| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | At 10:39AM on 11/14/2024, there was a two-inch by three-inch hole and several small holes throughout the screen in the window in the staff bedroom. | Screens, windows and doors shall be in good repair. | The screen in the staff¿s bedroom was repaired with a screen repair kit by the maintenance department on 12/03/2024. |
12/03/2024
| Implemented |
| 6400.77(b) | At 10:35AM on 11/14/2024, the home's first aid kit did not contain a thermometer | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The Nursing Coordinator will review the regulations regarding the contents of the first aid kits and train the other agency nurses on the required contents by 11/15/2024. The Nursing Coordinator will purchase the required thermometer and place it in the first aid kit by 11/15/2024. During one of the weekly nursing monitoring visits during the month, the first aid kits will be assessed for content and needed supplies to maintain regulatory compliance. This monthly monitoring by the agency nurses started on 12/2/2024. |
11/15/2024
| Implemented |
| 6400.163(d) | At 10:34AM on 11/14/2024, there were two single dose packets of Tylenol inside the first aid kit which was unlocked and accessible above the refrigerator in the kitchen of 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. | The Nursing Coordinator will review the regulations regarding the contents of the first aid kits and train the other agency nurses on the required contents by 11/15/2024. During one of the nursing monitoring visits during the month, the first aid kits will be assessed for content and needed supplies to maintain regulatory compliance. The two single dose packets of Tylenol inside the first aid kit were removed and disposed on 12/9/2024 according to the Medication Administration procedures due to not being prescribed by the Individuals¿ Doctors. The first aid kit was placed on the top of the refrigerator for easy access on 12/9/2024. |
12/09/2024
| Implemented |