| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(4) | Individual 5's bedroom does not contain a chest of drawers. The absence of this furniture is not addressed in their ISP or BSP. | In bedrooms, each individual shall have the following: A chest of drawers. | The individual cannot have a dresser in his room due to his behavior and property destruction. He destroys his clothes also. this is now documented in the ISP |
07/03/2025
| Implemented |
| 6400.81(k)(6) | Individual 4's bedroom did not contain a mirror. | In bedrooms, each individual shall have the following: A mirror. | JEVS acknowledges this citation and oversight on our part. This individual was moved here due to an emergency stemming from an incident where he lived previously. The room was empty and had no mirror because previous residents moved out and we were not planning to backfill any vacancies. |
07/01/2025
| Implemented |
| 6400.141(a) | Individual 5 - A review of Annual Physical was done, Physicals were dated 9/22/2023 and 10/18/2024, the current physical was late and exceeded the 15-day grace period. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | JEVS will initiate the scheduling for physical exams 90 in advance to ensure timely compliance. Some offices do not schedule that far in advance. JEVS is evaluating this issue and if needed, will transfer individuals to different doctor's offices with individual and/or team agreement |
07/01/2025
| Implemented |
| 6400.144 | Individual 4's PRN medications Cepacol Sore Throat Lozenges and Calcium Antacid 500mg Chewable tablets were not present during the inspection. | 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.
| Director called pharmacy the same day as the inspection, and the lozenges and antacid were delivered 6/5/25 |
07/05/2025
| Implemented |
| 6400.32(r) | Individual 5 - Individual rights do not indicate that an individual has the right to lock the individual's bedroom door. | An individual has the right to lock the individual's bedroom door. | JEVS does not agree that this individual should have a lock on their bedroom door for safety reasons. JEVS is holding team meetings about this issue. JEVS and the SC shall document the outcome in the ISP and assessment as this person cannot safely evacuate in an emergency if her bedroom door is locked
When it is determined that an individual can safely have a locked bedroom door, we will attempt to utilize keypad locks which do not require a key. This is a safer option. All team meetings and lock installations when requested will be completed by December 31, 2025. |
07/01/2025
| Implemented |
| 6400.165(g) | There were no psychiatric medication reviews done by the prescriber of the psychiatric medications from 07/2024 -- 01/18/2025 for individual 4. | 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. | The director contacted the psychiatrist who completed the 90 day review paperwork |
06/10/2025
| Implemented |
| 6400.167(a)(1) | Individual 4's MAR indicates that Metformin HCL 500mg tablet was administered 05/02/2025 at 5:00pm, however the medication for that time and date was still in the blister pack. | Medication errors include the following: Failure to administer a medication. | JEVS entered a medication error report in EIM. The EIM number is 9675147. The staff was counseled on this issue. The house supervisor was counseled as well as she should have caught this error |
08/14/2025
| Implemented |