Inspection Reports for Serene Gardens of Hartland

The complaint alleged Resident A was not monitored consistently, leading to increased falls and serious injuries, employees shared resident information with visitors, and the facility experienced physical maintenance issues. The monitoring allegation was substantiated; the others were not.

The investigation substantiated a violation related to inconsistent monitoring and incomplete incident reporting for Resident A's falls. The allegations of employees sharing resident information and physical maintenance issues were not substantiated, as staff training and prompt repairs were confirmed.

Complaint alleged Resident A fell and staff did not assist her, and that the facility stopped administering her prescribed medication. The fall allegation was not substantiated, but the medication administration allegation was substantiated with a violation established.

The investigation found that Resident A did fall but staff responded appropriately and no violation was established regarding the fall. However, the facility did not comply with medication administration rules because Resident A was admitted without a physician's medication order, resulting in missed medication doses and a violation was established.

The facility was found to be in non-compliance with multiple rules including lack of designated supervisor on each shift, incomplete medication administration records, insufficient instructions for as-needed medications, inaccurate therapeutic diet menus, incomplete meal census records, inadequate ventilation in soiled linen rooms, and expired or undated condiments in the kitchen refrigerator.