Mount Hood Serenity Care

Right to freedom from abuse and neglect

87468.2-Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1....(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by; Record review and interviews reflected that resident, R1 funds were stolen by staff , S1 while living at the facility which poses a immediate health and safety risks to residents in care.

Required administrator qualifications listed in this subsection

Based on observation and interview, the licensee did not comply with the section cited above as facility administrator was not working/accessible during inspection which poses/posed a potential health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on facility tour, LPA observed chemicals and knives were accessible in kitchen which poses an immediate health, safety or personal rights risk to persons in care.

Allow licensing inspection and controlled record removal

Based on facility tour, staff interviews, staff have no access to residents and staff's records for Department audit, which poses/posed a potential health, safety or personal rights risk to persons in care.

Store centrally held medications in locked secure place

Based on observation, the licensee did not comply with the section cited above as medications closet was found to be open and medications were accessible to residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Address and clearance obligations before facility work

Based on record review, Department found out that staff, S1 was not fingerprint cleared and was working at the facility for 2 weeks which poses an immediate health, safety or personal rights risk to persons in care.

Reporting requirements

87211-Reporting Requirements- (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following... this requirement is not met as evidence by; Staff interview reflected that resident, R1 was sent out to hospital after fall incident with right hip fracture on 03/24/25 but facility did not report this incident to Department per requirement which poses a potential safety and health risks to residents in care.

Maintain facilities for fire and panic safety

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as LPAs observed facility fire door to be propped open with a door stopper which poses an immediate health, safety or personal rights risk to persons in care.

Maintain records of centrally stored medication dosages

Based on interview and record review, the licensee did not comply with the section cited above as facility was not using Centrally Stored Medication Log for medication management as Required for all residents including R1, which poses/posed a potential health, safety or personal rights risk to persons in care.

Resident record must include minimum required items

Based on interview and record review, the licensee did not comply with the section cited above as resident, R1 file was missing LIC627C,Pre-admission appraisal,Needs and Service plan,LIC405, LIC621 which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain required personnel records for staff

Based on interview and record review, the licensee did not comply with the section cited above as staff ,S1 file were missing LIC503, LIC501,TB , Training Records for staff,S1, which poses/posed a potential health, safety or personal rights risk to persons in care.