| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | On 10/12/2023, there was a breezeway between the kitchen and garage with sliding glass doors. Both of the sliding glass doors were observed with wooden break-in bars in the lower door track, causing an obstruction of egress. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The wooden bars were immediately removed from the lower door track of each sliding glass door. |
10/12/2023
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment completed on 8/14/2023 does not include recommendations for specific areas of training, programming and services. Individual #2's, date of admission 7/31/2023, assessment completed on 8/07/2023 does not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The assessment for Individual #1 was updated to include recommendations for specific areas of training, programming and services. |
10/13/2023
| Implemented |
| 6400.165(b) | Individual #1, date of admission 8/01/2023, is prescribed Triamcinolone 0.1% Cream. The current written order from the physician as well as the October 2023 Medication Administration Record have directions to use twice daily as needed for rash. The prescription label on the medication has directions to apply twice daily. It was discovered that the prescription was filled on 6/20/2023; however, the most current order was written on 7/5/2023. The medication was not updated to match the newly prescribed order. | A prescription order shall be kept current. | The medication label was updated to match the current order. |
10/16/2023
| Implemented |