Healing Haven Home at Lake Country LLC

The facility failed to document that staff were competent and trained prior to assuming their responsibilities.

The facility failed to provide a locked area for all medications.

The facility failed to conduct criminal history checks of employees and applicants.

The facility failed to ensure that specific on-the-job training required for attendants in this type facility was completed in the required timeframe.

The facility failed to search the employee misconduct registry and nurse aide registry before hiring to determine if the individual is unemployable.

The facility failed to conduct a name-based criminal history check on an applicant for employment who indicated on the disclosure statement that they have lived in another state within the past five and years, or the facility failed to ensure that an employee did not have direct contact with residents pending the results of the name-based criminal history check.

The facility failed to have evidence showing that the manager completed the required 12 hours of annual continuing education.

The facility failed to either assess a resident or to develop, approve, sign, or follow a service plan within the allowable time.

The facility failed to comply with Chapter 33, Existing Residential Board and Care Occupancies.

The facility failed to ensure the required sprinkler system was inspected, tested, and maintained in compliance with NFPA 25.

The facility's plan failed to document the contact information for the EMC for the area.

The facility failed to ensure resident bedroom doors were in compliance with licensing standards for assisted living facilities.

The facility failed to provide an initial gas pressure test of the gas lines from the meter; and/or failed to ensure additional gas pressure tests were performed when gas service was interrupted; and/or that all gas heating systems were documented

The facility failed to ensure the building and structure complied with other applicable chapters of the Life Safety Code, NFPA 101.

The facility failed to maintain the building free of accumulations of dirt, rubbish, dust, and hazards.

The facility failed to notify the EMC of the facility's plan, take actions to coordinate with the EMC, and document communications with the EMC.

The facility failed to ensure the fire alarm and smoke detection system was in compliance with licensing standards for assisted living facilities.

The facility failed to ensure all monthly and yearly extinguisher inspections were performed and/or documented; and/or that unserviceable extinguishers were replaced.

The facility failed to review the plan at least annually to reflect changes in information, within 30 days following a disaster, within 30 days after a drill, and within 30 days after a change in rule or policy.

The facility failed to provide a written contract with a fire alarm firm to perform inspections, testing, and system maintenance at least every six months.

The facility failed to ensure lighting was in compliance with licensing standards for assisted living facilities.

The facility failed to include a section addressing transportation in the emergency preparedness and response plan.

The facility failed to ensure the smoke detectors were to be tested for sensitivity as required. The facility failed to provide all required fire alarm documentation, including as-built installation drawings, operation and maintenance manuals, and a written sequence of operation, must be available for examination by DADS.