| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | The doorknob handle on side-door on the home's attached garage came completely off when this licensing representative pulled on it to open the door from the outside. The doorknob handle could not be reattached by staff on site. This door was not in good repair.
One of the home's basement windows had a hairline crack extending in a crescent pattern across the window's upper-right corner. This window was not in good repair. | Screens, windows and doors shall be in good repair. | Upon inspection, it was identified that the doorknob handle came off, and a basement window had a crack. To correct this issue, maintenance installed a new door knob on the day of inspection. Maintenance ordered a new window and covered the crack in the current window for safety until the new window could be installed. |
03/25/2026
| Implemented |
| 6400.141(c)(7) | Per Individual #1's Individual Record, the individual attended OBGYN appointments on 01/02/2025 and 06/24/2025. The 01/02/2025 appointment form stated, "Refused all exams···", and the 06/24/2025 appointment form noted "Not tolerant of pelvic exam···". There was no further documentation of OBGYN appointments in the Individual Record. This individual did not have a gynecological examination conducted annually as required. | 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. | Upon discovery of the exam refusal, a record review was conducted by program leadership. Information was provided to licensing entity that included the required post appointment follow - up with the individual after the 1/2/2026 refusal. During the time of the appointment refusals, the individual had a med desensitization plan in place which was discontinued on 11/25/2025. The individual has been compliant with recent medical appointments. The individual has a 6/20/2026 appointment scheduled. |
03/25/2026
| Implemented |
| 6400.143(a) | Per Individual #1's Individual Record, the individual attended OBGYN appointments on 01/02/2025 and 06/24/2025. The 01/02/2025 appointment form stated, "Refused all exams···" and the 06/24/2025 appointment form noted "Not tolerant of pelvic exam···". There was no further documentation of OBGYN appointments in the Individual Record. The Individual Record did not contain documentation showing continued attempts to train the individual about the need for health care following each of the individual's refusals of treatment | 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. | Per Individual #1's Individual Record, the individual attended OBGYN appointments on 01/02/2025 and 06/24/2025. The 01/02/2025 appointment form stated, "Refused all exams···" and the 06/24/2025 appointment form noted "Not tolerant of pelvic exam··". There was no further documentation of OBGYN appointments in the Individual Record. The Individual Record did not contain documentation showing continued attempts to train the individual about the need for health care following each of the individual's refusals of treatment |
03/25/2026
| Implemented |
| 6400.166(a)(11) | Per Individual #1's January 2026 Medication Administration Record (MAR), the individual was prescribed Diazepam Tab 5mg with instructions to, "Take 1 tablet by mouth three times daily at 7am, 5pm, and 9pm." The MAR entry for this medication lacked a diagnosis or purpose for the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Non-compliant item on MAR was rectified on the day of discovery |
03/25/2026
| Implemented |