| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | At the time of inspection, there were no sources of artificial lighting in the home's living room---neither ceiling fixtures nor lamps were present. If it were dark outdoors, the windows would not provide any illumination to light the living room. The lighting conditions in this home's living room were therefore inadequate and unsafe. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| This was reported to the landlord, and they are working on putting light in the first living room there. I have instructed my maintenance to install a compact fluorescent light if the landlord refused to. |
02/20/2026
| Implemented |
| 6400.80(a) | The walkway leading from the home's side entrance to the front of the home was lightly coated with compacted, icy snow, creating an outdoor hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Doing the time of the inspection, the walkway in the rear of the home has snow and ice around it. At the time of the inspection, it snowed a lot and maintenance could not get all exits clean in time. They were still in the process of clearing the entire walkway. |
02/20/2026
| Implemented |
| 6400.106 | Per site records, the most recent furnace inspection for this location took place on 10/01/2024. There was no record of a more recent furnace inspection for this location. This location's furnace was not inspected annually as required. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The landlord scheduled the inspector twice and they reschedule every time. We tried to have our own contractor do it, but they also scheduled us in 3 months after. The landlord gave us a letter stating when the inspection will be done. They have done the inspection. |
02/20/2026
| Implemented |
| 6400.110(a) | This home consisted of three floors---a basement, ground floor, and attic. What was believed by Staff on Site to be a smoke detector in the home's basement was, upon examination, a carbon monoxide detector. This carbon monoxide detector was digital and indicated that it was measuring carbon monoxide on the display screen. There did not appear to be a setting to allow for the detection of smoke or---if there was one---Staff on Site were unable to activate it. As such, the basement of this home did not have an operable smoke detector at the time of inspection. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The basement has the same smoke/carbon monoxide detector as the first floor, apparently it was only set on carbon monoxide instead of both. Maintenance has added a regular interconnected smoke detector in the basement. The previous one was recommended by the city inspector so we cannot remove it. |
02/20/2026
| Implemented |
| 6400.110(e) | This home consisted of three floors---a basement, ground floor, and attic. The basement floor lacked a smoke detector altogether. Although all of them could be tested as operable independently, the smoke detector in the attic and the numerous smoke detectors on the ground floor were not interconnected with each other at the time of inspection. This three-story home did not have at least one interconnected smoke detector on each floor of the home as required. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The attic has always been sealed; the maintenance was not aware of the attic until recently. We have contacted our electrician to install the interconnected smoke detectors. |
02/20/2026
| Implemented |
| 6400.141(c)(7) | Individual #1's two most recent Gynecological Examinations, dated, 06/28/2024 and 09/15/2025, occurred more than one year apart. This individual did not receive a gynecological examination annually as required. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | It is difficult at times to schedule a specialized medical appointment. This was the date and time available at the time for the appointment at the doctor's office. Medical scheduler will reach out to doctor's offices 2 months in advance to find a spot. |
02/20/2026
| Implemented |
| 6400.142(a) | Individual #1's two most recent Dental Examination and Cleanings, dated, 05/09/2024 and 07/08/2025, occurred more than one year apart. This individual did not receive Dental Examinations and Cleanings 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. | The individual must go under general anesthesia for her dental procedure. Also, Special Smiles makes the schedule base on their availability. We will keep reaching out to Special Smiles for early appointments if possible. She has appointment in July 2026. |
02/20/2026
| Implemented |
| 6400.142(g) | Individual #1's two most recent Dental Hygiene Plans were dated 05/09/2024 and 07/08/2025. This individual's Dental Hygiene Plan was not updated annually as required. | A dental hygiene plan shall be rewritten at least annually. | The plan was updated late because the order changed doing her appointment on 7/8/25 from brushing 2x a day to 3x a day. The nurse will include the previous plan and the current plan to ensure it is rewritten. |
02/20/2026
| Implemented |
| 6400.151(c)(3) | Staff #1's most recent Staff Physical Examination, dated 03/29/2025, did not note whether the staff was free from communicable diseases. The area of the physical form designated for this information was left blank. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | There are two sections on the form about communicable disease. One says does the patient have communicable disease and the answer was NO. The other section says if you answer yes to question #1, is the patient able to work with individual if specific precautions are taken? The section that speaks about not having communicable disease was answered NO, only this section "is the patient able to work with individual if specific precautions are taken was left blank. We have added N/A to this section. |
02/20/2026
| Implemented |
| 6400.34(a) | Per Individual Rights forms in the Individual Record, Individual #1's two most recent reviews of Individual Rights occurred on 01/18/2024 and 01/29/2025---more than one year apart. Individual Rights were not reviewed with this individual annually as required. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Program specialist indicated that the right was signed on time but dated later. Program specialist will keep the current date for review in the future and ensure all review are done and signed a day before or on the exact date. |
02/20/2026
| Implemented |
| 6400.165(g) | Individual #1 takes psychotropic medications for the treatment of psychiatric symptoms. The physician encounter forms accompanying the 01/04/2025 and 01/22/2025 medication management appointments did not note the need to continue each of the individual's psychotropic medications. | 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. | The doctor's office does not usually fill out the case not to return with our staff. They usually fax it and it takes time when ask them to make corrections. We communicated with the office about our concerns and that we want them to return medical notes to our staff. |
02/20/2026
| Implemented |
| 6400.213(1)(i) | 213(1)(ii) Individual #1's Individual Record did not note the presence or absence of Identifying Marks on the individual; the area of the "Emergency Face Sheet" designated for this information was left blank. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The program specialist did not identify any mark on the individual and should have indicated as No. The program specialist has corrected the error. |
02/20/2026
| Implemented |