| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The bottom kitchen cabinets were dirty and grimy. Inside of the kitchen oven had baked in grease and grime. Individual Two and Individual One's bedroom window frames were dirty. Individual Two's bedroom floor appeared very worn and large black discoloration in front of the radiator and closet door. | Clean and sanitary conditions shall be maintained in the home. | Direct care staff cleaned the kitchen cabinets, the oven, the bedroom window frames for Individuals One and Two. Program leadership submitted a maintenance request to Merakey's facilities Department the week of the audit regarding Individual Two's bedroom floor and radiator. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.67(a) | The bathroom closet was full of unlocked cleaning supplies. | Floors, walls, ceilings and other surfaces shall be in good repair. | Staff at the home immediately removed the cleaning supplies to a locked cabinet upon discovery during the audit. Program leadership submitted a maintenance request to Merakey's facilities Department the week of the audit to obtain a lock for the cabinet. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.101 | The stairway into the attic was obstructed by boxes. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Staff at the home removed the boxes from obstructing the attic. |
04/30/2026
| Implemented |
| 6400.106 | Annual furnace inspection for the home was not provided. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The Director of Programs is actively collaborating with Merakey's real estate team and safety team to have the furnaces at each cited home reinspected as soon as possible. Copies of each inspection will be maintained in the Fire Safety Binder by the Director of Programs. |
04/30/2026
| Implemented |
| 6400.216(a) | The BSP for Individual One was in a binder that was unlocked in the living room. This was locked up during time of inspection. | An individual's records shall be kept locked when unattended.
| As noted in the deficiency, the BSP binders were locked at the time of inspection. |
04/30/2026
| Implemented |