| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 receives residential habilitation services 365 days per year. Individual #1 has several diagnoses and currently takes medications for the following: hypertension, hyperlipidemia, blood calcium levels, clot prevention, itching, hyperkalemia, vitamin deficiency, enlarged prostate, mood disorder/anxiety, and diabetes type II mellitus. According to the ISP, last updated 8/14/25, the individual needs staff to test their blood sugar levels and administer the proper amount of insulin as they are not self-medicating. The individual also needs some assistance to complete ADLs thoroughly. They are prescribed the medication HUMALOG KWIK INJ 100ML to be given on a sliding scale as follows -- inject sub q 3 times a day before meals as per sliding scale: 151-200=2u; 201-250 4u; 251-300=6u; 301-350 = 8u; 351-400 = 10u; 401-450 = 12u; >451=14u and call MD; For blood sugar <70 give juice and call MD *Max dose 42u/day (This medication was discontinued on 2/11/26 and changed to Novolog inj flexpen, the sliding scale remains the same).
The individual also had a PRN for glucose tab 4 GM to be given when blood sugar is below 70. This was changed to glucose gel 40% on 1/16/26 with directions to give every day for one day for hyperglycemia. The sliding scale protocol has not been updated to reflect this change in PRN medication or with additional information of when to use it.
There is a Humalog sliding scale protocol in place. The protocol and the MAR's do not match each other regarding what action to take when the individual's blood sugar is below 70. The MAR states to give juice and call MD while the protocol indicates to follow the Rule of 15 which is 1) Give 15 grams of fast acting carbohydrate (juice, glucose tabs, regular soda, 2) Wait 15 minutes then recheck blood sugar, 3) If still below 70, repeat steps 1 and 2 until bs is above 70 mg/dl. The individual's blood sugar was below 70, a total of 42 times between 5/1/25-2/11/26. There is no evidence that the protocol was followed as there is no documentation of juice/glucose tabs or gel/soda being given to the individual and no documentation of a blood sugar recheck being done. Refer to violation 144 of this LIS for exact dates the blood sugar was below 70.
In addition to the above, the insulin was improperly dosed 11 times between 5/1/25 -- 2/11/26. Refer to violation 167a3 of this LIS for exact dates the insulin was improperly dosed.
Also, there were 7 times (between 5/1/25-2/11/26) the individual should have received insulin based off their blood sugar reading and they did not. Refer to violation 167a1 of this LIS for exact dates no insulin was administered as required.
Failure to properly follow the sliding scale insulin protocol, failure to administer medications, and failure to administer the correct dose of medications created conditions conducive to serious harm for Individual #1. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | The Medical Specialist immediately reviewed the individual's diabetes management orders, sliding scale protocol, and PRN medication instructions. The protocol has been updated to ensure consistency between the physician orders, the MAR system, and the hypoglycemia response procedures. The PRN medication change from glucose tablets to glucose gel has also been incorporated into the protocol so staff have clear instructions regarding when and how the medication should be administered.
All staff responsible for medication administration have been retrained on the proper procedures for blood glucose monitoring, sliding scale insulin administration, hypoglycemia response (including the Rule of 15), documentation requirements, and physician notification expectations. Staff were also retrained on the importance of immediately documenting and reporting medication errors in accordance with agency policy |
02/16/2026
| Implemented |
| 6400.22(d)(1) | (repeat violation from the 4/28/25 inspection) For Individual #1, there was a receipt on 10/6/25 for a purchase amount of $23.31 from Ross department store, however, the amount that was entered on their Personal Finance Transaction Report was $26.69; this created an incorrect balance on the individual's financial ledger. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | The financial record was immediately reviewed and corrected to reflect the accurate transaction amount of $23.31. The individual's financial ledger was reconciled to ensure the balance accurately reflects all transactions. C-NTA reimbursed Individual #1 the $23.31.
