| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(c) | The fire extinguisher located in the kitchen is smaller than the required size. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | Provider replaced the fire extinguisher that was provided by the building owner with the approved fire extinguisher rated 2A-10BC. A video will be forwarded showing proof of the correction. |
03/11/2026
| Implemented |
| 6400.141(a) | Individual #1's only physical on file is dated 2/5/2026. A physical should have been completed between 12/15/2024 through 12/15/2025. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Provider escorted individual #1 to urgent care to get an updated physical. Physical will be forwarded showing proof of the correction. |
03/12/2026
| Implemented |
| 6400.141(c)(6) | The physical dated 2/5/2026 states TB test results as pending for individual #1. | 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. | Provider took individual #1 to urgent care to get an update and completed physical. Physical will be forwarded showing proof of the correction. |
03/12/2026
| Implemented |
| 6400.141(c)(10) | Individual #1's physical dated 2/5/26, the physician failed to circle whether or not the individual was free from communicable diseases. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Provider took individual #1 to urgent care to get an update and completed physical. Physical will be forwarded showing proof of the correction. |
03/12/2026
| Implemented |