Serenity at Lgar.

“A resident requiring incontinence care every 2 hours was found with two completely saturated pull-ups and saturated bedding at 7:00 AM after last documented check at 4:00 AM, constituting neglect. Additionally, the resident was wearing two pull-ups simultaneously, violating the facility procedure that only one brief or pull-up should be used at a time.”

“A gallon bottle of Bullseye degreaser cleaner concentrate and a gallon bottle of Fresh Start concentrated malodor counteractant, both labeled with poison warnings, were found unlocked, unattended, and accessible to residents in the activity room near the nurses station. The entire home is licensed as a secured dementia care unit with residents not assessed as capable of safely recognizing and using poisons.”

“The home did not have written emergency procedures that include contact information for each resident's designated person, the home's plan to provide emergency medical information with confidentiality, contact numbers for emergency agencies and resources, means of transportation for relocation, specific duties and responsibilities of staff during evacuation and emergency situations, and alternate means of meeting resident needs during utility outages.”

“Fire drill records from 9/8/2025 to 1/8/2026 did not document the actual number of staff who participated (indicated only 'y'), did not document whether the fire alarm was operative (indicated 'n/a'), and evacuation times were recorded in minutes only without seconds.”

“The home did not have a maximum safe evacuation time specified in writing by a fire safety expert at the time of the 9/8/2025 fire drill. Subsequent to obtaining a fire safety expert's specification of 6 minutes 10 seconds on 10/20/2025, all fire drills from 10/20/2025 to 1/8/2026 were completed in 15 minutes, exceeding the maximum safe evacuation time.”

“During fire drills held from 9/8/2025 to 1/8/2026, only the "main" exit route was used; alternate exit routes were not utilized.”

“Medical evaluations for Resident #1 and Resident #2 were not documented on the Department-specified form.”

“Trash cans in the common resident bathroom and staff bathroom by the Nurse's Station did not have lids to prevent penetration of insects and rodents.”

“A red stop sign was posted on the emergency exit leading to the courtyard, which obstructs safe evacuation routes and contradicts lighting and marking requirements for emergency exits.”

“Carbon monoxide alarms near fossil-fuel burning devices did not have dated batteries as required by the Care Facility Carbon Monoxide Alarms Standard Act. Batteries in dining room detector and laundry/generator room detector were not dated; main kitchen detector had no batteries. Additionally, an influenza poster was not posted in a public and conspicuous place as required by the Influenza Awareness Standards Act.”

“Lint trap in the clothes dryer had a coating of lint on half the trap, indicating lint was not removed after use as required to reduce fire hazards.”

“The administrator did not have a copy of the emergency preparedness plan for the local municipality as required.”