Serenity Seniors Home Iii

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA was unable to review P&I ledgers for clients #1-4 at the time of annual inspection which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above as LPA observed about a four foot cement area (accesssible to clients) in the backyard with uneven broken cement, which poses a potential health, safety risk to persons in care.

Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This deficiency was evidenced by the following: Staff indicated they were unaware of the condition of the wound due to home health agencies not providing documentation. However, it’s the facility staff’s responsibility to obtain the required documentation to confirm their resident is provided adequate care.

Prohibited Health Conditions(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:(1) Stage 3 and 4 pressure injuries. This deficiency was evidenced by the following: R1 was noted to have redness or a pressure injury around April or May 2019. Staff admitted the wound was worsening in August 2019. Treatment did not start until 8/22/19 when pressure injury was noted as a Stage IV.

Based on LPA observation and interviews conducted, the licensee did not comply with the section cited above trhe hot watwer temperature measured between 124.1 and 126.0 degrees F which poses an immediate health, safety or personal rights risk to persons in care.