| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | The ramped side door on the left side of the home was obstructed in opening by the bottom of the door and the threshold. The door was able to be opened but was difficult and required a few strong pulls. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The door was fixed by St. Joseph's Center Maintenance department and now opens freely without issue. A video of the properly operating door will be emailed to Kristen Salus. |
07/09/2026
| Implemented |
| 6400.141(c)(4) | Individual #1 had annual vision exams documented as completed on 3/20/25 and 4/23/26. The exams did not occur within the defined annual time frame and additional grace period as required. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #1 had their annual eye exam on 3/20/2025 at North East Eye. Individual #1 had his annual physical, inclusive of an eye exam on 7/8/2025. On 8/21/2025 Individual #1 was seen again at North East Eye for an exam due to injury where both eyes had full eye exams. Individual #1 was seen at North East Eye on 4/23/26 for another eye exam. Individual #1 had a total of 4 eye exams in a period of 13 months. |
07/09/2026
| Implemented |
| 6400.144 | Individual #1 was treated at Urgent Care on 11/18/25 for "right foot pain/lesion." They were diagnosed as having a "callous with mild cellulitis." Prescribed treatment included a "podiatry evaluation" and a "barrier for shoe such as mole skin to avoid friction trauma." Individual was treated by a podiatrist on 3/6/26 for a "right foot callous/blister." Diagnosis was a right Cavovarus foot, pressure callous and SIP Cellulitis." Prescribed treatment included "affix moleskin pad to all gear." Individual #1 was treated at wound care on 6/8/26 to address "callous of foot" with prescribed treatment of "offload feet when at rest/prevent foot sitting against footrest/let foot float when not transporting, use moleskin in shoes, use foam offloading boots or allevyn pads, wider shoes."
Creams and Allevyn pads prescribed were in use at the time of inspection.
Staff #2 was asked about mole skin being used in the Individual's shoes. Staff #2 did not appear to be aware of what the moleskin was, it was not demonstrated that the moleskin was in the home or in use as prescribed.
Receipt dated 6/8/26 indicates that Women's shoes were purchased for $39.99 in response to the wound care visit and recommendation for wider shoes. It was not clear at time of inspection which shoes had been purchased with Staff #2 presenting a pair of what appeared to be black water shoes and commenting that the purchase had been made hastily and staff not being aware that they were women's shoes. The purchased shoes were held up against a pair of slippers that were larger than the ones stated to have been purchased.
The purchase of moleskin was not recorded on receipts produced.
It could not be determined that the directives to use mole skin in all shoes and purchase wider shoes had been followed.
Health services, such as medical, that are planned or prescribed for the individual shall be arranged for or provided. | 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.
| The mole skin was positioned on a pair of shoes that were previously purchased. When the new shoes were purchased for the individual, the staff forgot to transfer the moleskin over and discarded the old shoes with the mole skin. Mole skin was purchased and applied to the new croc type style shoes that were recommended by the doctor at the visit. |
07/09/2026
| Implemented |
| 6400.151(a) | Staff #1 is documented as performing the duties of a Program Specialist as well as Director of Community Residential Services. The last documented physical for Staff #1 was 7/17/20. A staff person, including temporary, who comes into direct contact with the individuals for more than 5 days in a 6-month period must complete a physical every two years as required. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff #1 completed a physical on 7/10/2026. |
07/10/2026
| Implemented |