PENDAR'S RESIDENTIAL CARE

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview the licensee did not comply with the section cited above by having a pad lock on the gate exiting from backyard and front yard which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2025 Plan of Correction ADM/Licensee will submit a letter of understanding of regulation and inservice training for staff and email LPA proof of correction by poc date 07/25/25

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, the licensee did not comply with the section cited above by having the knives drawer and toxics under sink unlocked which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2025 Plan of Correction ADMLicensee will submit a letter of understanding of regulation and inservice training for staff and email LPA proof of correction by POC date 07/25/25

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, resident R3's file did not contain LIC 602 Physician's Report last Physicians Report was on 05/25/23 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Licensee to submit a written plan of action to maintain record of resident's medical assessment. POC will be submitted to LPA by POC due date 07/31/25

Official classification

Type A

Official code

87413(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not ensure that a staff member was present with 4 residents, when 2 out of 2 staff members left to pick up R1 after R1 eloped from the facility which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee will conduct staff training on the facility's elopement policies and procedures and ensuring proper supervision at all times. Licensee will submit training document to LPA Kabariti via email by POC due date.

Deadline recorded: May 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure the front door was not free of obstruction as the front door contained a pad lock at the bottom left side of the front door which poses an immediate health, safety and personal rights risk to persons in care.

Official plan of correction

Licensee removed the pad lock on the front door during visit. Licensee will conduct a staff training regarding ensuring exit doors are free of obstruction. Licensee will submit training document to LPA Kabariti via email by POC due date.

Deadline recorded: May 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(b)

Regulation authority

CCR

What the official deficiency says

(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not ensure to update R1’s reappraisal to document R1’s new behavior of elopement which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee corrected the deficiency prior to visit by updating R1's appraisal/needs and services plan on 03/27/2025. LPA obtained a copy of the updated appraisal/needs and services plan.

Deadline recorded: May 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

(a) ... : (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. … (D) Any incident which threatens the welfare, safety or health of any resident, ... or unexplained absence of any resident. Based on interview, record review and observation the licensee did not ensure to report R1's elopement incidnet on 04/25/2025 to the Department which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

Licensee will complete training with staff regarding reporting requirements. Licensee will submit the training document to LPA Kabariti via email by POC due date.

Deadline recorded: May 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(d)(4)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance. (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review the licensee did not correctly administer the medication for 3 out of 3 residents in care, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2024 Plan of Correction Administrator stated that she is the one that administers the medications. Administrator will recount the medication as her plan and will create a better system to track the medication that are being administered or given to the residents. ADM stated that she will create the POC by the due date.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not maintain the planks that was rotting and needs repair on the ramps of BR2 and BR5, the sliding door screen of BR2 was frayed and the bathroom shower chair has a broken leg and tied together by a rope, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2024 Plan of Correction Licensee and ADM stated that they will submit a plan of correction to repair the rotting plank, the frayed screen and the shower chair will be replaced . LIC and ADM will submit the plan of correction by the POC due date.

Official classification

Type B

Official code

87506(a)(17)(A-F)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. (17) Documents and information required by the following: (A)Section 87457, Pre-Admission Appraisal;(B)Section 87459, Functional Capabilities;(C)Section 87461, Mental Condition;(D)Section 87462, Social Factors;(E)Section 87463, Reappraisals; and(F)Section 87505, Documentation and Support. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not maintain an updated record for 3 out of 3 resident's file that was reviewed during the time of inspection which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Administrator, stated that the record will be updated/completed by the POC due date. Adminstrator stated understanding of the requirement based on Title 22.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by: Licensee did not ensure that resident R1 had a medical assessment that was updated annualy, which poses a potential safety risk to residents in care.

Official plan of correction

Licensee agrees to update R1's LIC602A Physician's Report by POC date and submit a copy of the report to licensing once completed.

Deadline recorded: Oct 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(b)(17)(B)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (b) Each resident’s record shall contain at least the following information: (17) Documents and information required by the following: (B) Section 87459, Functional Capabilities. This requirement was not met as evidenced by: Licensee did not ensure that resident R2's resident record included a Functional Capabilities form, which poses a potential safety risk to residents in care.

Official plan of correction

Licensee agrees to complete a Functional Capabiliities form for resident R2 and submit a copy of the completed form by POC date.

Deadline recorded: Oct 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87706(H)(1)

Regulation authority

CCR

What the official deficiency says

(H) Physical environment, including environmental factors that ensure a safe, secure, familiar and consistent environment for residents with dementia. 1. Environmental factors that may be considered include:... architectural and safety features (e.g., wide hallways, handrails, delayed egress, secured perimeters);... This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the facility's exterior handrails was observed to be in disrepair with broken/sharp pieces of wood which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2022 Plan of Correction Licensee will repair the exterior handrails. Licensee will send LPA a photograph of the repaired handrails via email by POC due date.