| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 has a diagnosis of Severe ID, anxiety, depression, impulse control disorder, sleep disorder, cerebral palsy, and a tremor in their hands. The individual requires staff assistance with all ADL's. Staff must be present to assist Individual #1 with all showers and bathing to ensure cleanliness. Individual #1 wears incontinence briefs but utilizes the toilet during the day. This is to be done at least every 2 hours, with staff assisting to ensure cleanliness and to help Individual #1 with their briefs.
Individual #1 has a body chart in their record. The directions for these charts indicate that the report must be completed twice daily, once while helping to dress in the morning and once while bathing in the evening. This is to be completed whether the individual's skin is clear, or an injury is noted. If staff notes an injury that is of unknown origin, staff must report it to the agency LPN. This form is not being completed twice daily, only when injuries are discovered. So, it is unclear if accurate checks are being completed daily to ensure the individual's health and safety. There were 5 occasions between 11/2/25 and 11/25/25 when injuries of unknown origin were noted, but no follow up action was taken.
On 11/7/25, multiple bruises of unknown origin were discovered by day program staff. These included bruises on the upper right arm, left arm, breast, 2 small bruises above buttocks, scratches/bruises on the abdomen, bruises inside and outside of both upper thighs near the individual's private area and left lower leg bruises. These unknown injuries were not reported by residential staff. The individual was transported to the emergency room, where a SAFE examination was conducted with law enforcement present. Adult Protective Services confirmed this incident as physical abuse.
Failure to document and report injuries of unknown origin timely creates conditions conducive to serious harm for Individual #1. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | ·Bruise Chart has been updated to clearly outline the steps that must be taken twice each day and exactly what staff are to do if an unknown bruise or injury appears. Added a section for staff to document if something occurred that could later turn into a bruise (bumped into a table etc)
·Staff were reprimanded for not following procedure for reporting bruises or completing documentation as required
·Applying for approval from ODP for cameras to be installed in the common areas for staff supervision |
03/20/2026
| Accepted |
| 6400.18(a)(4) | Individual #1 has had multiple injuries of unknown origin, potential physical abuse, in the month of November 2025 that were not reported in the department's incident management system:
· Scratches on their stomach first noted 11/2/25
· Right leg bruise first noted on 11/6/25
· Bruise on their lower leg first noted on 11/21/25
· Scratches on the back of their brief area on 11/22/25
· Scratch on their left forearm on 11/25/25 | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| Injuries noted on 11/2 and 11/6 were part of the investigation that Bell is completing.
11/21,11/22, and 11/25 were entered as incidents on 1/22/26. We included 11/25 as part of the investigation for unexplained injury, but the daily logs explain that Individual #1 was scratching themselves. |
02/13/2026
| Accepted |
| 6400.18(c) | The individual and designated persons were not notified of the potential physical abuse incidents as described in 6400.18a4. | The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual. | ·Individual and designated person were notified when incident was entered. |
02/18/2026
| Accepted |
| 6400.18(f) | Actions were not taken immediately to ensure the health and safety of Individual #1 in response to the potential physical abuse incidents described in 6400.18a4. | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | Staff are now notifying the LPN or the PC/APC for all bruises including sending pictures of the bruise so that the health and safety of the individual is addressed in a timely manner, even when the cause of the bruise is known. When the bruise is unknown incident management is also notified in addition to the PC/APC and LPN. |
02/19/2026
| Accepted |
| 6400.18(g) | There was not a certified investigation completed for the potential physical abuse incidents described in 6400.18a4. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | ·Incident was submitted on 1/22/26 (Incident number 9772616) investigation was completed and reviewed on 2/17/26 |
02/18/2026
| Accepted |