Serenity at Woodlands LLC

A revisit survey was completed on 8/28/25 for previous deficiencies cited on 4/30/25. The agency is in compliance with all regulations surveyed. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A revisit survey was completed on 8/28/25 for previous deficiencies cited on 4/30/25. The agency is in compliance with all regulations surveyed. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

8.7506.B Alternative Care Facility Definitions2. Protective Oversight means monitoring and guidance of a Member to assure their health, safety, and well-being. Protective Oversight also includes but is not limited to: monitoring the Member while on the premises of service setting, monitoring the Members' needs, and ensuring that the Member receives the services and care necessary to protect their health and welfare. Based on record review and interview, the facility (residence) failed to provide protective oversight to protect the health and welfare of members (residents), affecting seven current residents. Findings include:1. Residence Policiesa. The undated residence' s resident agreement read that the residence staff observed the residents' safety and well-being and summoned assistance when required.b. The residence' s undated Disaster Plan read in part that the residence staff members were responsible for the safety of all residents and responsible for knowing and being prepared for emergencies.2. Record ReviewA state fire authority (SFA) report, dated 4/23/25, read in part that the fire panel at the residence showed a trouble code.3. InterviewsOn 4/29/25 at 8:07 a.m., a SFA representative stated that he visited the residence on 4/23/25, and the fire panel showed a trouble code. He added that the residence staff could not answer questions about the code or how they should have responded to the code.On 4/29/25 at 9:15 a.m., a representative from the fire panel company stated that the residence had not contacted him when the fire panel showed a trouble code. He added the trouble code was related to the telephone line being down; however, the panel had a backup telephone line to contact the local fire authority (LFA) as needed. He added that the trouble code would not have shown that it was fully operational without a call to confirm with him. On 4/29/25 at 9:45 a.m., the administrator stated that the residence fire panel showed a trouble code last week as one of the telephone lines was down. He added that he was .. A certification complaint revisit was completed on 4/30/25 for all previous deficiencies cited on 4/8/24. A deficiency was cited.The regulations governing Home and Community-Based Services were revised and the new regulations were implemented on 2/15/25.