| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | At the time of the 03/04/26 inspection, the towel rack in the bathroom to the right of the hallway was broken. | Floors, walls, ceilings and other surfaces shall be in good repair. | Towel rack has been repaired and an additional rack added to the bathroom. |
03/30/2026
| Accepted |
| 6400.67(b) | At the time of the 03/04/26 inspection, there was a ping pong ball amount of lint in the dryer; the dryer was not in use and there were no clothes in the appliance at the time of the inspection. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Staff will be retrained in fire safety and the dangers of dryer lint. |
03/27/2026
| Accepted |
| 6400.81(k)(6) | At the time of the 03/04/26 inspection, there were no mirrors in either the first bedroom to the left or the last bedroom to the right of the hallway. | In bedrooms, each individual shall have the following: A mirror. | Mirrors were installed in the bedrooms. |
03/18/2026
| Accepted |
| 6400.82(f) | At the time of the 03/04/26 inspection, there were no towels available in the bathroom to the left of the hallway. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Towels were stocked in the bathroom. |
04/20/2026
| Accepted |
| 6400.144 | Individual #1 is prescribed anti-diarrheal tabs as a PRN. At the time of the inspection, they were not available in the home. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Anti-diarrheal tabs for Individual #1 are present it the home.
Quality Assurance will retrain Program Manager on checking meds in and ensuring med administrators know where they are located. |
04/20/2026
| Accepted |
| 6400.46(b) | At the time of the inspection, Staff #1 did not know how to set off the smoke detectors in the home. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Operations Director and Assistant Operations Director will retrain fire safety and how to set off smoke detectors. |
04/20/2026
| Accepted |
| 6400.166(b) | Individual #1 received Metformin, Oyst Cal, and Systane Eye Drops on 03/02/26 at 5pm. As of 03/04/26, the medication administrations were not logged on the MAR. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Program Manager will be retrained to check the Medication Administration Record daily to ensure medication is being given as directed and documentation is being completed. |
04/01/2026
| Accepted |