Serenity Villa II

The inspection involved an informal office meeting to discuss facility practices. Two deficiencies were noted concerning the proper use of gait belts and adherence to personal rights and staffing ratios. Both cited deficiencies are classified as Type B, indicating potential risks that require correction but do not present an immediate, direct threat to health or safety.

The inspection identified multiple deficiencies, including three Type A citations related to the use of postural supports as restraints, which presents an immediate risk to resident safety. Additionally, one Type B deficiency was cited for the presence of feces in a resident's closet drawer, indicating a sanitation issue. The facility was otherwise noted to have some compliance issues, such as a malfunctioning cabinet lock, but the primary concerns relate to resident rights and sanitation.

The facility was inspected via Case Management on 07/23/2025. The Licensing Program Analyst observed the rooms and noted that the facility appears to meet the requirements outlined in regulation 87307(a)(2). No deficiencies were cited during this visit.

The facility underwent a required Annual inspection and was generally found to be in good condition. The inspector noted several positive observations regarding cleanliness, safety equipment, and documentation review. No deficiencies were cited during this inspection.

COMPLAINT INVESTIGATION REPORT

The facility underwent a collateral visit on March 21, 2024. The analyst interviewed staff and residents regarding complaints unrelated to the facility. No deficiencies were cited during this inspection.

The facility underwent a required Annual inspection and was generally found to be clean with appropriate safety measures observed, such as locked cleaning supplies and accessible emergency equipment. The primary deficiency noted relates to the water temperature in resident care sinks, which was found to be outside the regulated range. The facility has established a plan to correct this issue by contacting a hot water tank installer.

The inspection was a Required 1-Year review focused on Infection Control procedures. While the facility was generally found to be clean and orderly, a significant deficiency was noted regarding visitor screening protocols. Specifically, staff were observed failing to screen visitors and the inspecting analyst until prompted, citing a violation of administrator qualifications.