| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The home's air fryer was observed to have left over grease and crumbs from previous use. | Clean and sanitary conditions shall be maintained in the home. | Direct care staff cleaned the air fryer the week of the audit. |
02/25/2026
| Implemented |
| 6400.65 | The residence' main bathroom did not have a window or mechanical ventilation. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Program leadership submitted a maintenance request to Merakey's facilities Department the week of the audit to obtain a ventilation system for the bathroom. The Facilities team expects all outstanding maintenance requests to be completed by 5/29/26. |
05/29/2026
| Implemented |
| 6400.72(a) | Window screens were observed missing from the living room area, the primary bedroom (2), and the second bedroom (2) | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Program leadership submitted maintenance requests to Merakey's facilities Department the week of the audit to fix the window throughout the home to ensure they have screens. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.82(e) | The primary bathroom shower stall did not have a nonslip surface or mat. | Bathtubs and showers shall have a nonslip surface or mat. | Program leadership submitted maintenance requests to Merakey's facilities Department the week of the audit to add a nonslip surface to the shower stall in the primary bathroom. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.32(r) | Individual's door locks throughout the residence existed with mechanisms using interior twist locks but not the recommended card access systems, keypads, biometric locking devices, or any other device not requiring a key to open the door. | An individual has the right to lock the individual's bedroom door. | Program leadership submitted a maintenance request to Merakey's facilities Department the week of the audit to change the lock on the door to an acceptable regulatory locking mechanism. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |