| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | 62(a).There were several cans of paint in the unlocked laundry room closet. The paint cans were removed and locked in the garage during the inspection. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Our maintenance personnel failed to lock the maintenance closet upon completion of some work performed. The door was immediately locked right after this violation was brought to our attention. |
12/24/2024
| Implemented |
| 6400.67(a) | 67(a). There are large sections of the kitchen flooring that have tears in it. | Floors, walls, ceilings and other surfaces shall be in good repair. | The vinyl flooring was repaired by our landlord. |
12/20/2024
| Implemented |
| 6400.112(c) | 112c: The problems encountered section of the fire drill form was not completed on the 10/5/24 fire drill. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | All staff and managers were trained on fire drill and the completion of the form. |
12/20/2024
| Implemented |
| 6400.163(h) | 163(h). Storage and disposal of medications. Triamcinolone 0.3% ointment was in with individuals' number one medications but was not on the MAR. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The PRN ointment was removed from the medication box and disposed off at the pharmacy. |
12/20/2024
| Implemented |
| 6400.166(a)(2) | 166(a)(2). Medication record. Individual number one prescribing doctor was not included on the MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Our contracted pharmacy acknowledged the omission of the prescribing physician and made the correction on the next MAR. |
12/01/2024
| Implemented |