| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Inside The windowsill in the living room has a build-up of dirt and the outside of the sill has mold and mildew. The basement floor has a puddle of water by the front window area, the kitchen cabinets are sticky with food. | Clean and sanitary conditions shall be maintained in the home. | The windowsill as well as it's outside, and the kitchen cabinets were cleaned 05/22/25. Please see attachments #1 and #2. The puddle of water in the basement floor was mopped on 05/22/25. Please see attachment #3. In addition, a new front door awning was installed as well as some bricks repointed on 06/03/25 to stop water from going into the basement. Please see attachments #4. |
06/05/2025
| Implemented |
| 6400.64(e) | One of the two outdoor trash cans did not have a lid. | Trash receptacles over 18 inches high shall have lids. | The outdoor trash receptacle without a lid was replaced on 05/24/25. Please see attachment #6. |
05/24/2025
| Implemented |
| 6400.64(f) | One of the two outdoor trash cans was overloaded with trash. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The overloaded trash can was emptied on 05/24/25. Please see attachment #6. Staff has also been addressed about ensuring equal distribution of trash amongst the outside closed receptacles. |
05/24/2025
| Implemented |
| 6400.67(b) | The lint trap in the dryer has excessive lint | Floors, walls, ceilings and other surfaces shall be free of hazards. | The excessive lint in the dryer was removed on 05/22/25. Please see attachment #7. |
05/22/2025
| Implemented |
| 6400.72(b) | The window in the dining room does not stay open, it slams shut. | Screens, windows and doors shall be in good repair. | The window was fixed on 06/02/25. Please see attachment #8. |
06/02/2025
| Implemented |
| 6400.76(a) | The dining room table is wobbly and need to be repaired or replaced. | Furniture and equipment shall be nonhazardous, clean and sturdy. | A new dining room table set was purchased and delivered on 06/05/25. Please see attachment #9. |
06/05/2025
| Implemented |
| 6400.76(b) | The chairs for the dining room table appear to be for children and are not appropriate for the age and size of the individuals residing in the home. | Furniture and equipment shall be appropriate for the age and size of the individuals. | A new dining room table set was purchased and delivered on 06/05/25. Please see attachment #9. |
06/05/2025
| Implemented |
| 6400.76(c) | The cushions on the leather couch have cracks and splits that need to be replaced or covered. | Furniture shall be comfortable and home-like. | A new couch cover was installed on 06/02/25. Please see attachment #10. |
06/02/2025
| Implemented |
| 6400.80(b) | The front lawn was overgrown and full of weeds.
The exterior bricks of the home underneath the second and first floor windows were dirty and grimy. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The front lawn was cut and maintained on 05/28/25. The entire front of the home was power washed on 05/29/25. Please see attachments # 11 &12. |
05/29/2025
| Implemented |
| 6400.216(a) | The individuals' records with the ISP and Medication logs were sitting on a shelf in the dining room unlocked. | An individual's records shall be kept locked when unattended.
| The individuals records including the ISP and Medication Logs were locked up on 05/24/25. Please see attachment #13 |
05/24/2025
| Implemented |
| 6400.24 | The staff was unable to open Individual #2 bedroom and did not have a key to access the area in the event of an emergency. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | A copy of the key to individual #2's bedroom was made on 05/23/25 and kept in the home, and access to that area exists effective the same date. Please see attachment #14. |
05/23/2025
| Implemented |
| 6400.32(d) | Individual # 1 was wearing both a pull up and a diaper, staff stated that it was the normal thing to do. The diaper was removed at time of inspection. There is a 1-hour toileting schedule available in the home.
There was no documentation available to validate the reason for double diapering the individual | An individual shall be treated with dignity and respect. | A meeting with the staff and this issue was addressed effectively during this meeting. Please see attachment #15. The same communication has gone out to all Residential staff. |
05/27/2025
| Implemented |
| 6400.32(h) | There are cameras in the dining room and at the top of the 2nd floor stairs. There was no documentation to validate the reason for cameras at time of inspection. | An individual has the right to privacy of person and possessions. | The reason for the cameras is to monitor only the common places for the health and safety of the individuals. Both individuals residing at the site have signed consents for the video monitoring of the site. Please see attachment # 16. Due to the inspection being unannounced, this documentation was not readily available for review at the time of inspection. |
05/24/2025
| Implemented |
| 6400.163(h) | There were two vials of Lorazepam 2mg with one tablet each for individual 1 where the label stated to be taken prior to mammogram appointment; however, Lorazepam 2 mg was not on the MAR.
Denta 5000 Plus Paste was in with individual 1's medications but was not 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. | The prescribed Lorazepam 2mg and Denta 5000 plus has been added into the MAR. Please see attachment # 17. |
05/23/2025
| Implemented |
| 6400.166(a)(11) | The medications on individual 1's MAR did not have the diagnosis or purpose for each of the medications. | 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. | The diagnosis/ purpose for each medication was listed on the lower part of Individual¿s MAR. However, the Individual #1¿s MAR has been updated to include the diagnosis /purpose for each medication along the same line that the medication is listed. Please see attachment #17. In addition, communication was made with the agency¿s pharmacy for the diagnosis to be prepopulated in this before delivery with the medications each month. |
06/01/2025
| Implemented |