Serenity Villa

Based on LPA's/staff observation, interview & record review, the licensee did not comply with the section cited above by not providig garbage cans with cover lids to resident's bedrooms and bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in two out of seven resident's care plans were not signed by their responsible parties which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the Licensee/Administrator did not comply with the section cited above in that a cleaning cart with chemicals was left unattended in the residents hallway which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the Licensee/Administrator did not comply with the section cited above in 4 out of 4 fire extinguishers were not serviced since December 21, 2023 which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that two Caregivers (S1) and (S2) were not associated with the facility in Guardian which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation the licensee did not comply with the section cited above that resident's (R1) had a whole tablet of an unidentifiable medication loose in the medication bin. In addition, resident's (R2) prescription for Aripiprazole had no prescription label on the bottle or in the medication bin. Both incidents pose an immediate health, safety or personal rights risk to persons in care.

Based on LPA/Licensee's observation, spot check, records review and interview, the licensee did not comply with the section cited above in 4 out of 7 medications reviewed for residents in care were not given according to the physician's orders, which poses an immediate health, safety or personal rights risk to persons in care.

87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical…& that appropriate assistance is provided when such observation reveals unmet needs...This requirement has not been met as evidence by: Based on interviews conducted and records review. Facility did not observe change of condition in R1 after blister popped out of R1’s right foot, which poses an immediate risk to the health and safety of the residents in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require… (1) A written report shall be submitted to the licensing...& person responsible for the resident within 7 days…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidence by: Based on LPA’s records review and interviews conducted Administrator did not ensure that CCL was notified of incidents involving R1’s Stage II pressure injury, which poses a potential health & safety risk to residents in care.

87303(a)Maintenance and Operation- (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services & procedures for the safety and well-being of residents, employees, and visitors. This requirement is not met: Based on records review and interviews conducted with Licensee, the facility did not ensure that front entrance was operating properly, which poses a potential risk to the health and safety of residents in care.

Based on observation, the licensee did not comply with the section cited above in 1 out of 5 emergency exits was locked with a combination lock, inabeling anyone not having the combination the ability to exit. This poses an immediate health, safety risk to persons in care. **Immediate Civil Penalty assessed in the amount of $500.