| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(d) | The second floor bathroom locked closet contained Clorox cleaning wipes, Clorox cleaner, macaroni and cheese, teddy grahams cookies and Gatorade bottles. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | Provider removed food from bathroom closet. Bathroom closet remained locked with cleaning supplies. Food and cleaning supplies were separated. |
11/14/2022
| Implemented |
| 6400.64(a) | The kitchen was not cleaned, specifically the food cabinets, trash can lid, oven, and freezer had food and/or grease stains and residue on their surfaces. | Clean and sanitary conditions shall be maintained in the home. | Provider completed a deep cleaning of kitchen areas. Deep cleaning specifically included grease removal, cleaning of trash can, and cleaning of the freezer. |
12/02/2022
| Implemented |
| 6400.64(f) | One of the outside trash cans were overflowing and some of the trash had blown onto the ground. The top to this trash can had also blown onto the ground as it could not be securely affixed to the can due to it overflowing. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Provider cleaned trashcans and placed lid securely on top. |
11/20/2022
| Implemented |
| 6400.67(a) | The second floor bathroom vanity cabinet knob was missing, but the screw that held the knob in place was still on the cabinet with the sharp pointy end of the screw facing outward. | Floors, walls, ceilings and other surfaces shall be in good repair. | Provider contacted maintenance to replace knob on vanity in bathroom. |
11/19/2022
| Implemented |
| 6400.67(b) | The first floor bathroom shower rod was rusted and loose on one end with the wall plate screws exposed and not securely affixed to the wall. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Provider replaced shower rod and tightened loose screws on wall plate. |
11/18/2022
| Implemented |
| 6400.76(a) | Individual 7's recliner chair in their bedroom, was broken and heavily soiled. The recliner part does not fold down, and the head rest area was heavily and visibly soiled.
Individual 7 also had a television stand that was turned on its side in their bedroom. This stand was being used to store clothing, however as it was standing upright on the wrong side it created a tipping hazard, in addition to the back and the middle shelves were damaged and not securely affixed to this piece of furniture. individual 8's bedroom closet doorknob was loose on both sides of the door and not securely affixed to the closet door. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Provider removed/disposed of old recliner and replaced it with a new reclining chair. |
11/25/2022
| Implemented |
| 6400.82(f) | The first floor bathroom did not contain a wastebasket. | 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. | Provider replaced wastebasket for bathroom. Provider placed wastebasket into bathroom |
11/15/2022
| Implemented |
| 6400.24 | Individual 8's controlled medication, klonopin was not double locked. This medication was stored inside of a medication box with a padlock on it. The medication box was stored inside of an unlocked file cabinet drawer in the dining room. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Provider replaced old file cabinet with new file cabinet in order to safely double lock medication box to comply with the Federal and State statutes and regulations and local ordinances. |
12/05/2022
| Implemented |
| 6400.52(c)(2) | Staff 1 did not have documentation of the core trainings: abuse and neglect, incident management, individual rights and person centered practices. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Staff will complete training in the areas of abuse and neglect, incident management, individual rights and person-centered practices |
12/31/2022
| Implemented |
| 6400.163(h) | Individual 9's prescribed medication debrox 6.5% eardrops expired 10/19/22 but was still being stored in the medication box. During the inspection, this medication was disposed of, and a replacement was ordered from the pharmacy. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Individual 9's expired prescribed medication was removed and a new order for ear drops was placed on 11/14/2022 and they were delivered 11/15/2022. |
12/07/2022
| Implemented |