| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Several tiles lining the entrance to the shower in the bathroom attached to Individual #1's bedroom were missing, exposing the grout underneath. Another tile in this area was loose to the touch, wiggling visibly. This surface was in not in good repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | Tiles replaced and secured to floor. Completed work order attached. |
03/04/2024
| Implemented |
| 6400.67(b) | There were two hazards identified in the home during the inspection:
1. After entering the home, this Licensing Representative noted that the air was noticeably humid to an extent that it was unusual. Upon inspection of the home, there were small, black, splotchy marks consistent in appearance with mold visibly coating portions of several surfaces, including: The windowpanes, windowsills, and window frames of the windows in Individual #1's bedroom; The windowpane and window frame of the window in the bathroom attached to Individual #1's bedroom; The windowpanes, windowsills, and window frames of the windows in Individual #3's bedroom.
The presence of mold in a home constitutes an environmental health hazard to individuals residing there.
2. Upon examination, the home's dryer lint trap contained a ping-pong-ball-sized accumulation of lint. This accumulation posed a fire hazard in the home. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Servpro was called to come and do an evaluation and identified the issue. Treatment has started inside the home to remediate the mold. Additional recommendations to be completed following further professional evaluation. Air quality test performed, see attached invoice.
Lint trap was cleaned. Staff were reminded to check and clean the lint trap before and after each use. |
03/01/2024
| Implemented |
| 6400.72(a) | One window in Individual #2's bedroom lacked a window screen at the time of inspection. There were no screens within the home that could be fit into this window should it be opened; therefore, this window was incapable of being securely screened. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Screen put in place. |
03/05/2024
| Implemented |
| 6400.82(e) | The shower in the bathroom attached to Individual #1's bedroom was not equipped with a nonslip surface. There was no bath mat available in the home to be placed in the shower if it were to be used. | Bathtubs and showers shall have a nonslip surface or mat. | Bath mat installed in the bathroom. |
03/06/2024
| Implemented |
| 6400.82(f) | The bathroom attached to Individual #1's bedroom lacked a trash receptacle at the time of inspection. | 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. | Trash receptacle was installed. |
03/06/2024
| Implemented |
| 6400.141(c)(9) | Individual #1's two most recent prostate examinations occurred on 08/24/2023 and 06/15/2022---more than 365 days apart. Individual #1 did not receive a prostate examination as a part of the individual physical examination annually as is required. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Prostate exam for 2024 is scheduled for 6/2024. |
03/04/2024
| Implemented |
| 6400.142(g) | Individual #1's two most recent Dental Hygiene Plans are dated 01/24/2024 and 05/26/2022---more than 365 days apart. Individual #1's Dental Hygiene Plan was not rewritten at least annually as required. | A dental hygiene plan shall be rewritten at least annually. | Supervisor retrained on regulation regarding regulation for Dental Hygiene Plans. |
03/07/2024
| Implemented |
| 6400.166(b) | Individual #1 is prescribed the following medications at 8:00am: Clonazepam 0.5mg, Sertraline 100mg, Levothyroxine 88mcg, Ferrous Sulfate 324mg, Pantoprazole 40mg, Daily Vitamin, and Metformin ER 500mg. Individual #1 is prescribed the following medications at 8:00pm: Clonazepam 0.5mg, Olanzapine 10mg, Atorvastatin 40mg, Tamsulosin 0.4mg, and Metformin ER 500mg. Individual #1's prescription medications come packaged together in plastic AM and PM dose packets such that all medications given at the 8:00am administration time are packaged together, and all medications given at the 8:00pm administration time are packaged together.
Individual #1's February 2024 Medication Administration Record (MAR) contains a separate page for each administration time and each page lists the medications to be administered at that time. However, instead of having a separate way for staff to record the administration of each individual medication given at the administration time, the MAR provides only one line for staff to sign their initials in order to signify that all medications at the administration time were given. The MAR must contain a way to record the administration of each medication individually. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | MAR updated to include spaces for initials for all medications given at the 8am dose. |
02/29/2024
| Implemented |
| 6400.213(1)(i) | Individual #2's Individual Record contains a demographic sheet titled "Intake Form." This form has a field to denote the presence or absence of identifying marks on the individual; however, this form field was left blank. It could not be determined whether the individual lacks identifying marks or whether the field was left blank unintentionally. Information relating to identifying marks was not located elsewhere in the Individual Record. | Each individual's record must include the following information: The race, height, weight, color of hair, color of eyes and identifying marks. | Intake form updated to include identifying marks. |
02/29/2024
| Implemented |