| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The vent in the hall bathroom needs to be cleaned, there is debris consistent with dust covering the vent. | Clean and sanitary conditions shall be maintained in the home. | 1. Staff working in the home completed a thorough cleaning of the home. The bathroom vent was cleaned. Attachment 14 |
11/02/2023
| Implemented |
| 6400.66 | The outside light at the front door only flickers when turned on. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| 1. This has been fixed, the proper sized bulbs were purchased and replaced for this light. Attachment 17 |
11/02/2023
| Implemented |
| 6400.67(a) | The deck needs to be repaired at the joints as there were nails exposed. The entire deck paint is peeling on the floor and posts. | Floors, walls, ceilings and other surfaces shall be in good repair. | 1. The Area director contacted a contractor to complete these needed repairs. The repairs have started on 10/30/23. Attachment 9 |
11/02/2023
| Implemented |
| 6400.72(a) | There was no screen present in the window at the 1st landing at the entrance. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | 1. This has been corrected. The screen was replaced in this window. Attachment 5 |
11/02/2023
| Implemented |
| 6400.141(a) | Individual #2's most recent annual physical exam did not include the following:
- Information pertinent to diagnosis in case of emergency
- Physical limitations of the individual
- Prostate or PSA exam (Most recent occurred on 5/23/22) | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | 1. Individual #2 had a PSA test on 10/30/23. Information pertinent to diagnosis and physical limitations were added to the physical exam. The physical exam was sent to Individual #1¿s primary care physician to review the additions. Attachment 10 and 11 |
11/02/2023
| Implemented |
| 6400.142(a) | There was no current dental appointment on file for individual #2 | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | 1. Individuals #2 had a dental appointment on 10/12/23. Attachment 6 |
11/02/2023
| Implemented |
| 6400.181(e)(5) | The self-medication section of individual #2's annual assessment dated 5/26/23 and their most recent ISP were incongruous and did not make their self-administration abilities clear. | The assessment must include the following information: The individual's ability to self-administer medications. | 1. Individual #2¿s assessment was updated for clarification to match his ISP which states that he can self-medicate his injectable insulin but, not his regular medications. This updated Assessment was also sent to Luis¿ team. |
11/02/2023
| Implemented |
| 6400.165(b) | For individual #2's Medication Seroquel-to treat bipolar disorder was not in the home at the time of the inspection.
Staff states the individual ran out of this medication. Last administered 9/18/23.
for the medication Bactrim there were two blister packs opened and being used. The staff present could not explain the count which appeared to be off according to the medication cycle of 9/16/23. | A prescription order shall be kept current. | 1. This medication was ordered on 9/13/23and delivered to the home on 9/26/23. |
11/02/2023
| Implemented |
| 6400.207(4)(I) | Individual #2's PRN Quetiapine tab 25mg is prescribed as: take 1 tab by mouth as needed for anxiety, mood symptoms, was not listed on the MAR but was in med box. This prescription as written is a chemical restraint, as the specific and exclusive use of the drug is for the purpose of controlling acute or episodic aggressive behavior. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | 1. This medication was discontinued and had never been administered. |
11/02/2023
| Implemented |