| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(b) | Rodent feces were observed on the clothes in the closet of Individual #1. | There may not be evidence of infestation of insects or rodents in the home. | On 12/30/2025 individual 1 bedroom and clothes were cleaned. Maintenance treated the home for pest control |
12/30/2026
| Implemented |
| 6400.66 | Individual #1 ceiling light in the front bedroom was not working. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| On 12/30/2025 a work order was placed with WHHC maintenance department to repair Closet organizer. A lock out tag out was placed on 12/30/2025 to ensure safety. 1/10/26 the organizer was completed by WHHC maintenance department. |
01/05/2026
| Implemented |
| 6400.67(a) | Individual #1's closet organizer was unsecure/detached from the wall. | Floors, walls, ceilings and other surfaces shall be in good repair. | On 12/30/2025 a work order was placed with WHHC maintenance department to repair Closet organizer. A lock out tag out was placed on 12/30/2025 to ensure safety. 1/10/26 the organizer was completed by WHHC maintenance department. |
01/05/2026
| Implemented |
| 6400.67(b) | Lint build-up and dried rags were observed behind the basement dryer. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On 12/30/2025 Lint buildup was removed from the dryer catch. |
12/30/2026
| Implemented |
| 6400.76(a) | The electrical outlet powering the refrigerator did not have a faceplate. | Furniture and equipment shall be nonhazardous, clean and sturdy. | On 12/30/2025 WHHC maintenance team was notified by management of the refrigerator face plate needing to be added on the wall. Expected completion 2/32026 |
02/03/2026
| Implemented |
| 6400.110(e) | The interconnected fire alarm system did not sound together when activated. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | On 12/30/2026 New interconnected fire alarm system was ordered. 1/10/26 This was installed by the WHHC maintenance department. |
03/12/2026
| Implemented |
| 6400.141(c)(10) | Physical dated 1/3/2025 does not indicate whether or not Individual #1 is free from communicable diseases. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | On 12/30/2025 an appointment was made for Individual 1 with their PCP for 3/12/26 to have their Physical form updated. |
03/12/2026
| Implemented |
| 6400.142(a) | Dental appointment card in the file for 11/22/2024. There is no proof the appointment was attended, or subsequent dental care has been received on an annual basis for Individual #1. | 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. | On 12/30 WHHC staff scheduled another appointment for individual #1 for dental care. This is to be done one 1/14/26 |
01/14/2026
| Implemented |
| 6400.144 | Two PRN medications (Trazadone 50mg and Artificial tears solution drops) were observed on the MAR but not in the Individual #1's medication container or in the home. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| On 12/30/25 PRN Trazadone and Artificial tears were placed in the correct location for individual 1. |
12/30/2025
| Implemented |
| 6400.166(a)(11) | Only one medication listed the diagnosis or purpose for its issuance to an individual #1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | On 1/1/2026 to date individual 1 MAR was updated with all diagnosis. |
01/01/2026
| Implemented |
| 6400.166(a)(13) | It was observed that a Staff Member #1 had initialed several times for administering medications to Individual #1 but had not signed the MAR. | 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. | On 12/30/26 staff member 1 signed the signature log for individual 1 MAR. All staff were re-educated. On proper documentation of the MAR. |
01/08/2026
| Implemented |
| 6400.167(a)(1) | Two instances were observed where it appeared medicine was signed as administered but appeared in the blister pack: Individual #1's medicine (Metformin ER 500mg) appeared signed as administered, but it was still in the blister pack for December 28 and 29, 2025; Individual #1's medicine (Famatodine 20mg) appeared signed as administered, but it was still in the blister pack for December 29, 2025. | Medication errors include the following: Failure to administer a medication. | On 12/30/25 staff were re-educated on the proper way to administer medication by utilizing the dates on the blister packs as well as signed on meds being given. |
01/08/2026
| Implemented |