Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.64(f) | The trash receptacle located in the back yard had a broken lid which did not cover the trashcan and not in good repair. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | On 11/19/2020, Trashcan with receptacles replaced in backyard, Assistant Site Manager will complete monthly inspections to assure regulations are in compliance |
11/19/2020
| Implemented |
6400.66 | The light at the front entrance was inoperable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| On 11/20/2020, Light in front of the home replaced. Maintenance department will complete monthly inspection to ensure that the light is work |
11/20/2020
| Implemented |
6400.101 | The back door egress exiting the kitchen was obstructed by large trash cans posing a hazard. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| 11/13/2020, the trash cans were removed immediately clearing the backdoor exit. Site manager will do monthly inspection during fire drills to ensure the exit remains clear. |
11/13/2020
| Implemented |
6400.144 | At inspection, medication Tylenol 325 mg. for individual#1 was listed on the MAR but the medication was not in the individual's medication box. | 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.
| COMHAR Nurse notified immediately about missing medication, The Tylenol 325mg was reordered and placed in the medication box on 11/13/2020; also retraining for the proper documentation and placement of medication has been done on 12/11/2020 and 12/14/2020 for the nurses and Assistant Site Managers. |
11/13/2020
| Implemented |