| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | On 11/6/25 at 10:35 AM, there were clumps of insulation that fell from the ceiling that were strewn about the floor and on bottled drinks on a cabinet in the garage of the home. At 10:40 AM, there was a black substance covering a large area of the sink and along the walls that appeared to be mold in the basement of the home. | Clean and sanitary conditions shall be maintained in the home. | On 11/14/2025 the clumps of insulation were removed from the floor and on bottled drinks on a cabinet in the garage of the home. The sink that had the black substance covering a large area of the sink and along the walls that appeared to be mold was disinfected and cleaned. |
11/14/2025
| Implemented |
| 6400.64(f) | On 11/6/25 at 10:15 AM, a large trash dumpster with boxes and bags of trash overflowing at the top, preventing the dumpster from being securely closed with the lid, was in the front yard of the home. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | On 11/6/2025 the overflowing trash that was in the large dumpster outside of the home was removed by UCIP maintenance. This was removed so that the dumpster could be securely closed with the lid. |
11/06/2025
| Implemented |
| 6400.67(b) | On 11/6/25 at 10:36 AM, two large water hoses were lying across the floor in the garage of the home, posing a tripping hazard. At 10:46vAM, the cover was missing from the light switch on the wall in Individual #2's bedroom. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On 11/6/2025 the two large water hoses lying acroos the floor in the garage of the home were cleaned up, coiled and hung on the wall. On 11/14/2025 the missing light switch cover was installed on the wall of individual #2's bedroom. |
11/06/2025
| Implemented |
| 6400.74 | On 11/6/25 at 10:33 AM, there was no nonskid surface on the twelve, wooden interior stairs leading to the basement of the home. | Interior stairs and outside steps shall have a nonskid surface.
| On 11/14/2025 a nonskid surface was added to the twelve wooden interior stairs leading to the basement of the home. |
11/14/2025
| Implemented |
| 6400.163(d) | Individual #1 is prescribed Albuterol Sulfate Inhaler with instructions to, "Inhale two puffs by mouth every four hours as needed for wheezing." On 11/6/25 at 10:45 AM, an Albuterol Sulfate Inhaler was unlocked and accessible on the nightstand next to the bed in Individual #1 bedroom located in the basement of the home. Individual #1 does not self-administer medications. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | On 11/6/2025 individual #1's prescribed Albuterol Sulfate Inhaler with instructions to, "Inhale two puffs by mouth every four hours as needed for wheezing." that was unlocked and accessible on the nightstand next to the bed in individual #1's bedroom in the basement of the home was taken upstairs to where the medications are located and locked up. |
11/06/2025
| Implemented |
| 6400.207(5)(II) | On 11/5/25 at 1:29 PM, the bed was equipped with bilateral full bedrails in Individual #2's bedroom. Individual #2 did not have a current order with a medical diagnosis from their physician for the bedrails. Individual #2's Service Plan, last updated 5/8/25, and their most recent assessment, did not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon request or indication by the individual for periodic relief to allow freedom of movement. [Repeated Violation-12/3/24, et al] | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Balance or support to achieve functional body position, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | UCIP has decided to adopt a non bedrail philosophy. UCIP maintenance has removed bed rails from all UCIP homes. All doctors of individuals that utilized bed rails have been contacted to provide alternate options to bed rails. |
11/25/2025
| Implemented |