| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The hot water in Individual #1's bedroom was measured at 140.9°F.
The hot water in Individual #5's bedroom was measured at 135°F.
The temperature was adjusted during the inspection and then measured at 105°F in both areas. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Water temperature was corrected |
10/08/2025
| Implemented |
| 6400.110(f) | Individual #1's ISP states that due to hearing impairment, they require fire safety equipment in the form of a strobe light and bed shaker, and would require support to safely evacuate as they would not be aware of sounding alarms. The individual's bedroom was equipped with a strobe light, but not a bed shaker. The provider submitted proof of purchase of a bed shaker within 24 hours post inspection.
Additionally, the strobe light was in just the individual's bedroom and was not installed in common areas of the home. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | A bed shaker was obtained and installed for Individual #1 on 9/17/25. |
09/22/2025
| Implemented |
| 6400.111(c) | The kitchen was not equipped with a fire extinguisher. A fire extinguisher was placed in the kitchen during the inspection | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | The fire extinguisher was located in the kitchen under the sink; however, it was not readily visible. The extinguisher was moved to the front to ensure ease of access. |
09/18/2025
| Implemented |
| 6400.112(f) | Monthly Fire Drills at the home were completed using only the front door egress. The home is equipped with a second egress located from the back deck leading to ground level. | Alternate exit routes shall be used during fire drills. | A drill using the back exit was completed 9/18/25 |
10/08/2025
| Implemented |
| 6400.181(a) | Individual #1 was admitted on 07/10/2025 and, to date, an initial 60-day assessment has not been completed. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Individual #1's assessment was finalized and completed on 9/17/25 |
09/17/2025
| Implemented |
| 6400.216(a) | The behavioral support plan for Individual #5 was left unattended and unlocked. | An individual's records shall be kept locked when unattended.
| Individual #5 BSP was secured and locked 9/16/25 |
10/08/2025
| Implemented |
| 6400.166(a)(2) | The MAR for Individual #1 did not include the prescribing physician. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Prescribing Physician was added to the MAR 9/17/25 |
10/01/2025
| Implemented |