Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.111(c) | No fire extinguisher present in kitchen. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | On March 17, 2021 Woods Maintenance Department installed a 20a10bc fire extinguisher in the Allgair kitchen. The fire drill report was updated on March 17, 2021 by Residential Director, to include the newly installed fire extinguisher. Attachment #1 |
05/31/2021
| Implemented |
6400.141(c)(4) | Hearing screening for individual#1 not addressed on medical form dated 11/11/2020. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Per APE 11/11/2020: "Last audiology exam:(6/13/18); Hearing is adequate for daily living(Yes)" |
02/15/2021
| Implemented |
6400.141(c)(7) | A gynecological examination including a breast examination and a Pap test for Individual#1 was not included on the medical form dated 11/11/2020. | 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. | Woods recently hired a Nurse Practitioner who will perform all gynecological examination. |
04/30/2021
| Implemented |
6400.163(a) | Medication Ear Drops Dro 6.5%, original label not visible and the expiration date is illegible | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Ear drops replaced with new bottle. |
05/31/2021
| Implemented |