| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | (Repeat from 10/20/25 inspection) On the special purchase ledger for individual #1 there was a purchase made on 3/4/26 in the amount of $43.38 per a handwritten receipt. The purchased item was not identified and was incorrectly logged onto the ledger as $42.38. Due to the discrepancy, the ledger is not considered up to date or correct currently.
Individual #1 purchased a civil war jacket for $128.95 and reimbursed the provider for this on 6/25/26. This item was not added to the individual's property record. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | The Program Specialist will review and reconcile Individual #1's special purchase ledger with all available receipts and financial documentation. The purchase dated 3/4/26 will be corrected to reflect the actual expenditure of $43.38, and the purchased item will be identified and documented to the extent supported by available records.
The Program Specialist will also update Individual #1's property record to include the Civil War jacket purchased for 128.95 and reimbursed to the provider. DPOC JC |
11/20/2026
| Accepted |
| 6400.64(a) | At the time of the inspection on 9/29/26, there were brownish-yellowish stains on the floor behind the base of both toilets in the home. | Clean and sanitary conditions shall be maintained in the home. | Both bathrooms have been cleaned and sanitized.
Program Managers will be retrained on checking daily cleaning lists from staff to ensure the house is clean and sanitary at all times.
Program Managers will complete monthly site checklist to ensure cleanliness is being maintained. |
11/13/2026
| Accepted |
| 6400.141(c)(14) | Individual #1's annual physical, dated 12/18/25, indicates this section of the physical is "Not applicable". This section of the physical is applicable. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Program Manager will return physical form to physician to have information corrected/updated.
Program Managers will be retrained on completing physical forms to help ensure the physician's have all areas completed correctly. |
11/13/2026
| Accepted |
| 6400.142(d) | Individual #1 had a gum check on 3/12/25 and not again since. | The dental examination shall include teeth cleaning or checking gums and dentures. | Individual #1 will be scheduled for a dental examination that includes an assessment of the gums and dentures. Documentation of the completed examination will be maintained in the individual's record. DPOC JC |
11/20/2026
| Accepted |
| 6400.145(1) | Individual #1's emergency medical plan does not identify the hospital of preference. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | Emergency Medical Plan will be updated with Individual #1's preferred hospital.
Program Managers will be retrained to ensure preferred hospital is added to all individuals' emergency medical plans. |
11/13/2026
| Accepted |
| 6400.163(h) | (repeat from 10/20/25 inspection) At the time of the inspection on 9/29/26, the PRN medication Senna-S 8.6-50mg was expired since 9/24/26. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Program Managers will be retrained on disposing of expired medications and ensuring replacement medications are obtained. |
11/13/2026
| Accepted |
| 6400.166(a)(11) | (repeat from 12/12/25 inspection) At the time of the inspection on 9/29/26, the medications Atorvastatin 10mg and Fluticasone Propionate 50mcg did not have a diagnosis on the September 2026 MAR. This was corrected onsite by staff. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Program Managers will be trained that all medications must have a diagnosis associated with them on the eMAR. |
11/13/2026
| Accepted |
| 6400.166(b) | Individual #1 was administered the PRN medication APAP 500mg on 3/28/26 at 1:45pm however this was not recorded on the eMAR until 2:36pm. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Program Managers will be retrained on documenting medication administration at the time of actual administration. |
11/13/2026
| Accepted |
| 6400.167(a)(1) | (repeat from 12/12/25, 3/4/26, 8/5/26 inspections) Individual #1 is prescribed the medication Loxapine 5mg as "take by mouth 1 capsule twice daily at 4pm and 8pm." This medication was not administered on the following dates/times: 11/23/25 4pm, 11/26/25 4pm, and 11/26/25 8pm.
Individual #1 is prescribed the medication Diclofenac Sodium 1% to be administered as "apply topically to bilateral knees once daily for pain." This medication was not administered on the following date/time: 11/28/25 8am. | Medication errors include the following: Failure to administer a medication. | Medication omissions were logged in EIM.
Program Manager will be retrained to check the eMAR daily to ensure medication is being given as directed and documentation is being completed. |
11/13/2026
| Accepted |
| 6400.213(1)(i) | (Repeat from 3/4/26 inspection) Individual #1's date of admission is incorrect in the record. The individual's demographic/face sheet has the admission date of 7/31/19 however the date of admission was 4/29/14.
Individual #1's religion is not identified. This was left blank on the demographic/face sheet. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.
Each individual's record must include the following information: Personal information, including: (iv) Religion | The individual demographic sheet will be updated with correct date of admission and reglion.
Program Manager will be retrained on completing all areas of the individual demographic form with accurate information, including religion and social security number. |
10/26/2026
| Accepted |