| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The surface of a broken bathroom shelf to the left of the upstairs bathroom vanity was covered in a thin layer of what appeared to be dust, hair and a greasy, sticky substance. The surfaces of the white glass light shades on each side of the upstairs bathroom vanity mirror were covered with what appeared to be a layer of dust with the tops discolored brown with what appeared to be a buildup of dust and dirt. | Clean and sanitary conditions shall be maintained in the home. | The entire bathroom including the shelf area was cleaned. The broken shelf was removed as well. |
05/25/2023
| Implemented |
| 6400.67(a) | The top of a small shelf affixed to the left of the bathroom vanity was broken and missing. A shelf in the shelf was also broken and laying on the bottom. | Floors, walls, ceilings and other surfaces shall be in good repair. | The Property Manager removed the broken shelf that was affixed to the vanity. |
05/25/2023
| Implemented |
| 6400.67(b) | The baseboard heat in the bathroom was missing approximately 18 inches of the metal housing exposing the sharp metal fins and pipe inside. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The Property Manager installed new metal housing to cover the 18 inches of exposed sharp metal finds and pipe inside the baseboard heat. |
05/25/2023
| Implemented |
| 6400.72(b) | The bottom portion of the screen in the rear side entrance screen door of the home was pulled away from the metal frame creating an opening between the screen and the frame approximately fourteen inches in length. | Screens, windows and doors shall be in good repair. | The screen was repaired by the Property Manager. |
05/25/2023
| Implemented |
| 6400.162(b) | At time of inspection on 5/11/23 a bottle of BP Wash was in use for Individual #5. The pharmacy label had deteriorated such that the label could not be read. The name of the prescribing practitioner could not be seen on the pharmacy label of the bottle in use at the time of inspection. | Nonprescription medications shall be labeled with the original label. | The Program Supervisor ordered a new bottle of BP Wash for Individual #5. The pharmacy delivered the new bottle of BP Wash which has a new label. |
06/05/2023
| Implemented |
| 6400.32(c) | At time of inspection Individual #5 was prescribed "BP Wash 5% liquid Apply topically to axilla and wash daily in shower." Individual Support Plan for Individual #5 with a plan last updated date of 5/10/23 notes that Individual #5 "does not meet the necessary criteria to self-administer" and is not self-medicating. Staff #2 reported that "we just hand her the bottle and let her take it to the shower." The medication was not administered as prescribed, the Individual plan was not implemented as written nor was the medication administered based upon the individual's needs. Pharmacy records indicate that the BP Wash in use at the time of inspection on 5/12/23 had last been filled on 1/18/23. At time of inspection the level of medication was checked finding that the bottle was full. At time of inspection the pharmacy label on the medication had deteriorated such that it was illegible. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | The Program Supervisor ordered a new bottle of BP Wash for Individual #5. The pharmacy delivered the new bottle of BP Wash which has a new label. |
05/25/2023
| Implemented |
| 6400.165(c) | At time of inspection on 5/11/23 a bottle of BP Wash was in use for Individual #5. The open bottle had no sign of being used as the contents were at the top of the bottle. The bottle in question was the only one at the home and was noted to have been brought to the home with Individual #5 when she was admitted on 5/2/23. May 2023 Medication Administration Records (MAR) for Individual #5 recorded daily initials for the medication indicating it had been given. The full contents of the bottle would indicate the documentation of administrations to be inaccurate. Additionally, Staff #2 noted that "we just hand her the bottle and let her take it to the shower." No supervision or assistance with the medication was provided to the Individual. The BP Wash was not administered as prescribed. (REPEAT VIOLATION 10/22, 1/23) | A prescription medication shall be administered as prescribed. | A medication error and neglect incident were submitted to determine whether the staff were appropriately administering the BP Wash to Individual #5. Staff will be retrained on appropriately administering the BP Wash to Individual #5 by the Medication Administration Instructor at their next monthly staff meeting. The Program supervisor was also retrained on monitoring the medications appropriately as well. |
06/05/2023
| Implemented |
| 6400.166(a)(10) | Individual #5 has a PRN (as needed) medication Diclofenac Sodium Gel 1% to be applied "4 times a day as needed for pain or muscle spasms." The May 2023 Medication Administration Record (MAR) for Individual #5 notes that the medication was administered by Staff #3 on 5/7/23. There was no record of what time the medication had been administered on the May 2023 MAR as required. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | The MAR was fixed by the employee that did not document correctly. The Program Supervisor confirmed that the time was added by the employee that administered the medication. |
05/25/2023
| Implemented |
| 6400.186 | Instructions on the May 2023 Medication Administration Record (MAR) for Individual #5 noted that "BP Wash 5% liquid (For BP Wash 5% liquid) Apply topically to axilla and wash daily in shower." Staff #2 reported that staff "just hand her the bottle and let her take it to the shower." Individual Support Plan (ISP) for Individual #5 with a plan last updated date of 5/10/23 notes that Individual #5 can "toilet and bathe independently" and "does not meet the necessary criteria to self-administer" and is not self-medicating. Per the ISP Individual #5 requires assistance with medication administration that staff did not provide for the BP Wash. | The home shall implement the individual plan, including revisions. | A medication error and neglect incident were submitted to determine whether the staff were appropriately administering the BP Wash to Individual #5. Staff will be retrained on appropriately administering the BP Wash to Individual #5 by the Medication Administration Instructor at their next monthly staff meeting. The Program supervisor was also retrained on monitoring the medications appropriately as well. |
06/05/2023
| Implemented |