| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Awesome floor cleaner present in bathroom and living room cabinets | Poisonous materials shall be kept locked or made inaccessible to individuals. | This cleaning product was immediately moved to the locked cabinet containing the other cleaning products for the site. The cleaning product was in the bathroom at the time of the visit, as a staff member was in the process of cleaning when the reviewer arrived. |
11/22/2024
| Implemented |
| 6400.64(a) | Urine was found on the floor in the bathroom.
Fecal residue was on top of the toilet.
Bathroom bathmat in bathroom 1 has black substance in bottom consist with dirt and/or mold.
Individual 1 CPAP equipment was left in a closet. Filter's that are needed for proper air flow were covered in dust. CPAP equipment was not stored or covered properly. | Clean and sanitary conditions shall be maintained in the home. | The toilet was cleaned and sanitized immediately following the unannounced visit. Staff had been in the process of cleaning this bathroom at the time of the unannounced visit. Staff clean the bathroom at a minimum of three times daily on an ongoing basis. (see State Rd Attachment pg2) |
11/22/2024
| Implemented |
| 6400.64(f) | There were no lids covering trash cans in the yard of the home | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Lids to outdoor trashcans were immediately placed on corresponding cans. (see State Rd Attachment pg3) At the time of the visit, the site was scheduled for its weekly trash collection which often results in the lids separating from the cans. Additionally, weather conditions included 20mpg wind gusts which could have also contributed to the lids becoming dislodged. |
11/22/2024
| Implemented |
| 6400.80(b) | Patio furniture including chairs, a table and chair padding left outside with black and brown spots consistent with mildew and mold. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | These items were disposed of promptly. Replacement outdoor furniture will be purchased in the spring. |
11/22/2024
| Implemented |
| 6400.82(f) | There was no hand soap in any of the bathrooms | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Hand soap was immediately replaced in all bathrooms. (see State Rd Attachment pg 4) |
11/22/2024
| Implemented |
| 6400.163(d) | Individual 2 controlled substance of diazepam 5mg was not double locked. This medication was left in the unlocked medication bin with the individual 1s other medication's inside of the medication closet.
Prescribed Medications for all three individuals that reside in the home left on counter in in living room office area. This area has no door or private area and is accessible and visible to anyone who enters the home | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Individual 2¿s controlled substance was secured in a locked box within the locked cabinet. All medication is stored securely at all times as well. Additional medication noted in the office area had been delivered by the pharmacy immediately prior to the visit. Staff had not yet had the opportunity to review the contents of the bags, to document receipt of the medications, and to store the new medications securely for each individual. This medication delivery was secured in the locked medication closet until staff had the opportunity to review and document each medication. |
11/22/2024
| Implemented |
| 6400.163(g) | There was leakage from medications that caused the bottom of the medication bin to become condensed and sticky. This condensed spillage also spilled on to other medications in the medication bin | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | Site Staff immediately cleaned the residue in the medication bin and on any affected medications. |
11/22/2024
| Implemented |
| 6400.163(h) | Latanoprost Sol 0.005% was expired 8/25/2023 for individual 1 and still in medication bin. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The medication was removed from the medication bin and returned to the pharmacy for destruction. The prescribing physician was contacted and the medication was discontinued. Individual 1 had not used this as-needed medication in some time. |
11/22/2024
| Implemented |
| 6400.165(c) | Doxycycline 100 mg was discontinued on DC 11/8/2024. Individual 1 was scheduled to take his doxycycline on 11/8, but according to the Medication Administration Record (MAR), he missed this dose.
The prescribed dosing schedule was for two doses per day, starting on 10/25, with the evening dose at 8 PM. Given this schedule, Individual 1 should have taken his morning dose by 11/8. However, the medication was discontinued on 11/8, and the MAR indicates that no medication was administered on that date. | A prescription medication shall be administered as prescribed. | This medication was prescribed for 14 days. The first dose was administered on 10/25/24 and the last dose was administered at 8pm on the 14th day, 11/7/24. There were no additional doses remaining in the blister pack. No doses of this medication were missed. |
11/08/2024
| Implemented |