| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The self-assessments for all of the homes do not include a written summary of corrections made for violations identified. | 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.
| Associate director immediately created a written summary of corrections form to accompany all self inspections. |
01/23/2026
| Accepted |
| 6400.62(c) | A spray bottle with fluid was found under the kitchen sink alongside cleaning supplies. | Poisonous materials shall be stored in their original, labeled containers. | Operations manager immediately disposed of fluids and bottle |
01/23/2026
| Accepted |
| 6400.67(a) | A ceiling tile was missing in the basement ceiling by a corner closest to the stairwell. | Floors, walls, ceilings and other surfaces shall be in good repair. | Associate director immediately notified maintenance to replace ceiling tile. Maintenance immediately replaced tile on 1/7/26. |
01/23/2026
| Accepted |
| 6400.72(b) | Individual #2's sliding closet door was off its track during the physical site walk through. | Screens, windows and doors shall be in good repair. | Associate director immediately notified maintenance of needed repair. Maintenance immediately replaced track and ensured smooth function |
01/23/2026
| Accepted |
| 6400.77(c) | The first aid kit did not contain a manual during the physical site walk through. | A first aid manual shall be kept with the first aid kit. | Manual was immediately placed into first aid kit on 1/7/2026 |
01/07/2026
| Accepted |
| 6400.112(c) | The fire drill conducted on 10/24/2025 does not include problems encountered. The space/check boxes were left blank. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | associate director immediately updated form to include highlighted section of problems encountered. |
01/23/2026
| Accepted |
| 6400.34(a) | Individual #1 was not informed of rights relating to regulation 33a and 33b as they are not listed on the Individual Rights signed in 2025. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | compliance officer immediately updated rights forms to include 6400 33a and 33b |
01/23/2026
| Accepted |
| 6400.166(a)(9) | Individual #1's MAR for January has a medication label of Clobetasol .05% cream apply to area twice a day, but the MAR reads two times per day as needed for eczema. The label and MAR do not match regarding frequency of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Operations manager contacted prescribing provider immediately and updated the label on the medication to match the newly prescribed medication |
01/23/2026
| Accepted |