Deficiencies per Year
4
3
2
1
0
Unclassified
Inspection Report
Follow-Up
Deficiencies: 2
Nov 6, 2025
Visit Reason
The inspection was a health care licensure and follow-up survey to verify compliance with prior requirements and assess current facility conditions.
Findings
The facility nurse did not consistently document nursing assessments after residents experienced changes in health status, including falls. Additionally, the fuel-fired heating inspection did not include the gas fireplace in the main sitting area, which was in use and had not been inspected.
Deficiencies (2)
| Description |
|---|
| The facility nurse did not consistently document nursing assessments when residents experienced changes in their physical or mental health status. |
| The fuel fired heating inspection/testing did not include the gas fireplace within the current inspection. |
Report Facts
Resident falls: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joy Cook | Administrator | Confirmed assessments were done but not documented; also noted the fuel fired heating inspection was incomplete |
| Bradley Perry | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Follow-Up
Deficiencies: 2
May 24, 2023
Visit Reason
The visit was a health care licensure and follow-up survey conducted to assess compliance with regulatory requirements at Serenity Place Residential Care.
Findings
The survey found that only one activity was offered to residents daily, with residents observed wandering and seeking activities. Additionally, the medication aide failed to observe all residents taking their medications, leaving pills unattended on the dining table for two residents.
Deficiencies (2)
| Description |
|---|
| Only one activity was offered to residents daily, with residents wandering and seeking things to do. |
| Medication aide did not observe all residents taking medications and left pills unattended on the dining table. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joy Cook | Administrator | Named as facility administrator during the survey. |
| Melvin Lu | Survey Team Leader | Led the health care licensure and follow-up survey. |
Inspection Report
Life Safety
Capacity: 16
Deficiencies: 3
Apr 18, 2022
Visit Reason
The inspection was conducted to assess compliance with fire life safety and sanitation licensure standards for a residential care facility licensed for three through sixteen residents.
Findings
The facility failed to maintain compliance with the 2018 edition of NFPA 101 Life Safety Code and related standards, including missing documentation for quarterly waterflow alarm testing and incomplete semi-annual kitchen hood suppression system inspections. Additionally, the facility lacked documentation for weekly inspections, monthly load tests, and battery conductivity testing of the emergency generator.
Deficiencies (3)
| Description |
|---|
| Facility could not produce documentation for quarterly waterflow alarm testing for 2021 or first quarter 2022. |
| Facility was missing one of two semi-annual kitchen hood suppression system inspections and hood cleaning/inspections; last known inspection was July 11, 2021. |
| Facility could not produce documentation for weekly inspections, monthly load tests, or monthly conductivity testing of the emergency generator battery. |
Report Facts
Total licensed capacity: 16
Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 10, 2021
Visit Reason
The inspection was conducted as a health care complaint investigation at Serenity Place Residential Care.
Findings
The facility was found to lack a secure outside area for residents despite identifying as a secured memory care unit, and there was no documentation that the facility nurse assessed residents after changes in their health status, including wounds, falls, and incidents of unresponsiveness.
Complaint Details
The visit was triggered by a health care complaint investigation as stated in the survey type.
Deficiencies (2)
| Description |
|---|
| The facility did not have a safe and secure outside area for residents in the secured memory care unit. |
| No documentation of nurse assessments after residents experienced changes in condition such as wounds, falls, and unresponsiveness. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joy Cook | Administrator | Named as the facility administrator who stated the facility did not have a secured outside area. |
| Tom Moss | Survey Team Leader | Led the health care complaint investigation survey. |
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