| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | There is a locked room, which staff described as an unused bathroom within individual 1's bedroom, for which staff did not have a key. The licensing representative was not able to gain access to this room during the inspection due to the door being locked and staff not having a key at the home. | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | The door in question had its lock replaced with a punch code lock so it can be accessed at anytime by entering the code. See attachment labeled ¿2045 Turk Rd Bathroom Door¿. |
10/10/2023
| Implemented |
| 6400.64(a) | The bottom of the oven was dirty with food residue and requires cleaning. | Clean and sanitary conditions shall be maintained in the home. | The oven was cleaned to ensure compliance with the requirement for clean and sanitary conditions being maintained in the home. See attachment labeled ¿Turk Rd Oven¿ |
10/05/2023
| Implemented |
| 6400.68(c) | Not completed within required minimum timeframes. (3 months) Completed dates provided: 9/18/23, & 5/16/23. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | The well inspection was late by one month as identified at the time of our licensing inspection. It had taken place one month late due to the inspection company being backed up with scheduled inspections. The following subsequent well inspections took place in a timely manner (12/12/23 and 3/13/24, see attachment labeled "Turk Rd Well Inspections"). |
11/01/2023
| Implemented |
| 6400.77(b) | There was no tape in the first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Tape was available at the time of the inspection in another First Aid kit that was not located at the time of the inspection. See attachment labeled "Turk Rd Tape in First Aid". First aid Kit missing tape was removed from the home. |
10/05/2023
| Implemented |
| 6400.111(f) | The tag on the fire extinguisher in the attic indicated that it expired in November 2022. The tag on the fire extinguisher in the basement indicated that it expired in November 2022. The tag on the fire extinguisher in the kitchen indicated that it expired in July 2023. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Fire extinguishers with current unexpired dates were brought over to the house the same day of our inspection to replace the extinguishers with expired tags. See attachment labeled "Turk Rd Extinguishers". |
10/05/2023
| Implemented |
| 6400.166(a)(13) | The medications for individual 1 were administered but not documented in the electronic Medication Administration Record (MAR) as administered for 8:00am on 10/5/23. It was noted that staff did complete the manual controlled medication counts for the 8:00am medication administration on 10/5/23 and document them appropriately. The following medications were administered and not signed as administered at 8:00am on 10/5/23: Quetiapine Fumerate 25mg tablet, Quetiapine Fumarate 300mg tablet, Sertraline HCL 100mg tablet, Clonazepam 0.5mg tablet, Clonazepam 1mg tablet, Try-Nymyo 28 tablet, Divalproex Sodium ER 250mg tablet, Divalproex Sodium ER 500mg tablet, Docusate Sodium 100mg tablet, Ferrous Sulfate ER 45mg, Fiber Lax Cap Tabs 625mg and Levothyroxine 50mcg tablet. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The staff in question was retrained on medication administration, specifically on correctly documenting administrations on the MAR. See attachment labeled "Turk Rd MAR Retraining" showing the sign off for the staff completing the training. The MAR in question was also corrected to reflect the actual administration of individual 1's medications as they were given correctly, see attachment labeled "Turk Rd. MAR_Form". |
10/10/2023
| Implemented |