Inspection Reports for
Serenity Place Residential Care

.330.04.c.vii. Resident care records: the facility nurse did not consistently document nursing assessments when residents experienced changes in their physical or mental health status, including falls on multiple dates; the administrator confirmed assessments were done but not documented.

.405.04. Fuel-fired heating: the facility had a gas fireplace in use that was not included in the current fuel-fired heating inspection, which had not been completed as required.

.151 Activity requirements: only one activity was offered per day, and residents were observed wandering and seeking things to do on multiple occasions.

.310.01.f Medication distribution system: the medication aide did not watch all residents take their medications and left multiple medication pills on the dining table for two unsampled residents without ensuring they were taken.

.403 Fire and life safety standards for existing buildings licensed for three through sixteen residents: the facility could not produce documentation for quarterly waterflow alarm testing for 2021 or first quarter 2022, and was missing one of two semi-annual kitchen hood suppression system inspections and hood cleaning/inspections with the last known inspection on July 11, 2021.

.155.03 Emergency generators: the facility could not produce documentation for weekly inspections, monthly load tests, or monthly conductivity testing of the battery.

.250.13 Secure Environment: the facility identified as a secured memory care unit assisting residents with cognitive impairments but did not have a safe and secure outside area; staff accompanied residents when going outside.

.305.03 Resident Health Status: there was no documentation that the facility nurse assessed residents who experienced changes of condition, including wounds, falls, and ingestion incidents.

.405.05 Structure, Maintenance, Equipment to Assure Safety: door at the top of the stairs separating the office level to the main facility was blocked open by a bag and would not fully self-close when released from the magnetic hold-open.

.415.05 Automatic Fire Extinguishing System Service and Testing: dry gauges were not inspected weekly, no records for quarterly waterflow alarm testing, no records for weekly or monthly control valve inspections, and sprinkler report dated 7/27/2018 lacked indicating marks showing status of inspection.

.310.01.a Medication Distribution System: the facilities medication cart was found unlocked on 10/18/17 at 2:50 PM and on 10/19/17 at 8:50 AM.

.335.03 Standard Precautions: a self reportedly ill staff member was observed cutting medications with a Buck knife on an office desk with no gloves.

.350.02 Administrator or Designee Investigation Within Thirty Days: the administrator did not initiate an investigation when caregivers reported potential allegations of abuse, including bruising and verbal and potential physical abuse (previously cited 3/30/11 and 12/19/14).

.350.03 Resident Protection: the facility administrator did not protect residents after an allegation of abuse was reported by caregivers.

.350.05 Facility Notification to Appropriate Agencies: the facility did not notify Adult Protection when allegations of abuse were reported to management from 7/12/17 to 9/21/17.

.350.06 Corrective Action for Known Allegations: there were no corrective actions implemented to protect all residents after repeated allegations of verbal and potential physical abuse were reported to the administrator by caregivers.

.600.06.a Sufficient Personnel: the administrator did not schedule sufficient personnel during all hours to provide the required two-person assistance with transfers for resident #4.

.405.03 Medical gases: three unsecured oxygen cylinders were found in the northeast bedroom; the facility placed them in a rack on the survey date and requires inservice training.

.405.07 Exit door locks: the facility is equipped with magnetic locking arrangements on exits without special locking arrangements as allowed under NFPA 101 Chapter 7.

.415.05 Automatic fire extinguishing system service and testing: the spare sprinkler box was only equipped with four spare sprinklers; the facility must maintain a minimum of six sprinklers.

.405.01 Medical gases: an oxygen concentrator was plugged into a relocatable power tap (power strip) in the northeast bedroom.