| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | On 8/16/23, the first aid kit did not include tweezers. | 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. | To correct the violation, tweezers were acquired and inserted into the first aid medical kit. Photos of tweezers inside the kit will be sent to the Department. |
08/30/2023
| Implemented |
| 6400.106 | Documentation of the furnace being inspected and cleaned at least annually by a professional furnace cleaning company was not provided. Therefore, compliance could not be measured. [Repeat violation: 8/17/22 Et al.] | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| LRS has updated our annual service agreement with Armstrong Comfort Solutions & Matz Plumbing to provide furnace inspection services for our Waterfront, Beacon Hill, and Lawrenceville apartment locations. Prior inspections only included LRS's single-family location. Upon completion, a copy of the furnace inspection and cleaning will be submitted to the Department. |
08/30/2023
| Implemented |
| 6400.110(b) | On 8/16/23, there was not an operable automatic smoke detector located within 15 feet of Individual #1's bedroom door. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | LRS contacted Morgan Properties' Leasing Professional, Savannah Russo, to install a fire/smoke alarm outside the kitchen's nearest bedroom in order to address the violation. A photocopy of the response from Morgan Properties will be sent the Department. |
08/31/2023
| Implemented |
| 6400.141(c)(6) | Individual #1's Tuberculin skin testing by Mantoux method completed 7/28/22 did not include the results of the testing. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The nurse coordinator emailed the investigator the results of Individual #1's Tuberculin skin test, conducted using the Mantoux method on 7/28/2022. The email was sent with the understanding that the violation was being dropped. A copy of the email will be sent to the Department. |
08/25/2023
| Implemented |
| 6400.165(b) | Individual #1 is prescribed Flovent HFA 220 MCG inhaler, inhale one puff by mouth twice a day for shortness of breath, as listed on the on the August 2023 medication administration record. The inhaler was not in the home at the time of inspection. Staff reported "[Individual #1] ran out and it isn't time to refill." | A prescription order shall be kept current. | To resolve the violation, the nurse coordinator will create a list of medications not included in the monthly cycled medication delivery from the contract Pharmacy at all sites. |
08/30/2023
| Implemented |
| 6400.165(g) | Individual #1 is prescribed psychiatric medications to treat mental illness. The most recent medication review was completed 5/2/23. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The Nurse Coordinator will update the weekly appointment reminder spreadsheet to ensure compliance. |
08/30/2023
| Implemented |