Heritage Village Bldg 2 LLC.

“Based on record review and interview, the manager failed to ensure that a caregiver or an assistant caregiver documented the services provided in the resident’s medical record for three of three residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan, and the Department was provided false and misleading information. Findings include: 1. A review of R1's, R2's, and R3's medical records revealed current service plans for each resident. Further review revealed corresponding Activities of Daily Living (ADL) sheets. The following discrepancies were noted: - According to the September 2025 ADL sheet for R1, the services of "Transfer 1-2 person assist" and "Use Fall mat when in bed" were not documented as provided from September 18-30, 2025. - According to the September 2025 ADL sheets for both R2 and R3, "Dressing," "Housekeeping," "Personal Hygiene," and "Toileting/Incontinent Care" were not documented as being provided on September 7-8, 2025; and "Bathing/Showering" were not documented as being provided on September 13, 2025, along with other miscellaneous undocumented services that could not be explained. - On September 30, 2025, R3 had no services documented as being provided except for "Meal Attendance." - R2 had gone to the hospital; however, four different caregivers documented as providing miscellaneous services to R2 while the resident was not in the facility, to include dressing, escorting to/from meals, housekeeping, mobility assistance, personal hygiene/oral care, toileting, and wellness/safety checks. 2. In an interview, E1 and E2 acknowledged that services had not been documented in the ADLs as being provided for the aforementioned residents, and that services for R2 had been documented in error during the time that R2 was out of the facility.”

“Based on the documentation review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. A documented report from Cisor Onesource revealed the log times in which the resident's call pendants were answered. The report log revealed answer times of forty-five minutes, sixty-four minutes, and twenty-two minutes. 2. In an interview, the manager acknowledged that some of the times were unacceptable and would have a meeting with staff to review this issue. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution, for three of three personnel sampled. The deficient practice posed a potential illness risk to residents.  Findings include:  1. A review of E3's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E3's date of hire, this documentation was required. 2. A review of E4's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E4's date of hire, this documentation was required. 3. A review of E5's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E5's date of hire, this documentation was required. 4. In an interview, E1 acknowledged E3's, E4's, and E5's personnel records did not include documentation of initial and annual training on recognizing the signs and symptoms of TB.  This is an uncorrected deficiency from the complaint investigation conducted on April 18, 2025.”

“Based on record review and interview, the manager failed to ensure that a caregiver provided a resident with the assisted living services in the resident’s service plan, for three of four residents sampled. The deficient practice posed a risk as the service plan to direct services was not followed. Findings include: 1. A review of R1's service plan revealed R1 required the following services: Encouragement to drink fluids, three times a day (tid) and as needed (PRN); Complete assistance with dressing; Assistance with personal hygiene, twice a da (bid); and Housekeeping services, twice a day bid. 2. A review of R1's activities of daily living (ADL) documentation for May 2025 revealed R1 did not receive encouragement to drink fluids at 5:30 PM on May 9, 2025. 3. A review of R1's ADL documentation for May 2025 revealed R1 did not receive assistance with dressing during the AM shift on May 1, 2025, and May 4, 2025. 4. A review of R1's ADL documentation for May 2025 revealed R1 did not receive assistance with personal hygiene during the AM shift on May 1, 2025, and May 7, 2025. 5. A review of R1's ADL documentation for May 2025 revealed R1 did not receive housekeeping services during the PM shift on May 9, 2025. 6. A review of R2's service plan revealed R2 required the following services: Encouragement to drink fluids, tid and PRN; One to two person assist with transfers; Assistance with personal hygiene, bid; and Assistance with laundry, 1 -5 times a week and PRN. 7. A review of R2's ADL documentation for May 2025 revealed R2 was not encouraged to drink fluids at 5:30 PM on May 7, 2025. 8. A review of R2's ADL documentation for May 2025 revealed R2 was not provided mobility assistance during the AM shift on May 5, 2025. 9. A review of R2's ADL documentation for May 2025 revealed R2 was not provided assistance with personal hygiene during the AM shift on May 5, 2025, and May 12, 2025. 10. A review of R2's ADL documentation for May 2025 revealed R2 was not provided assistance with laundry on the PM shift on May 1, 2025. 11. A review of R3's service plan revealed R3 required the following services: Verbal reminders for meals; Encouragement to drink fluids, tid and PRN; Physical assistance with bathing, twice a week; Assistance with personal hygiene, bid; and Reminder assistance with dressing. 12. A review of R3's ADL documentation for May 2025 did not include verbal reminders for meals as required. 13. A review of R3's ADL documentation for May 2025 revealed R3 did not receive encouragement to drink fluids at 5:30 PM on May 4, 2025, and 12:30 PM on May 5, 2025. 14. A review of R3's ADL documentation for May 2025 revealed R3 was not provided with assistance with bathing during the PM shift on May 4, 2025, and May 11, 2025. 15. A review of R3's ADL documentation for May 2025 revealed R3 was not provided assistance with personal hygiene on the following dates: May 3, 2025, during the AM shift; May 4, 2025, during the PM shift; and May 5, 2025, during the PM shift. 16. A review of R3's ADL documentation for May 2025 revealed R3 was not provided reminder assistance with dressing on the following dates: May 4, 2025, during the PM shift; May 7, 2025, during the AM shift; May 8, 2025, during the PM shift; May 10, 2025, during the AM shift; and May 11, 2025 during the AM shift. 17. In an interview, E2 acknowledged the facility's electronic ADL system documentation for R1, R2, and R3 indicated the aforementioned services were not provided. E1 acknowledged that R1, R2, and R3 were not provided with services per R1’s, R2's, and R3’s service plans.”

“Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for four of four residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's service plan revealed R1 required the following services: Providing meals, three times a day (tid); Encouragement to drink fluids, tid and as needed (PRN); Assistance of one to two for transfers depending on mood and behavior; Escorting to and from activities; Assistance for toilet use; Assistance with personal hygiene, twice a day (bid); Complete assistance with dressing; Frequent checks on whereabouts and actions; Housekeeping services, bid; and Visual checks frequently through the day and night to promote safety and to encourage participation in activities. 2. A review of R1's activities of daily living (ADL) documentation for May 2025 did not include documentation of meal attendance on the following dates: May 1, 2025, at 12:30 PM; May 3, 2025, at 8:30 AM; and May 3, 2025, at 12:30 PM. 3. A review of R1's ADL documentation for May 2025 did not include documentation of the encouragement of fluids provided at 8:30 AM and 12:30 PM on May 3, 2025. 4. A review of R1's ADL documentation for May 2025 did not include documentation of the escort to and from activities provided on the following dates: May 1, 2025, during the AM shift; May 5, 2025, during the PM shift; and May 11, 2025, during the AM shift. 5. A review of R1's ADL documentation for May 2025 did not include documentation of the assistance with toileting, assistance with personal hygiene, assistance with dressing, housekeeping services, and visual checks provided on the following dates: May 5, 2025, during the PM shift; and May 11, 2025, during the AM shift. 6. A review of R1's ADL documentation for May 2025 did not include documentation of the frequent rounding provided on the following dates: May 1, 2025, during the AM shift; May 5, 2025, during the PM shift; and May 11, 2025, during the AM shift. 7. A review of R2's service plan revealed R2 required the following services: Providing meals, tid; Encouragement to drink fluids, tid and PRN; Assistance of one to two for transfers; Mobility assistance; Assistance for toilet use; and Visual checks frequently through the day and night to promote safety and to encourage participation in activities. 8. A review of R2's ADL documentation for May 2025 did not include documentation of meal attendance and encouragement to drink fluids provided on May 1, 2025, at 5:30 PM. 9. A review of R2's ADL documentation for May 2025 did not include documentation of transfer assistance, mobility assistance, toileting assistance, wellness check, and visual safety check provided on May 1, 2025, during the NOC shift. 10. A review of R3's service plan revealed R3 required the following services: Providing meals, tid; Encouragement to drink fluids, tid and PRN; Reminder assistance with dressing and undressing; Housekeeping services, bid; and Visual checks frequently through the day and night to promote safety and to encourage participation in activities. 11. A review of R3's ADL documentation for May 2025 did not include documentation of meal attendance on the following dates: May 1, 2025, at 12:30 PM; and May 3, 2025, at 8:20 AM and 12:30 PM. 12. A review of R3's ADL documentation for May 2025 did not include documentation of encouragement to drink fluids on the following dates: May 1, 2025, at 8:30 AM; and May 3, 2025, at 8:30 AM and 12:30 PM. 13. A review of R3's ADL documentation for May 2025 did not include documentation of reminder assistance with dressing,, housekeeping services, and wellness visual checks on the following dates: May 1, 2025, during the AM shift; and May 5, 2025, during the PM shift. 14. A review of R4's service plan revealed R4 required the following services: Assistance of one caregiver for transfers; and Housekeeping services, bid. 15. A review of R4's ADL documentation for May 2025 did not include documentation of assistance with transfers and housekeeping services provided on the following dates: May 3, 2025, during the AM shift; and May 11, 2025, during the PM shift. 16. In an interview, E1 reported the missing documentation was due to the adaptation of a new electronic medical system, rather than an identification of services not provided. E1 acknowledged a caregiver failed to document the services provided in R1's, R2's, R3's, and R4's medical records.”

“Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution, for four of four personnel sampled. The deficient practice posed a potential illness risk to residents.  Findings include: 1. A review of E1's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Based on E1's date of hire, this documentation was required. 2. A review of E4's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Based on E4's date of hire, this documentation was required. 3. A review of E5's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Based on E5's date of hire, this documentation was required. 4. A review of E6's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Based on E6's date of hire, this documentation was required. 5. In an interview, E2 reported all facility staff are scheduled to receive education on recognizing the signs and symptoms of TB by the end of the month. E1 acknowledged training and education related to recognizing the signs and symptoms of TB was not provided initially and annually to individuals employed by the health care institution.”

“Based on observation, record 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 specific to adults, for one of four personnel records sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include:  1. While on-site for the complaint investigation, the Compliance Officer observed E1 at the facility. 2. A review of E1's personnel record revealed documentation of completed CPR training conducted on April 10, 2024. However, documentation of E1's completed first aid training was not available for review. 3. In an interview, E1 acknowledged E1's personnel record did not include documentation of E1's completed first aid training.”