| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.71 | At the time of inspection, an operable cordless telephone handset was located on a TV stand in Individual #1's bedroom. There were no emergency telephone numbers posted on or by this telephone. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| CareSense Living conducted a refresher training(s) with direct care staff (2.5.26 - admin staff and DSP) and a separate training on 2.19.26 for admin staff only to discuss their role/responsibilities as it pertains to the importance of ensuring that Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Please note: One DSP staff was unable to participate in the plan of correction refresher training because they were suspended at the time and subsequently never returned to work and is no longer a CareSense Living employee. On 1/21/26 - an updated phone list was added to the wall in proximity of the operable phone located in the individual's room. |
03/05/2026
| Implemented |
| 6400.141(a) | Individual #1's two most recent Physical Examinations took place on 05/22/2024 and 06/26/2025---more than one year apart. This individual did not receive a Physical Examination annually as required. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | CareSense Living conducted a refresher training(s) with direct care staff (2.5.26 - admin staff and DSP) and a separate training on 2.19.26 for admin staff only to discuss their role/responsibilities as it pertains to the importance of ensuring that an individual shall have a physical examination within 12 months prior to admission and annually thereafter. The next annual physical for this year is scheduled within the appropriate timeframe for 6.29.26 . Please note: one DSP staff was unable to participate in the plan of correction refresher training because they were suspended at the time and subsequently never returned to work and is no longer a CareSense Living employee. |
03/06/2026
| Implemented |
| 6400.141(c)(4) | Per Individual #1's Individual Record, this individual's two most recent hearing examinations were conducted by the individual's Primary Care Physician (PCP) along with the Physical Examinations occurring on 05/22/2024 and 06/26/2025. As these two appointments were more than one year apart, the hearing examinations were also more than one year apart; therefore, this individual did not receive a hearing examination annually as required.
(REPEAT VIOLATION: 02/19/2025) | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | CareSense Living conducted a refresher training(s) with direct care staff (2.5.26 - admin and DSP) and a separate training on 2.19.26 for admin staff only to discuss their role/responsibilities as it pertains to the importance of ensuring that an individual The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The next annual physical is scheduled within the appropriate timeframe for 6.29.26 during which the hearing will be reviewed. Please note: one DSP staff was unable to participate in the plan of correction refresher training because they were suspended at the time and subsequently never returned to work and is no longer a CareSense Living employee. |
03/06/2026
| Implemented |
| 6400.141(c)(7) | Per Individual #1's Individual Record, the individual's two most recent gynecological examinations occurred on 03/25/2024 and 07/14/2025---more than one year apart. This individual has not received gynecological examinations annually as required. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | CareSense Living conducted a refresher training(s) with direct care staff (2.5.26 - admin and DSP) and a separate training on 2.19.26 for admin staff only to discuss their role/responsibilities as it pertains to the importance of ensuring that an individual physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. During the training - what are the parts of a consult paperwork were reviewed and the importance of bringing all paperwork. The next physical is scheduled for 6/28/26, which a calendar appointment reminder is already made. The next GYN is scheduled for 7/20/2026. Please note: one DSP staff was unable to participate in the plan of correction refresher training because they were suspended at the time and subsequently never returned to work and is no longer a CareSense Living employee. |
03/06/2026
| Implemented |
| 6400.141(c)(11) | Individual #1's most recent Individual Physical Examination, dated 06/26/2025, did not contain the individual's medication regimen. The physical form did not list the individual's medications and there was no information about the medications attached to the form. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | CareSense Living conducted a refresher training(s) with direct care staff (2.5.26 - admin and DSP) and a separate training on 2.19.26 for admin staff only to discuss their role/responsibilities as it pertains to the importance of ensuring that an individual The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals as well as reviewing what are the components of the physical paperwork and what needs to be filled out in entirety. Please note: one DSP staff was unable to participate in the plan of correction refresher training because they were suspended at the time and subsequently never returned to work and is no longer a CareSense Living employee. |
03/06/2026
| Implemented |
| 6400.165(c) | Per Individual #1's January 2026 Medication Administration Record (MAR), the individual was prescribed Melatonin 3 MG Tablets. The instructions on the pharmacy label for this medication did not match the instructions of the MAR entry. The pharmacy label read, "Take one tablet by mouth at bedtime for sleep," while the MAR instructions read, "Take one tablet by mouth at bedtime as needed for sleep if awake after three hours." According to the administration record, this medication was administered to Individual #1 Pro Re Nata (PRN) per the incorrect or outdated instructions located on the MAR rather than daily per the correct instructions on the medication's pharmacy label. This prescription medication was not administered to the individual as prescribed. | A prescription medication shall be administered as prescribed. | CareSense Living conducted a refresher training(s) with direct care staff (2.5.26 - admin and DSP) and a separate training on 2.19.26 for admin staff only to discuss their role/responsibilities as it pertains to the importance of ensuring that an individual prescription medication shall be administered as prescribed. The prescribing doctor was contacted on 1/21/26 and they confirmed that the melatonin was to be administered as a PRN and to utilize the current script as prescribed. A current script from the doctor was received from the pharmacy and the MAR entry was updated to reflect the correct prescribed directions as PRN and both the MAR and blister pack reflect the same prescribed directions to be Administered as prescribed. |
03/06/2026
| Implemented |
| 6400.165(e) | Per Individual #1's January 2026 Medication Administration Record (MAR), the individual was prescribed Melatonin 3 MG Tablets. The instructions on the pharmacy label for this medication did not match the instructions of the MAR entry. The pharmacy label read, "Take one tablet by mouth at bedtime for sleep," while the MAR instructions read, "Take one tablet by mouth at bedtime as needed for sleep if awake after three hours." The MAR entry was not updated as soon as a written notice of the change in prescription was received. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | CareSense Living conducted a refresher training(s) with direct care staff (2.5.26 - admin and DSP) and a separate training on 2.19.26 for admin staff only to discuss their role/responsibilities as it pertains to the importance of ensuring that an individual's Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. The prescribing doctor was contacted on 1/21/26 and they confirmed that the melatonin was to be administered as a PRN and to utilize the current script as prescribed. A current script from the doctor was received from the pharmacy and the MAR entry was updated to reflect the correct prescribed directions as PRN and both the MAR and blister pack reflect the same prescribed directions to be Administered as prescribed. On the MAR entry was updated to reflect the correct prescribed directions and both the MAR and blister pack reflect the same prescribed directions. |
03/06/2026
| Implemented |
| 6400.165(g) | Per Individual #1's Individual Record, the individual was prescribed Sertaline 25mg tablets ("Take one tablet by mouth once every day at 8am for depression"). As this medication was prescribed to treat the symptoms of a psychiatric illness, it must be reviewed by a licensed physician at least once every three months. There was no record that such medication reviews occurred.
(REPEAT VIOLATION: 02/19/2025) | 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. | CareSense Living conducted a refresher training(s) with direct care staff (2.5.26 - admin and DSP) and a separate training on 2.19.26 for admin staff only to discuss their role/responsibilities as it pertains to the importance of ensuring that If an individual 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. An appointment was made for the individual's med review with her doctor for 2/20/2026, which they attended and the form was completed with the appropriate form. |
03/06/2026
| Implemented |