| 6400.81(i) | At the time of the inspection there were no coverings on the window in the bedroom of Individual #2. Window coverings are required to ensure privacy. The Individual Support Plan for Individual #2 last updated on 6/16/25 noted that "doesn't tolerate blinds or curtains". Additional measures above just blinds and curtains must be taken to ensure privacy. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | One way privacy film/window tint was ordered and will be arriving between Sept. 2 and Sept 6th. This will be installed on the bedroom window, so individual can see out but no one will be able to see in. |
09/12/2025
| Implemented |
| 6400.112(c) | The fire drill completed on 8/13/24, did not indicate that the smoke detectors were operative at the time of the drill. The sections noted for "Smoke detector used" and "Was it operative" were blank and nothing circled. | 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. | The Fire Drill form was updated to have smoke detectors listed as interconnected, BOLD responses and the word operative was changed to working. Information was added to the form advising managers to email facilities if not working and to enter a repair order in the system. |
08/20/2025
| Implemented |