| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | The home's dining area is connected via door to the garage; the dining area is elevated with respect to the floor of the garage. The garage has two exit doors, one in the front of the home and one in the rear of the home. The front exit from the garage is flush with the driveway while the rear exit from the garage has several steps descending down to meet the elevation of the backyard. A wooden wheelchair ramp is installed in the garage in order to provide wheelchair access between the dining area and garage, allowing individuals who use wheelchairs to exit the garage via the front exit.
Walking through the door from the dining area into the garage, the wheelchair ramp extends to ground level in one direction---to the left towards the front exit from the garage. From this same perspective, the rear exit from the garage is immediately to the right of the ramp. Access to the rear exit from the garage floor level is blocked by a washing machine and dryer, which abut the righthand exterior corner of the ramp, creating a barrier to egress from the garage floor level to the rear exit.
This layout leaves only a small, square area of garage floor---sectioned off by two walls, the laundry machines, and the aforementioned righthand side of the wheelchair ramp---in front of the rear exit from the garage, which must be accessed in order to use that exit as an egress. As such, the only way to exit the garage via the rear exit would be to step over the righthand side of the wheelchair ramp to the garage floor level; however, that side of the wheelchair ramp was not designed to be used as a step or as a thoroughfare. There is a lip around the edge of the ramp in order to keep wheelchairs from falling off of the sides of the ramp, which poses a tripping risk should someone attempt to use the righthand side of the ramp a means of accessing the rear garage exit. This constituted a hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | A 6x14 platform will be installed to level the entire walk path and eliminate the lip around the edge of the ramp. Our Maintenance Team developed a layout plan and work is scheduled to be completed by 11/15/23. |
11/15/2023
| Implemented |
| 6400.72(a) | One of the two operable windows in the home's garage lacked a screen. As there was no window screen available within the home that could be securely fitted into the window frame, this window was incapable of being securely screened when open. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Within 48 hours a screen was purchased and placed into the garage window. |
10/26/2023
| Implemented |
| 6400.76(a) | At the time of inspection, the right armrest of the home's couch was partially separated from the body of the couch and wobbled back and forth when it was gently pushed on. This armrest was attached to the body of the couch by a long metal bolt that appeared to be coming loose. The couch was not sturdy in this condition. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Couch was purchased on 10/11/23 to replace the defective one. |
10/11/2023
| Implemented |
| 6400.82(e) | At the time of inspection, the shower in the home's basement bathroom did not have a nonslip surface or mat. | Bathtubs and showers shall have a nonslip surface or mat. | A non-slip mat was purchased within 24 hours of the inspection and added into the basement bathroom. |
10/26/2023
| Implemented |
| 6400.101 | The sole egress from the home's basement to the outside of the home is provided via steps leading up to a hatch-style metal door that opens into the backyard. The hatch door is locked and unlocked by twisting a lever in the center of the door, which is intended to pull two cables leading to bolts on the righthand and lefthand sides of the door, thereby unfastening the bolts on each side and allowing the hatch door to be pushed upward into the open position. The lever was very loose to the touch and could be wiggled in any direction rather than only moving clockwise and counterclockwise as the design had apparently intended.
After this licensing representative failed to open the hatch door, it took staff on site approximately 10 minutes to open it successfully. Staff on site demonstrated how they accomplished opening the hatch door as this licensing representative observed. Staff on site turned the lever clockwise as apparently intended by the design of the mechanism, but---seemingly due to the looseness of the lever---this movement only unfastened the bolt on the lefthand side of the hatch door. In order to open the hatch door, staff had to manually grab and unfasten the bolt on the righthand side of the door before pushing the door upward into the open position.
At the time of inspection, the basement hatch door's locking mechanism was not functioning as intended or as would be expected by those attempting to open it. A person attempting to open the hatch door would have needed to be familiar with how the locking mechanism was malfunctioning in order to successfully open it in a timely manner. Even so, staff on site continued to have significant difficulty opening the hatch door despite two repeat attempts prompted by this licensing representative. As such, the state of the hatch door and its locking mechanism posed a barrier to safe egress from the home's basement. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The egress door was lubricated by our Maintenance Department on 9/27/23 and staff were able to open it without experiencing any issues. |
09/27/2023
| Implemented |
| 6400.113(a) | Per the Individual Record, Individual #2 received fire safety trainings on 08/17/2023, 07/26/2023, and 09/09/2021. The period between the trainings occurring on 07/26/2023 and 09/09/2021 exceeds one year; as such, Individual #2 did not receive training in fire safety annually as required. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Individual #1 had received Fire Safety training on 8/17/2023. Training will be provided in March and every 6 months following. |
10/26/2023
| Implemented |
| 6400.141(a) | Individual #2's two most recent physical examinations occurred on 04/30/2023 and 03/16/2022. As the interim between these two appointments exceeds one year, the individual did not receive a physical examination annually as required. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #2 had a physical conducted on 4/30/2023. The program supervisor will ensure a physical is scheduled and attended no later than 4/30/2024. |
10/26/2023
| Implemented |
| 6400.142(g) | Individual #2's most recent dental hygiene plan was located on a dental examination form dated 09/01/2022. There is no record of an updated dental hygiene plan. | A dental hygiene plan shall be rewritten at least annually. | Individual #2 had a follow-up appointment on 10/10/2023. Individual #2's denture will be religned-impression taken at appointment and will be delivered. A follow-up appointment will be scheduled no later than 10/10/2024 utilizing our dental form which includes an area to document a dental hygiene plan. |
10/26/2023
| Implemented |