Serene Haven Estates

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for one of three personnel sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E3’s personnel record revealed a hire date of January 28, 2026. The personnel record contained documentation of one negative TB skin test. A second TB skin test was not available for review. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, record review, documentation review, and interview, the manager failed to ensure that, before providing assisted living services to a resident, a caregiver provided current cardiopulmonary resuscitation (CPR) training specific to adults, for one of three personnel sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. During the environmental inspection, the Compliance Officers observed E3 assisting a resident in the restroom. 2. A review of E3's personnel record revealed a certificate of completion for CPR and Automated External Defibrillator (AED) from the NationalCPRFoundation with an expiration date of December 11, 2026. 3. A review of the National CPR Foundation website, https://nationalcprfoundation.com/, revealed the following: The website stated, “National CPR Foundation is known for providing Life-Skill Techniques for longer more lasting lives. Harness the Power of Our Online Training and Earn Your Certification Today - The Smarter Way.” In the FAQ’s section, stated “Do you offer hands-on training? No, we do not offer hands-on training.” 4. In an interview, E1 reported that E3 was a certified caregiver. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on records review and interview, the manager failed to ensure a resident’s service plan contained the frequency of assisted living services provided to the resident, for two of two residents sampled. The deficient practice posed a risk to the residents if their needs were not being met. Findings include: A review of R1’s medical record revealed a service plan dated January 23, 2026. The service plan listed services R1 received. However, the service plan did not specify the frequency R1 received the following services: “Observe good feet care” “Clothing: assist, max” “Nail care: assist” “Toileting” A review of R2’s medical record revealed a service plan dated January 20, 2026. The service plan listed services R2 received. However, the service plan did not specify the frequency R2 received the following services: “Observe good feet care” “Clothing: assist, min” “Nail care: assist” “Toileting: dependent” In the exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on records review and interview, the manager failed to ensure a resident’s medical record contained the dosage administered to the resident. The deficient practice posed a risk as medication could not be verified as administered according to a medication order. Findings include: 1. A review of R1’s medical record revealed R1 received medication administration. 2. A review of R1’s medical record revealed a list of medication orders signed by a medical provider, dated September 19, 2025, which stated, “Trazadone 50mg Tablet - Oral, take 1-2 tablets at bedtime for insomnia.” 3. A review of R1’s medical record revealed a medication administration record (MAR) dated January 2026, which stated, “Trazadone Tablet 50MG, take 50 mg Tablet by mouth at bedtime.” The MAR indicated the medication was administered nightly at 8:00 PM. However, there was no indication of whether one or two tablets were administered nightly to R1. 4. In an interview, E1 reported R1 received only one tablet of Trazodone 50mg nightly. 5. In the exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, except as provided in R9-10-814(B)(2), for two of two residents reviewed who were confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814(B)(2) states, “A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: The resident or resident’s representative requests that the resident be accepted by or remain in the assisted living facility; The resident’s primary care provider or other medical practitioner: Examines the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident’s condition; Reviews the assisted living facility’s scope of services; and Signs and dates a determination stating that the resident’s needs can be met by the assisted living facility within the assisted living facility’s scope of services and, for retention of a resident, are being met by the assisted living facility…” 2. A review of R1’s medical record revealed a service plan dated January 23, 2026. The service plan revealed a section titled, “Mobility” which revealed R1 was wheelchair bound. 3. A review of R1’s medical record revealed an Initial Physician Recommendation Form dated January 30, 2025, which revealed R1 was not confined to a bed or chair. No other medical determination was provided for R1 at the time of the inspection. 4. A review of R2’s medical record revealed two service plans dated October 20, 2025, and January 20, 2026. Both service plans revealed a section titled, “Mobility” which revealed R2 was bedbound. R2’s medical record did not contain a medical determination that R2 was bedbound, and no determination was provided at the time of the inspection. 5. In the exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on records review and interview, the manager failed to ensure the service plan of a resident receiving directed care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, and offered sufficient fluids to maintain hydration, for two of two residents sampled. The deficient practice posed a risk if the residents’ needs were not being met. Findings include: 1. A review of R1’s medical record revealed a service plan dated January 23, 2026. The service plan revealed a section titled, “Medication/Treatment” which stated, “Remind to drink water every hour to provide hydration.” However, this box was not checked for R1. 2. A review of R2’s medical record revealed a service plan dated January 20, 2026. R2’s service plan revealed the following: R2’s service plan revealed a section titled, “Medication/Treatment” which stated, “Remind to drink water every hour to provide hydration.” However, this box was not checked for R2. R2’s service plan revealed a section titled, “Skin Condition” which listed the following: “Intact; Rashes; Poor Skin Turgor; Wound: Site___, Other___; Lotion: __Daily, __As Needed.” However, none of these items were selected for R2. 3. In the exit interview, the findings were reviewed with E1, and no additional information was provided.