Inspection Reports for Serenity RCF
15225 SE Powell Blvd, Portland, OR 97236, OR, 97236
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24
18
12
6
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Inspection Report
Kitchen
Census: 19
Capacity: 25
Deficiencies: 24
Sep 17, 2024
Visit Reason
State-compiled facility profile showing 3 inspections from 2023-09 to 2024-09 with deficiency history and enforcement actions
Findings
Across three inspections from September 2023 to September 2024, the facility exhibited multiple deficiencies including failure to maintain food sanitation standards, incomplete acuity-based staffing tool implementation, inadequate resident care plans, medication administration errors, infection control lapses, and insufficient administrative oversight. Some deficiencies were corrected by the latest visits, but several remained uncorrected.
Complaint Details
Complaint investigation conducted on 2024-04-24 related to licensure complaint with 1 deficiency found regarding acuity-based staffing tool implementation
Deficiencies (24)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols were in accordance with Food Sanitation Rules including cleaning and food storage |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update an acuity-based staffing tool for residents |
| C0000 - Comment: Initial licensure survey findings and re-visit surveys documented compliance issues |
| C0150 - Facility Administration: Operation: Failed to provide adequate administrative oversight of facility operation and quality of services |
| C0155 - Facility Administration: Records: Failed to ensure preparation, completeness, accuracy and preservation of resident records |
| C0156 - Facility Administration: Quality Improvement: Failed to develop and conduct ongoing quality improvement programs |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report suspected abuse promptly and investigate with documented administrator review |
| C0243 - Resident Services: ADLs: Failed to provide services assisting residents with activities of daily living and behavioral symptoms |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure initial evaluations contained all required elements and evaluated assistive device use |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective, clear, available, and followed for residents |
| C0262 - Service Plan: Service Planning Team: Failed to ensure service plans were developed by a proper service planning team |
| C0270 - Change of Condition and Monitoring: Failed to evaluate, communicate, and document changes of condition and interventions |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to coordinate care with outside providers to ensure continuity |
| C0295 - Infection Prevention & Control: Failed to maintain infection prevention protocols and comply with masking requirements |
| C0302 - Systems: Tracking Control Substances: Failed to have a system for tracking controlled substances accurately |
| C0303 - Systems: Treatment Orders: Failed to ensure medication orders were carried out as prescribed and properly documented |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when resident refused medications or treatments |
| C0310 - Systems: Medication Administration: Failed to ensure resident MARs were accurate and included specific parameters for PRN medications |
| C0340 - Restraints and Supportive Devices: Failed to ensure assessments and documentation prior to use of supportive devices with restraining qualities |
| C0361 - Acuity-Based Staffing Tool: Failed to implement and update acuity-based staffing tool appropriately (repeat citation) |
| C0420 - Fire and Life Safety: Safety: Failed to conduct and record fire drills every other month and provide staff training |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
| C0515 - Resident Units: Failed to provide lockable storage space that was secure for residents' valuables |
| C0530 - Housekeeping and Laundry: Failed to ensure washers had minimum rinse temperature or used chemical disinfectant when washing soiled linens and clothing |
Report Facts
Inspections on page: 3
Total deficiencies: 23
Licensing violations: 4
Abuse violations: 0
Notices: 0
Licensed beds: 25
Facility census: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director (ED), also Infection Control Specialist | Named in multiple findings including kitchen sanitation, acuity-based staffing tool, infection control, and administrative oversight |
| Staff 2 | Director of Nursing Services | Named in findings related to resident records, medication administration, and supportive device assessments |
| Staff 3 | Resident Care Coordinator (RCC) | Named in findings related to abuse reporting, care coordination, and quality improvement |
| Staff 4 | Administrator / Behavior Coordinator | Named in findings related to acuity-based staffing tool and service plan issues |
| Staff 13 | Owner | Named in multiple findings discussions and acknowledgments |
| Staff 14 | Program Director | Named in multiple findings discussions and acknowledgments |
| Staff 17 | Owner | Named in multiple findings discussions and acknowledgments |
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