| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | no screen in Ind. #1 and Ind. #2-bedroom windows. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | New window screens installed, attachment. |
| Implemented |
| 6400.76(a) | blinds in bathroom are damaged and need to be replaced. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Bathroom window blind replaced, attachment. |
02/02/2024
| Implemented |
| 6400.111(c) | There was no fire extinguisher in the kitchen. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | Fire extinguisher installed in the kitchen, attachment. |
05/08/2024
| Implemented |
| 6400.112(f) | only front door used for all fire drills. There is another exit in the home. | Alternate exit routes shall be used during fire drills. | Right Hall exits were used for the March & April practice drills, attachment. |
04/15/2024
| Implemented |
| 6400.151(c)(2) | Staff #2 -last tb test completed 8/23/21-T.SPOT TB Test | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Upon receipt of name selection, a member of the PQM (Performance Quality Managment) will contact the appropriate department to supply requested documentation. |
05/30/2024
| Implemented |
| 6400.32(d) | Camera in the kitchen-staff states its disabled. | An individual shall be treated with dignity and respect. | The camera was operable when the home was licensed under 3800 regulations. When the home transferred to a 6400 license, the camera was turned off, however the wiring and the camera have remained in place. There are no plans to use the camera while the home operates under 6400 license, however if it ever converts back to a 3800 license (and there is no plan to do this), the camera and its hardware, wiring, computer access would already be in place. |
05/30/2024
| Implemented |
| 6400.32(i) | There were two locked personal refrigerators for individuals in 13a/b, staff stated to prevent staff from stealing but the staff have keys to the refrigerators to access the contents. | An individual has the right of access to and security of the individual's possessions. | Wrong information was given at the time of inspection. Refrigerators are locked to prevent other residents from taking food that does not belong to them. That individual was discharged from Woods on 4/5/24. |
04/05/2024
| Implemented |
| 6400.165(b) | Guanfacine tab 3mg 2 tablets by mouth once a day at 8am. Not in home at inspection. Blister pack was empty. Electronic record indicates it was ordered on date of inspection. For Ind. #1 | A prescription order shall be kept current. | Medication delivered by pharmacy. |
01/24/2024
| Implemented |