| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | On 10/2/2024 at 10:12am, the operable window in the staff office was observed without a securely fitting screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The window screen was installed. |
10/08/2024
| Implemented |
| 6400.82(e) | On 10/2/2024 at 10:23am, the shower in the basement level bathroom was observed without a nonslip surface or mat. | Bathtubs and showers shall have a nonslip surface or mat. | The shower and toilet were removed from area making it an empty room and no longer a bathroom. |
10/08/2024
| Implemented |
| 6400.82(f) | On 10/2/2024 at 10:23am, the basement level bathroom was observed without a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels, and trash receptacle. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | The shower and toilet were removed from area making it an empty room and no longer a bathroom |
10/08/2024
| Implemented |
| 6400.101 | On 10/2/2024 at 10:22am, the basement level bathroom was observed with a padlock on the exterior side of the door, creating an obstructed egress. This door is the only means of egress from the bathroom. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The padlock was removed from the door |
10/08/2024
| Implemented |
| 6400.106 | The furnace was cleaned and inspected by a professional furnace cleaning company on 8/13/2023 and again on 9/19/2024. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The furnace was cleaned and inspected by a professional furnace cleaning company on 9/19/2024 |
10/02/2024
| Implemented |
| 6400.163(a) | On 10/2/2024 at 10:42am, Advanced Eye Relief 0.3%/1.0% Optic Eye Drops, prescribed to individual #1, did not contain a label issued by a pharmacy. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Doctor¿s notes regarding the PRN are taped to the PRN medication. |
10/02/2024
| Implemented |