| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Clean and sanitary conditions shall be maintained in the home.
There was a rusted heat vent along the floor in the hall bathroom with rust flakes and dirt/debris on the floor underneath the vent. | Clean and sanitary conditions shall be maintained in the home. | There was a work order for maintenance cleaning the vent, but they could not get it done on time. Maintenance has already changed the vent. Picture will be sent. |
02/20/2026
| Implemented |
| 6400.143(a) | Individual #1 refused psychiatric medication reviews on 5/01/2025 and therapy appointments on 6/27/25, 8/29/25 and 10/03/25 and there was no documentation of attempts to train the individual and the desensitization plan was last updated on 1/17/2023. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | The individual may sometimes refuse an appointment; however, staff usually encourage him and in more cases he will go. Staff did not document his case note to indicate their effort. The desensitization plan has been updated and staff have been retrained. |
02/20/2026
| Implemented |
| 6400.171 | Food shall be stored under safe conditions. An opened bottle of Jerk sauce was found stored in a kitchen cabinet. The label on the bottle stated that the sauce should be refrigerated after opening. The Agency representative accompanying the licensing representative disposed of the sauce after discovery.
*Repeat violation at this site -- other opened condiments requiring refrigeration were found stored in kitchen cabinets at this site at previous inspection May 2025. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The supervisor reported that a staff member took the jerk sauce for their own consumption and was supposed to remove it when leaving shift but forgot to. The sauce was removed, and all staff there were retrained for food safety. Training sign-in-sheet will be sent |
02/20/2026
| Implemented |