In Angel Arms, LLC.

“Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record. Findings include: 1 . A review of R1's medical record revealed a signed medication order for the following medications: -Acetaminophen PM Caplet once a day; -Budesonide 0.5 MG/2 ML Susp inhale 1 vial twice daily; -Finasteride 5 MG tablet once a day; -Olanzapine 5 MG tablet once a day; -Tamsulosin HCT 0.4 MG tablet once a day; and -Trazodone 50 MG tablet once a day. However, the following medications were not documented as administered on the following dates: -Acetaminophen PM Caplet on July 1, 2025; -Budesonide 0.5 MG/2 ML Susp (8 PM) on July 1, 2025; -Finasteride 5 MG tablet on July 1, 2025; -Olanzapine 5 MG tablet on July 1, 2025; -Tamsulosin HCT 0.4 MG tablet on July 1, 2025; and -Trazodone 50 MG tablet on July 1, 2025. 2 . In an interview, R1 reported R1 had received R1's medications every day. 3 . In an interview, E1 reported R1 received R1's medication every day. E1 acknowledged the medications for R1 were not documented correctly.”

“Based on record review and interview, the manager failed to ensure medications administered to a resident were documented in the resident's medical record for one of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered. Findings include: 1. A review of R2's electronic medical record revealed the following medications were not documented as administered to R2: -Carbidopa and Levodopa 25-100 mg at the following days/times: -6:30 AM on March 10, 2024 -10:00 AM on March 10 and March 11, 2024 -1:30 PM on March 4, 2024 -5:00 PM on March 6, 7 and 11, 2024 -8:30 PM on March 8, 9 and 12, 2024 -Denepezil HCL 10 mg at the following days/times: -8:00 PM on March 8, 9 and 12, 2024 -Oxybutynin Chloride 5 mg at the following days/times: -8:00 AM on March 10, 2024 -Desvenlafaxine ER 100 mg at the following days/times: -8:00 AM on March 10, 2024 -Entacapone 200 mg at the following days/times: -6:30 AM on March 10, 2024 -10:00 AM on March 10 and March 11, 2024 -1:30 PM on March 4, 2024 -5:00 PM on March 6, 7 and 11, 2024 -8:30 PM on March 7, 8, 9, 12, 2024 -Mirtazapine 7.5 mg at the following days/times: -8:00 PM on March 8, 9 and 12, 2024 -Acetaminophen 500 mg at the following days/times: -6:30 AM on March 10, 2024 -5:00 PM on March 6, 7 and 11, 2024 -Senna Plus 8.6-50 mg at the following days/times: -8:00 AM on March 10, 2024 -8:00 PM on March 8, 9 and 12, 2024 -Depakote 125 mg at the following days/times: -1:30 PM on March 4, 2024 -8:00 PM on March 8 and 9, 2024 -Trazodone Hydrochloride 50 mg at the following days/times: -8:00 PM on March 8, 9 and 12, 2024 2. In an interview, E3 acknowledged R2's electronic medical record (EMR) did not contain documentation on certain days and times, as medications were administered. E3 reported the facility was still learning a new electronic medical program and reported the medications had been administered to the residents, however, were not documented in a timely manner, in the EMR, therefore the EMR "locked out" the caregivers, not allowing the caregivers to document the medications had been administered.”