| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The window blind located in the back sunroom was frayed at the bottom and needs to be replaced.
The basement floor had water damage and is cracked. | Floors, walls, ceilings and other surfaces shall be in good repair. | Damaged window blind in the sunroom has been replaced. Basement cracked line showing water traces is on our contractor repair commencement on last week of Dec 2023. |
10/16/2023
| Implemented |
| 6400.67(b) | There is a black substance consistent with mold on ceiling in basement. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Rehoboth Inc Contractor has followed necessary guidelines, removed affected area and replaced and repaired the surface on 10/12/2023. |
10/16/2023
| Implemented |
| 6400.82(c) | No bathmat located in the basement bathroom. | (c) For homes serving one or more individuals who have physical disabilities, at least one sink, one toilet and one tub or shower shall be adapted so that individuals who have physical disabilities have easy access and use.
| Rehoboth Inc has placed a bathmat in the basement bathroom on 10/11/2023. |
10/11/2023
| Implemented |
| 6400.166(a)(12) | MAR was not signed for the dates (October 1-10) for 8pm dose of Propranolol 10mg for individual 1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | Staffs were Retrain on Medication logs on 10/16/2017. |
10/16/2023
| Implemented |
| 6400.213(1)(i) | Religious affiliation on face sheet is blank for individual 1. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Religion affiliation was added to the face sheet on 10/12/2023. |
10/12/2023
| Implemented |