| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | On 8/15/2024 at 1:18pm, the windowsills and window frames throughout the basement and basement level garage were observed with dust, debris, dead bugs, cobwebs, and what appeared to be spider eggs. On 8/15/2024 at 1:19pm, the washtub in the basement of the home was observed with dirt and debris to include a dirty rag, unidentifiable pieces of fabric, and pieces of broken plastic in the sink basin. On 8/15/2024 at 1:27pm, dust and dead bugs to include a moth were observed on the windowsills in Individual #1's bedroom and the vacant bedroom. On 8/15/2024 at 1:28pm, the floors throughout the main level of the home were observed with dust and debris to include hair and, what appeared to be, chipped white paint. On 8/15/2024 at 1:34pm, two small pieces of, what appeared to be, white pills and a small amount of white pill dust were observed in the bottom of the locked controlled medication box. [Repeat violation: 3/5/2024 et al and 7/17/2024] | Clean and sanitary conditions shall be maintained in the home. | The debris was removed from the windows, the medication storage container, and utility sink. |
09/04/2024
| Implemented |
| 6400.64(d) | On 8/15/2024 at 1:25pm, a blue disposable glove was observed on the floor behind the toilet in the main level bathroom. | Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. | The glove located on the floor right below a box of gloves was immediately discarded in the presence of the state representative. |
09/13/2024
| Implemented |
| 6400.67(a) | On 8/15/2024 at 1:13pm, the ceiling in the kitchen adjacent to the mechanical vent was observed with chipped and peeling paint. | Floors, walls, ceilings and other surfaces shall be in good repair. | The kitchen ceiling was painted. |
09/13/2024
| Implemented |
| 6400.67(b) | On 8/15/2024 at 1:25pm, a small puddle of water measuring approximately six inches by three inches was observed on the bathroom floor between the toilet and the vanity cupboard. [Repeat violation: 3/5/2024 et al and 7/17/2024] | Floors, walls, ceilings and other surfaces shall be free of hazards. | The floor was dried. |
09/23/2024
| Implemented |
| 6400.76(a) | On 8/15/2024 at 2:00pm, the seat on the toilet in the main level restroom was lose and wobbly. [Repeat violation: 7/17/2024] | Furniture and equipment shall be nonhazardous, clean and sturdy. | The male individual has an ileostomy and does sit on the toilet. The toilet seat was replaced. |
09/13/2024
| Implemented |
| 6400.80(b) | On 8/15/2024 at 1:15pm, the vegetation in the backyard was overgrown with ferns growing against the side of the home and long pieces of ivy growing near the rear patio. On 8/15/2024 at 1:18pm, the basement window well, near the back patio to the right when exiting the rear kitchen door, was observed with dirt, cobwebs, and dried leaves collected in the well. [Repeat violation: 3/5/2024 et al and 7/17/2024] | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | All debris was removed from rear and sides of the home. |
09/13/2024
| Implemented |
| 6400.144 | On 8/15/2024 at 1:55pm, a note was observed on the side of the refrigerator reminding staff to limit Individual #1's water and fluid intake. Appointment details from individual #1's follow-up appointment with their Primary Care Physician also states that Individual has a history of medication induced hyponatremia. The appointment paperwork also states that individual #1 was admitted into the ICU for hyponatremia in April 2024 and that the individual is on a fluid restriction. Individual #1's support plan, last updated 6/25/2024, also states that "[Individual #1] WAS DIAGNOSED WITH LOW SODIUM LEVELS AND WAS PLACED ON FLUID RESTRICTIONS OF 1500 ML PER DAY... [Individual #1] CURRENTLY HAS A FLUID RESTRICTION OF 1500 ML PER DAY." According to Chief Executive Officer #1, the agency is not restricting Individual #1's fluids per the doctor's recommendation and the agency is not currently tracking the individual's daily fluid intake. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The agency does not have an order for a fluid restriction. The individual has a follow-up appointment on September 26, 2024, to assess if a nephrology consult is needed. The Assessment & Plan section written by his physician states, ¿Hyponatremia, likely 2/2 antiepileptic medication. Patient has had 2 normal Na since change in AEM in 4/2024. If hyponatremia persist can consider nephrology referral." |
09/27/2024
| Implemented |
| 6400.171 | On 8/15/2024 at 1:07pm, the following food items were observed open to contamination in the refrigerator and freezer: a 30-ounce jar of Berryhill Grape Jelly, a 26-ounce bag of Cooked Perfect Frozen Meatballs, and a 22-ounce bag of frozen Arby's Seasoned Curly Fries. On 8/15/2024 at 1:08pm, A 0.695 pound package of Ekrich Beef Bologna was observed in the refrigerator with a sell by date of 8/14/2024. On 8/15/2024 at 1:09pm, The following food items were observed open to contamination in the upper pantry cupboard to the left of the stove: a 1.5-ounce can of black pepper, an 8-ounce container of Tony Chachere Seasoning blend, and a 10-ounce bag of Louisiana Seasoned Fish Fry Breading Mix. [Repeat violation: 3/5/2024 et al and 7/17/2024] | Food shall be protected from contamination while being stored, prepared, transported and served.
| The listed food items were discarded. |
09/13/2024
| Implemented |
| 6400.32(d) | On 8/15/2024 at 1:55pm, Individual #1's personal information to include fluid restrictions and history of bedwetting was displayed on the side of the refrigerator in the kitchen. Additionally, posted on the side of the refrigerator was a reminder for staff to empty Individual #1's colostomy bag after snacks. | An individual shall be treated with dignity and respect. | The family note was removed immediately. An email was sent to the individual¿s family to educate them on the violation and inform them that their note has been discarded. The noted contained techniques that the individual¿s parents used with him when he resided at home. |
09/23/2024
| Implemented |
| 6400.32(t) | On 8/15/2024 at 1:55pm, a note was observed on the side of the refrigerator stating that Individual #1 could be given ice cream as a "reward for good behavior." [Repeat violation: 3/5/2024 et al] | An individual has the right to access food at any time. | The family note was removed immediately. An email was sent to the individual¿s family to educate them on the violation and inform them that their note has been discarded. The noted contained techniques that the individual¿s parents used with him when he resided at home. |
09/23/2024
| Implemented |