Serenity Family Care Home

The facility failed to ensure that all staff members had Health Care Personnel Registry (HCPR) checks completed prior to being employed. Specifically, personnel records for three out of four sampled staff members lacked documentation of HCPR checks at the time of hire.

The facility failed to ensure that resident care plans were updated. Based on interviews and record reviews, the facility did not meet the requirements for maintaining current resident assessments.

The facility failed to complete annual resident assessments for three sampled residents. Specifically, one resident had no care plans since April 2023, and another had an incomplete care plan lacking required signatures from the assessor and the Primary Care Provider.

The facility failed to ensure the accuracy of Medication Administration Records (MAR) for a resident. Specifically, the MAR for Resident #2 lacked entries for the administration of prescribed albuterol treatments during January, February, and March of 2021.

The facility failed to ensure that one of two sampled residents was notified of their discharge and appeal rights at least 30 days prior to discharge. Specifically, Resident #4 was transferred without receiving proper notice, and the resident's family was not notified of the change in residence.