Careheart 24 Assisted Living, LLC.

“Based on record review, documentation review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery, to include initial training and continued competency training, for two of three personnel sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents. Findings Include: 1. A review of E2’s personnel record revealed a hire date of June 12, 2024. Further review of E2’s record revealed no initial or continued competency fall prevention and fall recovery training was documented. Based on E2’s hire date, this documentation was required. 2. A review of E3’s personnel record revealed a hire date of April 3, 2026. Further review of E3’s record revealed no initial fall prevention and fall recovery training was documented. Based on E3’s hire date, this documentation was required. 3. A review of the facility's staff schedule revealed E2 and E3 provided services to the residents. 4. A review of the facility’s policies and procedures revealed a policy titled “Fall Prevention & Recovery Training” which stated, "6. All employees hired by the facility will either; supply evidence of completion of a comparable fall prevention and recovery training provider meeting this policy requirements or attend training with the facility’s provider. 7. All employees of the facility will attend refresher training on an annual basis on Fall Prevention and Fall Recovery that meets the same guidelines as initial training.” 5. In an interview, E1 acknowledged that E2 and E3 did not have the required fall prevention and fall recovery training. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review and interview, the health care institution's chief administrative officer failed to implement tuberculosis (TB) infection control activities that included annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a potential risk of illness to residents.  Findings include: 1. A review of the facility’s documentation revealed no annual assessment of the facility's TB risk assessment.  2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, record review, and interview, the manager failed to ensure a manager and caregiver who was expected to have more than eight hours per week of direct contact with residents, provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services, for two of three employees sampled. The deficient practice posed a potential TB exposure risk to residents.  Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed E3 providing services to residents. 2. A review of E1's personnel record revealed no screening for risks of prior exposure or assessment of signs or symptoms of TB. Based on E1's date of hire, the documentation was required. 3. A review of E3’s personnel record revealed no screening for risks of prior exposure or assessment of signs or symptoms of TB screening, and one TB skin test was documented in 2025 for E3. No additional TB test was documented for E3. Based on E3's date of hire, this documentation was required. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, record review, documentation review, and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults, for one of three employees sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed E3 providing services to residents.  2. A review of E3's personnel record revealed a hire date of April 3, 2026. Further review revealed no first aid or CPR training was documented for E3. 3. A review of the facility’s policies and procedures revealed a policy titled, “Staffing Documentation and Recordkeeping” which stated, “1. Before an employee is hired the following items will be collected: 1. b. CPR and First Aid Training documents.” 4. In an interview, E1 acknowledged E3 did not have first aid or CPR documentation in E3’s personnel record. 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on record review, documentation review,  and interview, the manager failed to ensure a resident had a written service plan reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of two residents sampled. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed R1 sitting in R1’s bed complaining that R1 could not leave R1’s bed. 2. A review of R1's medical record revealed a service plan dated March 23, 2026 for supervisory care services. The service plan indicated R1 was on hospice but was ambulatory. 3. In an interview, E1 reported R1 had fallen and broken R1’s hip around March 26, 2026, after R1’s service plan was updated. Since then, R1 had been confined to R1’s bed so R1 can heal from R1’s injury. E1 reported E1 was unaware R1’s service plan needed to be updated after R1’s condition changed. 4. A review of the facility’s policies and procedures revealed a policy titled, "Service Plan” which stated, “7. Service plans will be reviewed no later than 14 calendar days after a significant change in the resident’s physical, cognitive, or functional condition…” 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented that when updated, was signed and dated by the manager and if a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan, for one of two residents sampled. The deficient practice posed a health and safety risk if the required individuals did not acknowledge and agree to the services that were to be provided. Findings include: 1. A review of R1's medical record revealed a service plan dated March 23, 2026 for supervisory care services. The service plan indicated R1 received medication administration. Further review of R1’s service plan revealed the service plan was not signed by the manager or a nurse or medical practitioner who reviewed the service plan. 2 A review of the facility’s policies and procedures revealed a policy titled, “Service Plan” which stated, “When the service plan is initially developed and when updated, is signed and dated by … the manager, the nurse who reviewed the service plan, if required…” 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident’s medical record, for one of two residents sampled. The deficient practice posed a risk to the resident’s health and safety. Findings include: 1. A review of R1's medical record revealed a service plan dated March 23, 2026. The service plan indicated R1 received medication administration. 2. A review of R1's medical record revealed an electronic medication administration record (eMAR) dated April 2026. The eMAR revealed R1 was administered Umeclidinium (Incruse Elipta) 0.0625 milligrams (mg) daily from April 1, 2026, to present. Further review of the eMAR revealed this medication was discontinued on February 10, 2026. 3. A review of R1’s medications revealed R1 did not have a bottle of Umeclidinium (Incruse Elipta) 0.0625 mg, and the medication was not in R1’s medication organizer. 4. A review of R1's medical record revealed no discontinued order for Umeclidinium (Incruse Elipta) 0.0625 mg from a medical practitioner. 5. In an interview, E2 reported the medication was discontinued on February 10, 2026. E2 reported that E2 mistakenly continued marking the medication on the MAR after that date, but the resident never received it after it was discontinued. E2 reported that E2 could not locate the discontinue order for the medication. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, documentation review, and interview, the manager failed to ensure a rechargeable fire extinguisher was serviced at least once every 12 months. The deficient practice posed a risk to the resident’s health and safety in the event of a fire emergency. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed one rechargeable fire extinguisher located in a hallway and another fire extinguisher located in the kitchen. Both fire extinguishers had service tags dated 2019. 2. A review of the facility’s documentation revealed no documentation of fire extinguisher servicing. 3. In an interview, E4 reported the fire extinguishers had recently been serviced and they forgot to retag them. No documentation was provided during the inspection that the fire extinguishers were recently serviced. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”