In Angel Arms II

Based on observation and interview, the manager failed to designate a caregiver who is present on the assisted living facility’s premises and accountable for the assisted living facility when the manager is not present on the assisted living facility premises. Findings include: 1 . When the Compliance Officer arrived at the facility at approximately 9:30 AM on July 24, 2025, it was observed only E3 was on the premises. 2 . During an environmental inspection of the facility, the Compliance Officer observed a document titled "Delegation of Manager's Authority." However, this document did not include E3 on the list of delegated individuals. 3 . In an interview, E1 acknowledged there was no designated caregiver at the facility when the Compliance Officer arrived at approximately 9:30 AM.

Based on observation and interview, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver. Findings include: 1 . When the Compliance Officer arrived at the facility at approximately 9:30 AM on July 24, 2025, it was observed only E3 was on the premises. 2 . In an interview, E1 reported E3 was only an assistant caregiver. E2 reported E1 had worked with residents at the facility by themselves. E1 acknowledged E3 had worked without supervision.

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services and according to policies and procedures. Findings include: 1 . A review of facility documentation revealed a policy titled "Employees and Volunteer Qualifications." The policy stated, "Skill and knowledge verification will be conducted during the working interview. Skills and knowledge will be documented using required forms initialed by the interviewee and signed off by the manager for hire." 2 . A review of E3's personnel record revealed documentation of skills and knowledge was not available for review at the time of inspection. 3 . In an interview, E1 acknowledged E3 had no documentation of skills and knowledge.

Based on documentation review and interview, the manager failed to ensure documentation is maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. Findings include: 1 . A review of facility documentation revealed a document titled "Work Schedule" for July 2025. However, there was no documentation of hours worked for caregivers or assistant caregivers from July 19, 2025 to July 24, 2025. 2 . In an exit interview, the findings were discussed with E1 and E2, 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, an assistant caregiver received orientation that is specific to the duties to be performed by the assistant caregiver. Findings include: 1 . A review of facility documentation revealed a policy titled "Employees and Volunteer Qualifications." The policy stated, "Must complete orientation before aiding residents." 2 . A review of E3's personnel record revealed documentation of orientation was not available for review at the time of inspection. 3 . In an interview, E1 acknowledged E3 had no documentation of orientation.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical record, for five of five residents sampled. Findings include: 1 . A review of R1's medical record revealed a current service plan. The following services were listed on the service plan: -Dressing twice daily and as needed; and -Bathing twice weekly and as needed. However, a review of R1's Activities of Daily Living (ADL) sheets revealed the following services were not documented as provided on the following days: -Dressing (Wake Up) from July 8, 2025 to July 10, 2025; July 12, 2025 to July 17, 2025; July 19, 2025 to July 22, 2025; and Dressing (Bed Time) from July 8, 2025 to July 10, 2025; July 11, 2025; July 12, 2025 to July 17, 2025; July 19, 2025 to July 22, 2025; and -Bathing from July 7, 2025 to July 23, 2025. 2 . A review of R2's medical record revealed a current service plan. The following services were listed on the service plan: -Grooming (Oral Care) daily; -Dressing assistance (Daily); and -Bathing three times weekly and as needed. However, a review of R2's Activities of Daily Living sheets revealed the following services were not documented as provided on the following days: -Oral Care (Wake Up) on July 2, 2025; July 4, 2025 to July 5, 2025; July 8, 2025 to July 10, 2025; July 12, 2025 to July 17, 2025; July 19, 2025 to July 22, 2025; and Oral Care (Bed Time) from July 1, 2025 to July 5, 2025; July 8, 2025 to July 17, 2025; July 19, 2025 to July 23, 2025; -Dressing (5 AM) from July 1, 2025 to July 5, 2025; July 8, 2025 to July 23, 2025; and Dressing (Bed Time) from July 1, 2025 to July 5, 2025; July 8, 2025 to July 17, 2025; July 19, 2025 to July 23, 2025; and -Bathing from July 8, 2025 to July 23, 2025. 3 . A review of R3's medical record revealed a current service plan. On the service plan, bathing was listed as twice a week. However, a review of R3's Activities of Daily Living sheets revealed bathing was not documented as provided from June 27, 2025 to July 23, 2025. 4 . A review of R4's medical record revealed a current service plan. The following services were listed on the service plan: -Dressing twice daily and as needed -Oral care twice daily and as needed; and -Bathing twice weekly and as needed. However, a review of R4's Activities of Daily Living sheets revealed the following services were not documented as provided on the following days: -Dressing (Wake up) on June 29, 2025; July 1, 2025 to July 4, 2025; July 8, 2025 to July 17, 2025; July 19, 2025 to July 23, 2025; and Dressing (Bed time) from June 28, 2025 to July 5, 2025; July 8, 2025 to July 17, 2025; July 19, 2025 to July 23, 2025; -Oral care (Wake up) on June 29, 2025; July 1, 2025 to July 4, 2025; July 8, 2025 to July 17, 2025; July 19, 2025 to July 21, 2025; July 23, 2025; and Oral care (Bed Time) from June 28, 2025 to July 5, 2025; July 8, 2025 to July 17, 2025; July 19, 2025 to July 20, 2025; and July

