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Inspection visit

Complaint

SERENITY VILLA IILicense 4968037201 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

Continued from 9099A... Complaint alleges facility is not meeting resident's care needs. Per review of records, resident was admitted to facility 2/20/2024 during a transitional time regarding their healthcare team. There were multiple changes in the persons providing care or assigned to the resident’s healthcare team. Resident is pre-diabetic and requires a consistent controlled carbohydrate (CCHO) and mechanically soft diet. Resident is non-ambulatory and requires assistance with ADLs, with the exception the resident is able to feed themselves. Per record review, facility has monitored blood sugar of resident beginning the day after admittance. Interviews with staff indicate an initial lack of clarity by resident’s healthcare team in regards to what actions need be taken if the blood sugar is too high or too low. Licensee requested clarification from resident’s healthcare nurse and received instruction as of 3/23/2024. On 3/27/2024 licensee held training with staff and made a chart for them specific to resident, as to an action plan regarding blood sugar readings. Record review shows that the resident was to receive a shower or sponge bath on Tuesdays, and a shower on Fridays. Record review shows that resident refused showers on a regular basis. Resident is not ambulatory and works with physical therapy to regain ambulatory status. Per interviews with staff and outside party, resident is often resistant to physical therapist’s suggestions for activity. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

Citations

1 citation recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • Dignity in personal relationships

    Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:Based on LPA interviews, the licensee did not comply with the section cited above in that facility staff was observed to have yelled at residents, which poses an immediate health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the June 28, 2024 inspection of SERENITY VILLA II?

This was a complaint inspection of SERENITY VILLA II on June 28, 2024. 1 citation were issued: 1 Type B.

Were any citations issued to SERENITY VILLA II on June 28, 2024?

Yes, 1 citation was issued (0 Type A, 1 Type B). The first citation was for: "Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall ha..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.