Halyna's Care

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. Findings include: 1 . A review of facility documentation revealed an undated policy and procedure book. However, documentation the policy and procedure book was reviewed at least once every three years was not available for review at the time of inspection. 2 . In an interview, E1 acknowledged documentation of the policy and procedure review was not available for review at the time of inspection.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility which included whether the individual requires continuous medical services, continuous or intermittent nursing services, or restraints, and is dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. Findings include: 1 . A review of R1's medical record revealed documentation showing if R1 needed continuous medical services, continuous or intermittent nursing services, or restraints, dated March 3, 2025. However, the documentation was not signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2 . In an interview, E1 reported E1 had forgotten to get the documentation signed.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort which provided access to an outside area which monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1 . A review of Department documentation revealed the facility was licensed to provide directed care services. 2 . During an environmental inspection of the facility, the Compliance Officers observed a sliding glass door leading to the backyard. However, the door had no alert, and no monitoring system was in place. 3 . In an interview, E1 acknowledged the back door had no alert or monitoring system for egress of residents from the facility.

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 Officers observed a cabinet under the kitchen sink locked by a chain wrapped around the handles with a padlock securing the chain in place. However, the chain length was loose, which allowed the Compliance Officers to open the cabinet enough to be able to pull out the following items: -A bottle of "Lysol" bathroom cleaner; -A bottle of "Soft Scrub" cleaner; -A can of "Comet" bleach; and -A bottle of "409" multi-purpose cleaner. 2 . In an interview, E1 acknowledged that the lock on the kitchen sink cabinet was ineffective, and as a result, toxins were not inaccessible to residents.

Based on observation, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's skills and knowledge applicable to the individual's job duties, for two of two caregivers sampled. The deficient practice posed a risk if E1 and E2 were unable to meet a resident's needs. Findings include: 1. The Compliance Officer observed E1 and E2 on the premises upon arrival at 12:20 PM. 2. In an interview, E1 reported working during the day and E2 worked at night. 3. 4. A review of E2's (hired in 2007) personnel record revealed documentation of E1's verified skills and knowledge was not available for review. 4. A review of E2's (hired in 2012) personnel record revealed documentation of E2's verified skills and knowledge was signed, but the individual catagories verifying skills had not been initialed by E1. 5. In an interview, E1 acknowledged E1's and E2's skills and knowledge were not verified and documented before E1 and E2 provided physical health services.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for one resident sampled who received directed care services. . The deficient practice posed a risk as a service plan direct services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed service plans for R2 dated July 1, 2022; January 1, 2023; and June 21, 2023. However, documentation of service plans for October 2022 and April 2023 were not available for review. 2. In an interview, E1 acknowledged E1 failed to ensure a written service plan was reviewed and updated at least once every three months.