| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | There was unknow material in a spray bottle not labeled locked with poisonous material | Poisonous materials shall be stored in their original, labeled containers. | In speaking with staff, they report that this was kitchen disinfect spray and the spray bottle hat they filled from a larger container. They put the cleaning solution in a new, un labeled spray bottle and was not aware that this was a violation of the regulations. The cleaning solution and spray bottle were discarded on the day of inspection 6/23/23 and the staff was counseled and retrained on the proper storage of poisonous materials on 8/30/2023. |
08/30/2023
| Implemented |
| 6400.65 | There was no ventilation by a operational window or by a mechanical ventilation (fan) in the bathroom, the skylight was sealed and did not allow ventilation when opened. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| A mechanical ventilation by use of a oscillating fan has been provided 6/29/23, the oscillating fan is operable now. |
06/29/2023
| Implemented |
| 6400.70 | The home did not have a operable telephone with an outside line | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| The individual who resides in that home was utilizing both phones during the night and did not place them back on the charger after use. During the inspection, there were two operational phones and phones lines; however, they were not fully charged, and the battery was low. The phones were placed on the charger to recharge and a upon return to the main office, we called the phone line and the staff and individual answered the phone confirming that the phone was operational while the inspector was giving his exit interviews. Going forward staff will check to ensure that the phones are on the base charging after each use. |
06/23/2023
| Implemented |
| 6400.71 | There was no emergency numbers near or on the 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.
| There were two phones located at the home, emergency number was posted on the phone located in the living room, The second phone is located in a room that is unoccupied and a phone list was omitted. The telephone list was reprinted and reposted next to the telephone. Staff were informed that the telephone list should always remain posted wherever the phone is stationed. |
06/30/2023
| Implemented |
| 6400.82(e) | Paint thinner was found unlocked in a closet on the third floor. Individual #1 is not poison-safe per their ISP. | Bathtubs and showers shall have a nonslip surface or mat. | Staffs has all been counseled and retrained to secure all poisonous and hazardous material in a secure locked place to ensure health and safety. This home does not have a third floor, this maybe an error. |
08/30/2023
| Implemented |
| 6400.24 | Controlled substance medication was not double locked per federal guidelines. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | The medication storage box was locked but was in a closet inside of a room that is not utilize as a bedroom that closed but the room door was not locked. on 6/30/2023 , A lock was installed on the room door where the medication box is stored to ensure that all controlled substances will be double locked going forward. |
06/30/2023
| Implemented |