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of five residents sampled. Findings include: 1 . A review of R1's medical record revealed a current signed medication order list. The list included the following medications: -Buspirone HCL 10 MG tablet twice daily; -Divalproex Delayed 250 MG tab once daily; -Divalproex Delayed 500 MG tab twice daily; -Lactulose 10 GM/15 ML solution 30 ML by mouth twice daily; -Mirtazapine 15 Mg tablet once daily; and -Risperdal Consta 50MG once every two weeks. However, the following medications were not documented as administered on the following dates: -Buspirone HCL (8 PM) on July 11, 2025; July 18, 2025; July 21, 2025; -Divalproex Delayed 250 MG on July 11, 2025; July 18, 2025; July 21, 2025; -Divalproex Delayed 500 MG (8 PM) on July 11, 2025; July 18, 2025; July 21, 2025; -Lactulose 10 GM/15 ML solution (5 PM) (8 PM) on July 11, 2025; July 21, 2025; July 22, 2025; -Mirtazapine 15 Mg on July 11, 2025; July 18, 2025; July 21, 2025; and -Risperdal Consta 50MG on July 19, 2025. 2 . A review of R2's medical record revealed a current signed medication order list. The list included the following medications: -Arthritis Pain ER 650 MG 1 tablet three times daily; -Aspirin EC 81 MG tablet once a day; -Atorvastatin 40 MG tablet once a day; -Divalproex Sodium 125 MG capsule twice a day; -Famotidine 20 MG tablet twice daily; -Ferrous Sulfate 324 MG tablet once daily; -Gabapentin 300 MG capsule twice daily; -Isosorbide MN ER 30 MG tablet once a day; -Latanoprost eye drops once daily; -Quetiapine 50 MG tablet once daily; and -Sennoside S 8.6 MG-50MG tablet twice a day. However, the following medications were not documented as administered on the following dates: -Arthritis Pain ER 650 MG (8 AM) from July 8, 2025 to July 11, 2025; July 13, 2025 to July 17, 2025; July 21, 2025; Arthritis Pain ER 650 MG (2 PM) on July 3, 2025; July 8, 2025 to July 19, 2025; July 22, 2025 to July 23, 2025; Arthritis Pain ER 650 MG (8 PM) on July 1, 2025; July 3, 2025 to July 4, 2025; July 8, 2025 to July 17, 2025; July 19, 2025; July 21, 2025; -Aspirin EC 81 MG from July 8, 2025 to July 11, 2025; July 13, 2025 to July 17, 2025; July 21, 2025; -Atorvastatin 40 MG on July 1, 2025; July 3, 2025 to July 4, 2025; July 8, 2025 to July 17, 2025; July 19, 2025; July 21, 2025; -Divalproex Sodium (12 PM) on July 3, 2025; July 8, 2025 to July 19, 2025; Divalproex Sodium (5 PM) from July 3, 2025 to July 4, 2025; July 8, 2025 to July 17, 2025; July 21, 2025 to July 22, 2025; -Famotidine 20 MG (8 AM) from July 8, 2025 to July 11, 2025; July 13, 2025 to July 17, 2025; Famotidine 20 MG (5 PM) from July 3, 2025 to July 4, 2025; July 8, 2025 to July 17, 2025; July 21, 2025 to July 22, 2025; -Ferrous Sulfate 324 MG from July 8, 2025 to July 11, 2025; July 13, 2025 to July 17, 2025; -Gabapentin 300 MG (8 AM) from July 8, 2025 to July 11, 2025; July 13

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food or medication contained a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a thermometer in the refrigerator in the kitchen. However, the thermometer was not functional. 2 . In an interview, E1 acknowledged the thermometer was not functional. Technical assistance was provided for this citation on an abbreviated inspection conducted on May 17, 2024.