plan matches the interventions being implemented in the home. The revised plan was reviewed and signed by the required team members. |
08/05/2025
| Implemented |
| 6400.213(1)(i) | Individual #1 record did not include a religious affiliation, that area of the record stated it was unknown. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Individual #1 was asked about their religious affiliation, and the response was documented in their record. If the individual chose not to disclose or had no affiliation, this was clearly noted. |
08/05/2025
| Implemented |