Healing Hearts Assisted Living

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance for one of two resident records sampled. Findings include: 1. A review of R1's medical record revealed an initial service plan for directed care level of services with medication administration, dated January 19, 2023. Based on R1's date of acceptance, the service plan was not completed within 14 calendar days of R1's date of acceptance. 2. In an interview, E1 acknowledged the service plan was not completed within 14 calendar days of the residents' date of acceptance.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of the facility's work schedule revealed the facility had three shifts: "first shift" from 6:00 AM to 2:00 PM, "second shift" from 2:00 PM to 10:00 PM, and "third shift" from 10:00 PM to 6:00 AM. 2. A review of documented facility disaster drills conducted during the prior 12 months revealed the following drill: -January 19, 2023 at 11:00 AM, during first shift. No other documentation of disaster drills was provided for review. 3. In an interview, E1 acknowledged disaster drills were not conducted and documented on each shift at least once every three months.

Based on documentation review and interview, the manager failed to ensure an evacuation drill was conducted at least once every six months. Findings include: 1. A review of facility documentation revealed no documented evacuation drills. 2. In an interview, E1 acknowledged an evacuation drill was not conducted at least once every six months.