Serenity Assisted Living

Based on the record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or resident’s representative for two of the three residents reviewed. The deficient practice posed a health and safety risk if the resident or representative did not acknowledge the services to be provided. Findings include: 1. A review of R1's medical record revealed the most recent written service plan for personal care services dated January 16, 2025. However, this service plan did not include a signature and date from the resident or the resident’s representative. 2. A review of R2's medical record revealed the most recent written service plan for personal care services dated February 13, 2025. However, this service plan did not include a signature and date from the resident or the resident’s representative 3. In an interview, E1 acknowledged that R1's and R2’s service plan did not include a signature and date from the resident or the resident’s representative.

Based on the record review and interview, the manager failed to ensure that a resident's medical record contained documentation showing that the pneumonia vaccination was offered every 12 months for two of three residents reviewed. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of R1's and R2's records revealed no documentation showing that the pneumonia vaccination was offered or received. 2. In an interview, E1 acknowledged that R1's and R2's records did not include current documentation showing that the pneumonia vaccination was offered or received.