| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.65 | At the time of the inspection, the side entrance interior steps did not have a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface. | On 01/30/2025, non-skid surface was added to the side entrance interior steps (Attachment #1). |
01/30/2025
| Implemented |
| 2380.70(d) | At the time of the inspection, there was not a thermometer in the first aid kit. | First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors. | On 01/30/2025, a thermometer was added to the first aid kit (Attachment #2). |
01/30/2025
| Implemented |
| 2380.72(a) | At the time of the inspection, there was snow and ice covering the sidewalks on the side and back of the facility. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | On 01/30/2025, the outside walkways were free from ice and snow (Attachment #3 and Attachment #4). |
01/30/2025
| Implemented |
| 2380.83(b) | At the time of the inspection, there were not diagrams of the exits in all areas of the facility. | An evacuation diagram shall be posted in all areas of the facility. | The diagrams of exits in all areas of the facility were present and posted on the walls during the time of inspection on 01/22/2025 (Attachment #5-10). |
01/22/2025
| Implemented |
| 2380.90(a) | At the time of the inspection, there was not an exit sign placed at the kitchen exit. | Signs bearing the word "EXIT" in plain, legible letters shall be placed at exits. | On 01/30/2025, an exit sign was placed above the kitchen exit (Attachment #11). |
01/30/2025
| Implemented |