Pendo 1 Care Homes LLC

Based on record review, documentation review, and interview, the manager failed to ensure a service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; offering sufficient fluids to maintain hydration; and incontinence care that ensures that a resident maintained the highest practicable level of independence when toileting, for two of five residents sampled receiving personal care services. Findings include: 1. A review of R1 and R4's medical records revealed documentation of their current written service plans for personal care services did not contain the following: - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; - Offering sufficient fluids to maintain hydration; and - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting. 2. A review of R2 and R3's medical records revealed documentation of their current written service plans for personal care services did not contain the following: - Offering sufficient fluids to maintain hydration; and - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting. 3. In an interview, E1 reported being unaware the service plans did not include the documentation of skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; and offering sufficient fluids to maintain hydration.

Based on documentation review, record review, observation, and interview, the manager of a facility providing directed care services failed to ensure a means of exiting the facility providing access to an outside area alerted employee of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of the license issued by the Department revealed the facility was licensed at the directed care level. 2. A review of R2, R3, and R4's medical records revealed all three were receiving directed care services. 3. While on-site the Compliance Officer observed R4 wandering about the facility opening and closing doors in the kitchen, the patio and other rooms in the facility. 4. During a tour of the facility the Compliance Officer observed when exiting from the facility onto the patio no alarm alerted employees of an individual exiting the facility. The Compliance Officer observed an alarm at the top of the door, however, the alarm was not on. When turned on the alarm sounded and would not shut off. E2 reported turning it off due to the noise. The Compliance Officer observed part of the alarm was broken and did not make contact with the other part to allow the alarm to shut off. The alarm was not in working condition. 5. During a telephonic interview, E1 reported being unaware the door alarm was not working. This is a repeat citation from the abbreviated inspection conducted on May 21, 2024.

Based on observation, documentation review, record review, and interview, the manager of a facility providing directed care services failed to ensure a means of exiting the facility providing access to an outside area alerted employee of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of the license issued by the Department revealed the facility was licensed at the directed care level. 2. When the Compliance Officers entered the facility they observed the door did not alert employees of the egress of a resident. The Compliance Officers observed an alarm on the top of the door however, the alarm was not on. E2 turned the alarm on. The alarm would only alert when the door was closed, it did not alert when the door opened. The facility's entrance door did not have any means to alert employees of a resident's egress. 3. A review of R1, R2, and R3's medical records revealed all three were receiving directed care services. 4. While on-site the Compliance Officers observed R1 wandering about the facility opening and closing doors in the kitchen, the patio and other rooms in the facility. 5. During a tour of the facility the Compliance Officers observed when exiting from the facility onto the patio no alarm alerted employees of an individual exiting the facility. The Compliance Officers observed an alarm at the top of the door, however, the alarm was not on. E2 tried to turn the alarm on and it was not in working order. 6. Outside the facility the Compliance Officer observed a gate leading into the street and the surrounding neighborhood. The Compliance Officer observed the gate did not have a lock. The Compliance officer was able to open the gate and enter the street and surrounding neighborhood. E2 reported taking the lock off the gate to remove the trash and forgetting to put it back on. The patio door and the gate did not have any means to alert employees of a resident's egress. 7. During an interview, E2 acknowledged the front door alarm was not working, the patio door alarm was not working, and the gate leading to the road did not have any means to alert employees of a resident's egress. 8. During a telephonic interview, E1 and E3 reported being unaware the door alarms were not working and the gate had been left unlocked.