| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | During the inspection conducted 10/19/2022, the water temperature measured 125.0°F at 10:45am at the bathtub in the second-floor full bathroom, across from Individual #1's bedroom. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The water temp was reduced to not exceed 120 degrees on 10/20/22. |
10/28/2022
| Implemented |
| 6400.72(a) | During the inspection conducted 10/19/2022, the following windows did not have screens: the middle window in the dining room, Individual #1's bedroom window behind his bed, Individual #2's bedroom window to the left of the room, and the second-floor spare bedroom window to the right of the room. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Window screens were ordered on 10/25/22 and installed on 10/27/22. |
10/27/2022
| Implemented |
| 6400.110(a) | During the inspection conducted 10/19/2022, there was no smoke detector located in the attic. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | An automatic smoke detector was ordered from Becdel Controls on 10/27/22. They will install it once it arrives. To ensure safety while we are waiting on delivery and installation of the automatic detector, we installed battery operated smoke detector. |
10/27/2022
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed 3/15/2022 did not include medical information pertinent to diagnosis and treatment in case of an emergency. It was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Physical form was sent to the doctor and the medical information section of the form was completed on 10/19/22. |
10/26/2022
| Implemented |
| 6400.142(e) | Individual #1 had a dental examination and cleaning conducted 3/29/2022 with a requested follow up in 6 months. There is currently no scheduled appointment for the follow up. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | A dental appointment is scheduled for this individual on 11-7-22 at 10:45am. |
10/27/2022
| Implemented |
| 6400.166(a)(13) | During the inspection conducted 10/19/2022, Individual #1's October 2022 medication administration record did not include the name and initials of the person who administered the 8AM doses on 10/19/2022 for the following medications: Benztropine Mesyl 0.5mg tablet, Citalopram Hbr 40mg tablet, Omeprazole Dr 20mg capsule, Risperidone 2mg tablet, Thera-M tablet, Panoxyl 4% acne cream, and Polyethlene Glycol 3350. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Staff had administered the morning doses of medication however fail to document the administration. He was called in to complete the documentation process and was retrained on Medication Administration and the importance of documentation. |
10/27/2022
| Implemented |