Deficiency Records for Serenity Rehabilitation and Health Center LLC
Updated as of April 01, 2024
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 dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-20 | 2023-11-10 | 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 | 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 |
| Respond appropriately to all alleged violations. | Health | 2023-10-20 | 2023-11-10 | N |
| Ensure each resident receives an accurate assessment. | 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 |
| Assist a resident in gaining access to vision and hearing services. | 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 |
| 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 |
| 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 |
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2023-10-20 | 2023-11-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-07 | 2023-08-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-07 | 2023-08-03 | Y |
| Ensure each resident receives an accurate assessment. | 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 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | 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 |
| 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 |
| 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 |
| 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 |
| Respond appropriately to all alleged violations. | 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 |
| 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 care and assistance to perform activities of daily living for any resident who is unable. | 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 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 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 |
| 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 safe, appropriate pain management for a resident who requires such services. | 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 |
| 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 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 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 |
| 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 |
| 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 |
| Honor the resident's right to manage his or her financial affairs. | 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 |
| 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 |
| 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 |
| Ensure services provided by the nursing facility meet professional standards of quality. | 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 |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | 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 |
| 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 |
| 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 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 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 |
| Provide routine and 24-hour emergency dental care for each resident. | 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 |
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2019-09-03 | 2019-11-22 | N |
| Keep all essential equipment working safely. | 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 |
| 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 |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-13 | Not Fixed | N |
