Villas at Green Valley, Villa G.

“Based on record review, and interview, the manager failed to ensure entries in the medical record were not changed to make the initial entry illegible for two of two resident records sampled. Findings include: 1. A review of R1's and R2's medical record revealed a documented titled, "Caregiver ADL Checklist," (ADL) used for documenting services and activities of daily living during the month of February 2024. The document included a section at the bottom for caregivers to enter their name and initials used for documenting. Initial entries into the records for R1 on February 4 and February 7, 2024 had initially been made in ball point pen. However, a different set of initials had been entered with a felt tip pen making the initial entry illegible. Similarly, entries into R2's ADL on February 4 and 7, 2024, which had been entered in ball point pen, were written over with a felt tip pen, making the original entry illegible. 2. In an interview, E1 acknowledged the entry into R1's and R2's medical record had been changed to make the initial entry illegible.”