Serenethos Care Center, LLC

In the surveyor’s words

From the most serious findings on record at Serenethos Care Center, LLC, in the surveyor’s own words.

• Immediate jeopardy, widespreadF801Dec 16, 2022

  Based on observation, review of facility documents, and staff interviews, the facility failed to comply with federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC S 1265.4) for food service managers which required, employment of a full-time dietetic supervisor when the dietitian was not full time. […]

• Immediate jeopardy, isolatedF726Dec 16, 2022

  Based on observation, interview, and facility document review, the facility failed to ensure nursing staff demonstrated appropriate competencies and skillsets necessary to care for residents' needs when physician prescribed food texture was not verified before serving food to residents, and when Certified Nursing Aide 3 (CNA 3) did not have the knowledge to identify the appropriate food texture in accordance with the diet order before serving food to a resident. These failures had the potential for one resident (Resident 34) out of a facility census of 35, to aspirate (to breath in or inhale foreign objects into the lungs. […]

• Immediate jeopardy, isolatedF800Dec 16, 2022

  Based on observation, interview, and document review, the facility failed to provide a resident (Resident 34) a special dietary need as well as ensure Food and Nutrition Services had a system in place for preparing and serving the correct diet texture according to the physician's order when a regular texture diet (a diet that includes all textures of food including hard, tough, chewy, fibrous, stringy, dry, crispy, and crunchy; and intended for people without chewing and swallowing issues) was prepared for a resident (Resident 34) with prescribed modified texture Full Liquid diet (a diet made with fluids and foods that are normally liquid and/or turn to liquid when they are at room temperature). […]

• No harm, potential for more than minimal, widespreadF689Mar 9, 2023

  Based on observations, interviews, and record reviews, the facility failed to ensure an environment free of accident hazards when: 1. For 36 of 36 residents, the facility main entrance door was not securely closed to prevent unauthorized entrance or exit by residents or visitors. 2. For one of four sampled residents (Resident 1), the existing door alarm system did not alert staff to his unauthorized exit. These failures resulted in Resident 1 eloping on two occasions with minor scrapes and scratches sustained after the second elopement, and had the potential to result in elopements by other residents and access to residents by unauthorized visitors. Findings: During an observation on 2/13/23, at 11:45 a.m., the facility main entrance door was ajar several inches. […]

• No harm, potential for more than minimal, widespreadF802Dec 16, 2022

  Based on observation, interview, and facility document review, the facility failed to ensure the competency of staff when: 1. Staff did not know how to test the food-contact surface sanitizer; 2. Staff were not able to calibrate thermometers used to measure the temperature of food; 3. Staff did not know appropriate procedures for manual dishwashing; 4. Staff did not follow a recipe for the planned menu; and 5. Staff did not know the appropriate water temperature required for the dish machine. […]