| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The toothbrush for Individual #2 was found in the top left drawer of the bathroom vanity in the bathroom of the shared bedroom. The toothbrush was laying upon the wooden surface of the drawer. This surface had multiple blobs and smears of what appeared to be dried toothpaste. It was noted by staff that the toothbrush was placed in the drawer while the toothbrush holder was being washed. Toothbrushes shall be maintained in sanitary conditions and surfaces shall be clean and sanitary. | Clean and sanitary conditions shall be maintained in the home. | Toothbrush holder was purchased and placed at the home on 1/14/26. |
01/14/2026
| Implemented |
| 6400.67(a) | The floor of the hallway bathroom was discolored around the back of the toilet, extending to the front of the toilet and around the base of the tub. When stepped upon the floor between the toilet and bathtub made a cracking sound. The underside of the floor was then checked in the basement. Signs of water damage were shown by blackened areas of wood along the waste pipes for the bathroom in the ceiling of the basement. | Floors, walls, ceilings and other surfaces shall be in good repair. | Provider maintenance work order was placed on 1/5/26 to have maintenance review the floor for safety to ensure a safe environment |
01/05/2026
| Implemented |
| 6400.141(c)(7) | A letter from the physician dated 1/22/24 was located in the file for Individual #1. The letter stated that "due to patient being uncooperative with previous pap and pelvic exams [they} won't be getting this done. There was no record of GYN exams being completed. The documentation presented does not meet the minimum requirements for not completing the eamxs as outlined in the Regulatory Compliance Guide (RCG) as gynecological examinations and mammograms are required unless:
1. There is documentation from a licensed physician that the examinations are not required based on the individual's physical condition or based on standards of care; exempting a person from preventative screening based solely on the person's intellectual disability or autism is not permitted." | 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. | A new letter from the doctor was obtained on 1/1/26 ensuring it met regulatory requirements |
01/01/2026
| Implemented |
| 6400.143(a) | Individual #1 is also documented to refuse GYN examinations. There was no documentation to illustrate that the refusals and continued attempts to train the individual about the need for health care was completed as required. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | A new letter from the doctor was obtained on 1/1/26 ensuring it met regulatory requirements |
01/01/2026
| Implemented |
| 6400.144 | At the 9/18/25 dental visit it was recommended that Individual #1 use an electric toothbrush. At the time of inspection there was no electric toothbrush for Individual #1.
On 12/21/25 Individual #1 was seen at the ED for a fall. Discharge instructions noted that they should "Follow up with PCP in 3 days." There was no documentation that this occurred.
On 12/13/25 Individual #1 was seen at the ED for a fall. Discharge instructions indicated that they should "Follow up PCP for further care." There was no documentation that this occurred as directed. | 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.
| Electric toothbrush was purchased on 12/30/25.
On 1/14/25 provider is contacting the PCP to secure documentation around the fall and their verbal decline to see them on the days of the falls. |
01/14/2026
| Implemented |