| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The security light at the entrance to the home did not operate. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Security light at the entrance of 426 has been replaced. (see shared folder) |
08/21/2026
| Implemented |
| 6400.67(a) | The right, front eyelet of the stove did not ignite when activated. | Floors, walls, ceilings and other surfaces shall be in good repair. | Front eyelet of stove replaced, now in working condition (see shared folder) |
08/14/2026
| Implemented |
| 6400.68(a) | The water temperature in the second-floor bathroom tub measured 94.8 degrees. Body temperature is 98.6. The first-floor bathroom sink had extremely low water flow. | A home shall have hot and cold running water under pressure. | Water pressure was checked and tap head responsible for low pressure was replaced. Water temp was also adjusted to 113 degrees (see shared folder) |
08/21/2026
| Implemented |
| 6400.71 | The emergency contacts listed hospitals that were closed. | 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.
| Emergency contact list was updated to reflect current hospital and relevant providers |
08/14/2026
| Implemented |
| 6400.72(b) | The screen door to the residence was missing the handle/lock. The second-floor bathroom had several broken blinds. | Screens, windows and doors shall be in good repair. | Screen door to the residence has been replaced as well as the second-floor bathroom blind, (see shared folder) |
08/28/2026
| Implemented |
| 6400.74 | Anti-skid material was missing from the staircase to the second floor. | Interior stairs and outside steps shall have a nonskid surface.
| Anti-skid carpet has been placed on all the interior stairs.(see shared folder) |
08/21/2026
| Implemented |
| 6400.112(d) | Eleven out of 12 fire drills in the past year exceeded the two minute-thirty second requirement and did not have additional drills recorded in the month to achieve the required evacuation time.
Drills recorded:
08/05/2026 -- 2 minutes 86 seconds
07/07/2026 -- 2 minutes 56 seconds
06/15/2026 -- 2 minutes 43 seconds
04/14/2025 -- 2 minutes 35 seconds
03/03/2026 -- 2 minutes 49 seconds
02/10/2026 -- 2 minutes 57 seconds
01/30/2026 -- 5 minutes 30 seconds
12/15/2025 -- 2 minutes 46 seconds
11/14/2025 -- 2 minutes 54 seconds
10/08/2025 -- 2 minutes 41 seconds
09/01/2025 -- 2 minutes 66 seconds | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Site supervisors and staff have been retrained on proper fire drill expectations and a fire drill was repeated to establish learning (see shared folder) |
08/26/2026
| Implemented |
| 6400.112(e) | In the last 12 months, the home did not complete a sleep drill conducted during recognized sleeping hours (11:00pm-07:00am). | A fire drill shall be held during sleeping hours at least every 6 months. | A fire drill has now been conducted during a sleep hour.(see shared folder) |
08/26/2026
| Implemented |
| 6400.171 | An open jar of mayonnaise with a label indicating it required refrigeration after opening was found in the kitchen cabinet. This was removed during the inspection. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Open jar of mayonnaise was discarded immediately on discover. |
08/14/2026
| Implemented |