To prevent this issue from recurring, the Program Specialist reviewed financial documentation procedures with staff responsible for handling individual funds. Staff were reminded that all purchases must be recorded exactly as reflected on the receipt and verified for accuracy when completing the Personal Finance Record. |
03/02/2026
| Implemented |
| 6400.67(b) | At the time of the inspection on 2/10/26, there was a ping pong size amount of lint in the dryer. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The lint was immediately removed from the dryer, and the area was cleaned to ensure the appliance was free of debris and safe for continued use.
Staff were reminded of the expectation to check and remove lint from the dryer after each use to prevent buildup and maintain a safe environment. The House Manager reviewed housekeeping and safety expectations with staff to reinforce routine maintenance responsibilities. |
02/10/2026
| Implemented |
| 6400.141(c)(13) | (repeat from 4/28/25 renewal inspection and 8/11/25 unannounced inspection) There is a discrepancy across documents in individual #1's record regarding allergies. The ISP indicates the individual has no allergies, the annual physical dated 11/17/25 lists allergies as amoxicillin, metformin, terbinafine, and metronidazole, and on the provider's emergency information form the allergies are listed as metformin, amoxicillin, and terbinafine. | The physical examination shall include: Allergies or contraindicated medications. | The Medical Specialist reviewed the individual's medical records and consulted with the primary care provider to confirm the individual's current allergies and contraindicated medications. All applicable documents, including the ISP, emergency information form, and medical record, were updated to reflect the correct allergy information so that all records are consistent and accurate.
The Residential Director Staff retrained Residential Management on the importance of ensuring that allergy information is consistently documented across all records to support safe medication administration and medical care. |
02/23/2026
| Implemented |
| 6400.144 | (repeat from 4/28/25 renewal inspection) Individual #1 has a protocol in place for their blood sugar. The protocol states if blood sugar is below 70 to follow the rule of 15 and 1) give 15 grams of fast-acting carbohydrate (juice, glucose tabs, regular soda), 2) wait 15 minutes, then recheck blood sugar, 3) if still below 70, repeat steps 1 and 2 until blood sugar is above 70mg/dl. There is no evidence that this protocol is being followed properly. The individual had blood sugar below 70 on the following dates:
· 5/3/25 60 8am
· 5/13/25 66 8am
· 5/15/25 62 8am and 61 5pm
· 5/17/25 53 8am
· 5/18/25 56 8am
· 5/20/25 68 8am
· 7/1/25 50 7:30a
· 7/10/25 68 7:30a
· 7/17/25 61 7:30a
· 7/18/25 61 7:30a
· 7/19/25 67 7:30a
· 7/31/25 69 7:30a
· 8/8/25 66 7:30
· 8/22/25 63 4:30p
· 8/30/25 66 7:30p
· 10/13/25 69 7:30a
· 10/23/25 60 7:30a
· 10/25/25 60 7:30a
· 10/26/25 4:30p 58
· 10/30/25 65 7:30a
· 10/31/25 63 7:30a
· 11/1/25 59 7:30a
· 11/13/25 60 7:30a
· 11/16/25 66 7:30a
· 11/18/25 67 7:30a
· 11/20/25 64 7:30a
· 11/26/25 63 7:30a
· 11/27/25 69 7:30a
· 12/16/25 64 7:30a
· 12/21/25 69 7:30a
· 12/25/25 69 7:30a
· 12/26/25 68 7:30a
· 12/28/25 66 7:30a
· 12/31/25 64 7:30a
· 1/13/26 67 11:30a
· 1/16/26 69 7:30a
· 1/17/26 65 7:30a
· 1/18/26 65 7:30a
· 1/21/26 63 7:30a
· 1/22/26 65 11:30a
· 2/9/26 58 4:30p
· 2/10/26 64 7:30a
· 2/11/26 59 7:30a
There is no documentation that the individual was given juice or soda. The MAR's confirm no glucose tabs were ever given. There is no evidence that the blood sugar was retested as the protocol states.
