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Deficiency Records for Serenity Rehabilitation and Health Center LLC
A list of the most recent deficiencies for Serenity Rehabilitation and Health Center LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Serenity Rehabilitation and Health Center LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-20 | 2023-11-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-13 | 2023-11-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-20 | 2023-11-10 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-10-20 | 2023-11-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-20 | 2023-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-20 | 2023-11-10 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-10-20 | 2023-11-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-20 | 2023-11-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-20 | 2023-11-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-20 | 2023-11-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-20 | 2023-11-10 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-10-20 | 2023-11-10 | N |
| Respond appropriately to all alleged violations. | Health | 2023-10-20 | 2023-11-10 | N |
| Respond appropriately to all alleged violations. | Health | 2023-07-07 | 2023-08-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-07 | 2023-08-03 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-07-07 | 2023-08-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-07 | 2023-08-03 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-07 | 2023-08-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-07 | 2023-08-03 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-07-07 | 2023-08-03 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-06-29 | 2022-11-08 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-06-29 | 2022-11-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-29 | 2022-09-23 | N |
| Keep all essential equipment working safely. | Health | 2022-06-29 | 2022-09-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-29 | 2022-09-23 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-06-29 | 2022-09-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-29 | 2022-09-23 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-06-29 | 2022-09-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-29 | 2022-09-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-06-29 | 2022-09-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-29 | 2022-09-23 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-06-29 | 2022-09-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-29 | 2022-09-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-29 | 2022-09-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-06-29 | 2022-09-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-29 | 2022-09-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-29 | 2022-09-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-29 | 2022-09-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-29 | 2022-09-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-29 | 2022-09-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-29 | 2022-09-23 | N |
| Respond appropriately to all alleged violations. | Health | 2022-06-29 | 2022-09-23 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-29 | 2022-09-23 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-09-03 | 2019-11-22 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-09-03 | 2019-11-22 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-09-03 | 2019-11-22 | N |
| Keep all essential equipment working safely. | Health | 2019-09-03 | 2019-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-03 | 2019-11-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-03 | 2019-11-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-03 | 2019-11-22 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-09-03 | 2019-11-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-09-03 | 2019-11-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-09-03 | 2019-11-22 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-09-03 | 2019-11-22 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-09-03 | 2019-11-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-03 | 2019-11-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-03 | 2019-11-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-03 | 2019-11-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-03 | 2019-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-03 | 2019-11-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-03 | 2019-11-22 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-09-03 | 2019-11-22 | N |
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