Halyna's Care

Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder was contacted. Findings include: 1 . A review of R1's and R2's medical record revealed documentation of a maintained standardized form for the emergency responder was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure a designated caregiver was present on the assisted living facility’s premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. Findings include: 1 . When the Compliance Officer arrived at the home at approximately 9 AM, the Compliance Officer observed E2 working alone at the facility. 2 . A review of E2's personnel record revealed no documentation of a designee form signed by the manager. 3 . In an exit interview, the findings were discussed with E3 and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident that covered assistance in the self-administration of medication and medication administration. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed keys for the medication cabinet sitting on top of the cabinet. 2 . A review of facility documentation revealed a policy titled "Medications including Opioids, Narcotics, and Schedule 2." Under "Part II-Receiving, Storing Medications," the policy stated, "Only the Manager and trained caregivers shall be in possession of the keys to the medication storage area." 3 . In an exit interview, the findings were discussed with E3 and no additional information was provided.

Based on documentation review, record review and interview, the manager failed to ensure before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults, for two of three personnel sampled. Findings include: 1 . A review of facility documentation revealed a policy titled "First Aid and CPR training." The policy stated "In order to keep first aid and CPR training and skills up to date it is required that each employee and volunteer provide the following: -1 . Documentation that verifies that the employee or volunteer has received CPR training; and -2 . Documentation that verifies that the employee or volunteer has received First Aid training." 2 . A review of E1's personnel record revealed documentation of a CPR card. However, the card expired on August 7, 2025, and no additional documentation of a current CPR card was provided during the inspection. 3 . A review of E2's personnel record revealed documentation of a CPR card. However, the card expired in September 2025, and no additional documentation of a current CPR card was provided during the inspection. 4 . In an exit interview, the findings were discussed with E3 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility which included if the individual was expected to receive supervisory care services, personal care services, or directed care services, and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of two residents sampled. Findings include: 1 . A review of R1's medical record revealed documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility which included if the individual was expected to receive supervisory care services, personal care services, or directed care services, and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E3 and no additional information was provided.

Based on observation and interview, the manager failed to ensure medication was stored in a separated locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed filled medication bottles sitting on the table in the main entryway. 2 . In an exit interview, the findings were discussed with E3 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a disaster plan review was reviewed at least once every 12 months. Findings include: 1 . A review of facility documentation revealed a disaster plan annual review conducted on October 29, 2024. However, documentation of a disaster plan review done within 12 months after October 29, 2024 was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E3 and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed an unlocked cabinet in a common hallway bathroom which held a bottle of "True Living" Multi-Purpose Cleaner. Further inspection revealed a can of "CVS Health" disinfecting spray sitting on top of the toilet tank. 2 . During an environmental inspection of the facility, the Compliance Officer observed an unlocked cabinet under the kitchen sink which contained a container of "Comet" bleach. 3 . In an exit interview, the findings were discussed with E3 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure pets or animals are licensed consistent with local ordinances. Findings include: 1 . A review of O1's record revealed documentation of a rabies vaccination. However, documentation of a registration with Maricopa County was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E3 and no additional information was provided.

Based on observation and interview, the manager failed to ensure at least the manager or caregiver was present at the assisted living home when a resident was present in the assisted living home. The deficient practice posed a risk as no qualified employee was present to meet residents' needs. Findings include: 1 . Upon arrival at the facility at approximately 9:30 AM, the Compliance Officers observed O1 answer the door to the facility. O1 let the Compliance Officers inside the home and asked the Compliance Officers to wait for the manager to arrive. 2 . The Compliance Officers observed E1 arrived at the facility at approximately 10:00 AM. 3 . In an interview, E1 reported O1 was not a caregiver at the facility and was a family member of E1. O1 was left alone with R1 while E2 left to pick up a part to fix something at the facility at approximately 8:00 AM. E1 acknowledged no caregiver was present at the facility when the resident was present.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, which posed a health risk to the resident. Findings include: 1 . A review of R1's medical record revealed a signed medication list dated February 25, 2025. The following medications were listed: -Temazepam 15 milligrams (MG), 1 tablet once a day; and -Tramadol 100 MG, 1 Tablet twice a day. However, a review of R1's Medication Administration Record (MAR) for March 2025 revealed Temazepam had only been administered on March 1, 2025, March 5, 2025, March 8, 2025, and March 11, 2025. Further review revealed Tramadol was administered three times a day instead of two times a day from March 1, 2025 to March 13, 2025. 2 . In an interview, E1 reported R1 kept asking for more Tramadol due to pain so E1 had increased the times E1 had received the medication without an order. E1 acknowledged R1 was not administered medication in compliance with signed medication orders for R1.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed the following in an unlocked storage area located next to a resident room: -A can of "Krylons" white primer; -Two bottles of paint thinner; and -Several cans of "Valspars" and "Sherwim Williams" paint. 2 . During an environmental inspection of the facility, the Compliance Officers observed a bottle of "Comet" kitchen cleaner and bleach in an unlocked cabinet under the kitchen sink. 3 . In an interview, E1 acknowledged toxic materials at the facility were accessible to residents.