| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The home completed a self-assessment on 9/25/25 where a 6400.141c3 was identified as a violation but contained no written summary of corrections or preventions, as the above violation was noted with the following: "TDAP Past due; last vaccination 2/12/15. [Agency #1] nurse will administer TDAP once it is delivered on next month's cycle". in addition, there was documentation in the self-assessment indicating that Individual #1's Tdap vaccination was administered late on 2/28/25. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Immediate Plan of action:
The corrections and preventions for violation 6400.141c(3)were added to the Self Assessment by the CEO on 10/8/25 |
10/15/2025
| Implemented |
| 6400.68(b) | On 10/7/25 at 11:47 AM, the hot water temperature at the bathtub located on the home's first floor measured 133.1 degrees Fahrenheit. [Repeated Violation-10/8/24, et al] | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Plan to fix the immediate problem: Individual 1 is able to temper water appropriately and understands how to regulate hot and cold water. This information is in the individual's isp and current residential assessment. |
10/16/2025
| Implemented |
| 6400.141(c)(3) | Individual #1 had a Tdap vaccination administered on 2/12/15, and then again on 2/28/25. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Plan to fix the immediate problem: Individual 1 received the Tdap vaccination on 2/28/25 |
10/16/2025
| Implemented |