Serenity Care Mid Valley.

“Staff became aware of a possible incident at 4:00 p.m. on 11/18/2025, but the home did not report it to the Department until 11:30 a.m. on 11/20/2025, exceeding the required 24-hour reporting timeframe.”

“Medication Administration Records contained false documentation for a PRN medication. Staff person A documented the medication was administered on multiple dates and times (11/15 at 2pm, 11/16 at 8:00 a.m., 11/17 at 6:00 a.m., 11/18 at 12:00 a.m., and 11/18 at 6:00 a.m.), but resident interviews verified the medication was only given once on 11/15/2025 at 2:00 p.m.”

“Unlabeled and undated food items (tube of meat, plastic bag of chicken, and plastic bag of tater tots) were found in the kitchen freezer. Food served and returned from an individual's plate may not be served again, and leftover food must be labeled and dated.”

“A bedroom housing two residents with mobility needs who use wheelchairs measured only 193.95 square feet, but required at least 200 square feet (100 per resident) to allow for easy passage and use of assistive devices.”

“The facility had no evidence of annual furnace cleaning as required by manufacturer's instructions. Required documentation was not maintained.”

“Windows and screens were not in proper repair and secure. New windows had been installed but ordered screens for the unoccupied Secured Dementia Care Unit had not yet been delivered.”

“The enabler bar attached to a resident's bed was not covered as required by FDA guidelines to prevent entrapment. The gap in the bars measured approximately 12 inches wide and 10 inches high.”

“Required emergency telephone numbers were not posted near the phone located in the activity room.”

“Combustible and flammable materials were stored near heat sources: a tissue and sock were found behind the dryer in the laundry room; six cans of flammable spray paint were located in a cardboard box within 3 feet of the natural gas furnace; and a canister of flammable denatured alcohol was stored in the furnace room.”

“Documentation of Medical Evaluation (DME) forms for residents #2 and #3 contained information that was recorded after the physician signed and returned the forms. For resident #2, supplemental oxygen orders and allergies were added after physician signature; for resident #3, allergies were added after physician completion.”

“A resident with an order for weekly injections had the injections administered by a med tech staff person who is not licensed to administer this type of injection.”

“A resident's support plan did not document required information about the enabler bar device: the resident's ability to use the device safely, the risks associated with use, and whether the enabler bar must be covered to meet FDA guidelines.”