| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At the time of the inspection, the front section of the main floor bathroom shower floor had a brown/red and black like substance on it resembling mold/mildew. (Repeat Violation 11/1/23) | Clean and sanitary conditions shall be maintained in the home. | Maintenance team was contacted on 11/06/2024.Team removed old caulking and re-caulked perimeter of the shower/bathtub.¿ Work order #22827¿entered 2:02PM 11/6/24 completed by 11/08/2024 |
11/06/2024
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Fluticasone SPR 5, use 2 sprays in each nostril daily. The pharmacy label on the medication had a Dispense (DISP) date of 4/10/2024, and the bottle of the medication was approximately ¾ of the way full at the time of the inspection. The medication is not being administered as prescribed.
Individual #1's record has a standing orders for Over-the Counter (OTC) medications dated 1/9/24 from the physician for
Tylenol 325mg tabs, give 2 tablets (650 mg) as needed every 4 hours. Call doctor if fever lasts 3 days or longer, At the time of inspection in with Individual #1's medication was a bottle of Tylenol Extra Strength 500 mg caplets. The medication is not being administered as prescribed as the dosage is not the same as prescribed. (Repeat Violation 11/1/23) | A prescription medication shall be administered as prescribed. | Site Supervisor of Leos Den disposed of incorrect Tylenol, and ordered new Tylenol with the correct strength. Leo's den Supervisor also returned to PDC any extra Nose Spray bottles that she had at the site, to only reorder as needed. |
11/06/2024
| Implemented |
| 6400.166(b) | Individual #1's Tylenol was not on the November 2024 Medication Administration Record (MAR) did not record their Over-the Counter (OTC) medication Tylenol. As per the Regulatory Compliance Guide (RCG) Over the counter (OTC) medications must be record on the medication record. The MAR did not include the name of the medication, strength of the medication, dosage form, dose of the medication, route of administration, frequency of administration, diagnosis, or purpose for the medication. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Tylenol was reordered at the correct strength and written into the MAR by Site Supervisor Vanessa Lara on 11/06/2024. |
11/06/2024
| Implemented |