Also, the directions given on the MAR and on the sliding scale protocol do not match each other. The MAR says if blood sugar is <70 give juice and call MD while the protocol says give juice/glucose/soda and retest in 15 minutes and to repeat this until blood sugar is above 70.
Also for Individual #1, Milk of magnesium is prescribed to be taken as needed for constipation and at the time of the inspection on 2/10/26, this medication was not available in the house. | 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.
| To correct this issue, the Medical Specialist immediately reviewed the physician's orders, sliding scale protocol, and MAR instructions. The blood sugar protocol and MAR directions were updated to ensure consistency with the physician's orders and the Rule of 15 response for hypoglycemia. The PRN medication Milk of Magnesia was obtained and placed in the home on 2/11/2026.
All staff responsible for medication administration were retrained on proper blood glucose monitoring, the hypoglycemia response protocol (Rule of 15), documentation requirements, and the importance of ensuring all prescribed medications are available in the home. Staff were also reminded that any medication changes must be immediately communicated to nursing so that MAR instructions and protocols can be updated accordingly. |
02/16/2026
| Implemented |
| 6400.163(h) | Individual #1 was prescribed Triple antibiotic cream which was discontinued on 5/19/25
and at the time of the inspection on 2/10/26, this medication was still in the home and was not discarded. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | On 2/10/2026 Triple Antibiotic Cream was immediately removed from the medication supply and returned to the pharmacy for destruction.
Staff responsible for medication administration were retrained on the requirement that prescription medications that are discontinued or expired must be destroyed in a safe manner according to Federal and State statutes and regulations. Staff were also reminded to review medication orders and discontinue medications promptly when changes occur. |
02/16/2026
| Implemented |
| 6400.165(c) | (repeat from 4/28/25 renewal inspection) Individual #1 was prescribed Triple antibiotic ointment as apply topically to affected area 4 times per day for 10 days. The first dose of this medication was given 5/9/25 at 12p and continued to be given until 5/19 at 8pm. The medication was given for 10.75 days instead of 10 days. The last dose should have been given on 5/19 at 8am for a total of 10 days.
Individual #1 was prescribed SMZ/TMP DS Tab 800-160 as take 1 tablet by mouth twice per day for 7 days for infection. The individual began this medication on 10/1 at 8pm and took the last dose 10/8 at 8pm. The individual took the medication for 7.5 days instead of 7 days as ordered. The last dose should have been given on 10/8 at 8am for a total of 7 days.
Individual #1 was prescribed Erythromycin ointment 5mg/gm as apply 0.5in ribbon topically to left eye 4 times a day for 7 days for infection. The individual started the medication on 1/2/26 at 4pm and stopped on 1/9/26 at 8pm. The individual received the medication for 7.5 days instead of the prescribed 7 days. The last dose of the medication should have been on 1/9/26 at 12pm. | A prescription medication shall be administered as prescribed. | The Medical Specialist reviewed the individual's medication orders and MAR documentation to ensure all current medication orders accurately reflect the prescribed duration. Staff responsible for medication administration were retrained by the Registered Nurse on the importance of administering medications exactly as prescribed, including monitoring start and stop dates for time-limited medications such as antibiotics and topical treatments.
Staff were also retrained on verifying medication orders and ensuring medications are discontinued in the MAR at the appropriate time. Any questions regarding medication duration or stop dates must be immediately reported to the Medical Specialist for clarification. |
02/16/2026
| Implemented |
| 6400.165(g) | (repeat from 4/28/25 renewal inspection and 8/11/25 unannounced inspection) Individual #1 is prescribed Sertraline 100mg for depression. There is no evidence of psychotropic medication reviews being done between the reviewed months of May 2025-February 11th 2026. The individual's psychotropic medication is prescribed by their PCP and while the individual did see their PCP during the review period, there is no evidence of psychotropic medication reviews being completed during these appointments. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The Medical Specialist contacted the individual's prescribing physician to ensure a psychotropic medication review was completed and properly documented. Documentation confirming the reason for prescribing Sertraline, the continued need for the medication, and the current dosage has been obtained and placed in the individual's medical record.
