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

A licensure complaint revisit was completed on 4/30/25 for all previous deficiencies cited on 4/8/24. A deficiency was cited.The regulations governing Assisted Living Residences were revised. The Chapter 2 regulations were implemented on 7/1/24 and the new Chapter 7 regulations were implemented on 3/17/25. Based on record review and interview, the residence failed to either directly or indirectly provide protective oversight, including, but not limited to, taking appropriate measures when confronted with an unanticipated situation or event affecting seven current residents. Findings include:1. References and Residence Policiesa. Chapter VII regulations governing assisted living residences:Part 2.38, defines "Protective oversight" as the guidance of a resident as required by the needs of the resident or as reasonably requested by the resident, including the following:(B) Monitoring the activities of the resident while on the premises to ensure the resident' s health, safety, and well-being.b. The undated residence' s resident agreement read that the residence staff observed the residents' safety and well-being and summoned assistance when required.c. 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..