| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | At time of inspection poisons were unlocked in the facility. There was University Medic hand sanitizer and McKeeson Antibacterial soap unlocked in the Women's bathroom. The label on both bottles noted to contact poison control if ingested. Identically labeled McKeeson soap was also unlocked in the first aid room and Men's bathroom. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | All of the soaps that were in the mens and womens bathroom as well as the nurses station were all locked up in the closet next to the bathroom. There are wall mounted soap dispensers in both the mens and womens bathroom. The soap in the nurses station and bathroom was replaced with soap that does not say about contacting poison control. This was done on 6/29/23, the day after the inspection. |
06/29/2023
| Implemented |
| 2380.55(d) | The two trashcans located in the Men's bathroom did not have lids and were not covered to prevent the penetration of insects and rodents. The trashcan located in the Women's bathroom did not have a lid and was not covered to prevent the penetration of insects and rodents. | Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents. | The trash cans that did not have lids were removed and replaced with new trash cans with lids. One in each bathroom. |
06/29/2023
| Implemented |
| 2380.58(b) | One of the ceiling tiles in the drop ceiling of the Women's bathroom contained a large metal circular vent. This ceiling tile was dipping out of and below the metal drop ceiling tile framework on one side creating a potential hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The handy man was notified the same day of the issue with the tiles. He fixed the tiles the next day on 6/29/23. |
06/29/2023
| Implemented |
| 2380.59(a) | At the time of inspection, the water in both bathrooms used by the facility measured at 70°. Water in the facility shall be hot. | The facility shall have hot and cold running water under pressure in bathrooms and kitchen areas. | The maintenance man was contacted and turned up the temperature of the water. Once checked again by the program specialist on 6/30/23 it was reading 110 degrees. |
06/30/2023
| Implemented |
| 2380.88(f) | The hallway fire extinguisher located outside of the library was tagged to have been last been inspected on 8/2021. | Fire extinguishers shall be inspected and approved annually by a firesafety expert. The date of the inspection shall be on the extinguisher. | The fire extinguisher located outside of the library was removed and one that was in compliance was put in its place. All extinguishers are serviced yearly. |
06/30/2023
| Implemented |
| 2380.90(a) | At time of inspection there were no "EXIT" signs placed at the exits in the program. | Signs bearing the word "EXIT" in plain, legible letters shall be placed at exits. | Exit signs were purchased the next day on 6/29/23 and placed on each door in the program areas and hallways on 6/30/23. |
06/30/2023
| Implemented |