The Residential Director re-trained staff responsible for scheduling on the regulatory requirement that psychotropic medications must be reviewed by a licensed physician at least every three months and that documentation of these reviews must include the reason for the medication, the need for continued use, and the appropriate dosage. |
02/16/2026
| Implemented |
| 6400.167(a)(1) | There were several instances when individual #1 was not administered insulin according to the sliding scale protocol as they should have been. Examples are:
· 6/3 blood sugar was 165 @ 4:30pm, no insulin given when 2 units should have been administered
· 6/10 blood sugar was 160 @11:30am, no insulin given when 2 units should have been administered
· 6/18 blood sugar was 160 @ 11:30am, no insulin given when 2 units should have been administered
· 7/8 blood sugar was 161 @ 11:30a, no insulin given when 2 units should have been administered
· 9/26 blood sugar was 209 @ 7:30a, no insulin given when 4 units should have been administered
· 11/5 blood sugar was 158 @ 4:30p, no insulin given when 2 units should have been administered
· 1/28 blood sugar was 152 @ 7:30a, no insulin given when 2 units should have been administered | Medication errors include the following: Failure to administer a medication. | To correct this issue, the Medical Specialist reviewed the individual's insulin orders, sliding scale protocol, and MAR documentation to ensure the physician's orders are clearly reflected and understood by staff responsible for medication administration. The Medical Specialist provided retraining to all staff responsible for medication administration on proper blood glucose monitoring, interpretation of the sliding scale, and accurate administration and documentation of insulin as prescribed.
Staff were re-trained on the importance of verifying blood sugar readings against the sliding scale prior to each administration and immediately reporting any medication errors to management in accordance with agency policy |
02/16/2026
| Implemented |
| 6400.167(a)(3) | (repeat from renewal inspection 4/28/25) Per individual #1's Humalog Sliding scale protocol they were administered the wrong dose of Humalog on the following dates/times:
· 5/24/25 blood sugar was 184 @ 11:30am and was administered 4 units but should have been administered 2 units according to the protocol
· 6/3/25 blood sugar was 165 @ 4:30p but no insulin was administered when 2 units should have been administered per the protocol
· 6/10/25 blood sugar was 241 @ 4:30pm but no insulin was administered when 4 u should have been administered per the protocol
· 6/18/25 blood sugar was 160 @ 11:30am but no insulin was administered when 2 units should have been administered per the protocol
· 6/23/25 blood sugar was 254 @ 7:30am and was administered 2 units but should have been administered 6 units according to the protocol
· 7/8/25 blood sugar was 161 @ 11:30am but no insulin was administered when 2 units should have been administered per the protocol
· 9/26/25 blood sugar was 209 @ 7:30am but no insulin was administered when 4 units should have been administered per the protocol
· 10/9/25 blood sugar was 413 @ 4:30pm and 8 units were administered when 12 units should have been administered per the protocol
· 10/15/25 blood sugar was 206 @ 4:30pm and 2 units were administered when 4 units should have been administered per the protocol
· 10/23/25 blood sugar was 146 @ 11:30am and 2 units were administered when 0 units should have been administered per the protocol
· 11/5/25 blood sugar was 158 @ 4:30pm but no insulin was administered when 2 units should have been administered per the protocol | Medication errors include the following: Administration of the wrong dose of medication. | To correct this issue, the Medical Specialist reviewed the individual's insulin orders, sliding scale protocol, and MAR documentation to ensure the physician's orders are clearly reflected and understood by staff responsible for medication administration. The Medical Specialist provided retraining to all staff responsible for medication administration on proper blood glucose monitoring, interpretation of the sliding scale, and accurate administration and documentation of insulin as prescribed.
Staff were re-trained on the importance of verifying blood sugar readings against the sliding scale prior to each administration and immediately reporting any medication errors to management in accordance with agency policy |
02/16/2026
| Implemented |