Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.67(b) | The carpeting on both the second and fourth steps leading to the upstairs had approximately 2-inch tears in them. This poses a tripping hazard. Surfaces shall be free of hazards. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The tears on the stairs were repaired immediately. The new product to replace the entire stairway carpeting will be installed when it arrives on December 28th. All other flooring/surfaces in other homes were checked to see if they are in good repair. When surfaces are not free of hazards, the maintenance department will be made aware. |
12/03/2021
| Implemented |
6400.144 | During the monitoring Individual #1's pro re nata (PRN) medication Lotrimin Cream was not at the site. | 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.
| The PRN Medication was made available immediately. All medications were compared to the MARs to be sure they were available. Upon receiving medications from the pharmacy they will be checked for accuracy. |
12/07/2021
| Implemented |
6400.166(a)(11) | The December Medication Administration Record (MAR) for Individual #1's pro re nata (PRN) medication Lotrimin Cream did not include the diagnosis or purpose for the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The MAR was corrected immediately to include the diagnosis or purpose for the medication. All other MARs were reviewed to ensure they included the necessary information and were accurate. All Medication entries will be reviewed to ensure they contain all information. |
12/02/2021
| Implemented |