| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The water temperature in the bathroom read at 133.3 degrees, exceeding the 120-degree limit | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Maintenance department repaired hot water tank, water is under 120 degrees. |
07/08/2025
| Implemented |
| 6400.144 | Individual 1 - Ear wax Remover 6.5% drops. Not available in the home at time of inspection
Propranolol 10MG tab, take 1-2 tablets by mouth twice a day as needed for tremors. No available in the home at time of inspection. | 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.
| Ear Wax remover and Propranolol was D/C and reflected on the MAR on 7/9/2025. |
07/09/2025
| Implemented |
| 6400.163(h) | Individual 1 - Risperdone 0.5 MG Tab, take 1 tablet by mouth daily @9pm as needed for anxiety or agitation.
Medication available in the home, but not listed on the MAR | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | PRN medication was added to MAR to reflect the current instructions by the Medical Coordinator. |
07/09/2025
| Implemented |
| 6400.166(a)(11) | Individual 1 - Citrucel 500 MG tab, 4p/8p No diagnosis on MAR
Ear wax Remover 6.5% drops. 3 drops in both ears at Bedtime 8pm, twice weekly, Mon/Thu No diagnosis on the MAR | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Medical Coordinator added the diagnosis to the MAR for the Citrucel ad Ear Wax. Individual 1was discharged from Olalus Group, LLC dated 7/10/2025. Will attach the discharge letter for individual 1. |
07/09/2025
| Implemented |