Deficiency Records for Serenity Bay Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Serenity Bay Nursing and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-10 | 2023-05-11 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-10 | 2023-05-11 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-10 | 2023-05-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-10 | 2023-05-11 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-10 | 2023-05-11 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-10 | 2023-05-11 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-01-20 | 2023-02-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-20 | 2023-02-10 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-01-20 | 2023-02-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-20 | 2023-02-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-20 | 2023-02-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-20 | 2023-02-10 | 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 | 2023-01-20 | 2023-02-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-20 | 2023-02-10 | N |
| Meet other general requirements. | Fire Safety | 2023-01-19 | 2023-02-10 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-01-19 | 2023-02-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-19 | 2023-02-10 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-01-19 | 2023-02-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-10 | 2022-09-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-10 | 2022-09-10 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-08-27 | 2021-09-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-27 | 2021-09-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-27 | 2021-09-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-27 | 2021-09-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-27 | 2021-09-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-27 | 2021-09-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-27 | 2021-09-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-27 | 2021-09-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-27 | 2021-09-27 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2021-08-27 | 2021-09-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-27 | 2021-09-27 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-08-29 | 2019-09-30 | 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 | 2019-08-29 | 2019-09-30 | N |
| Keep all essential equipment working safely. | Health | 2019-08-29 | 2019-09-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-08-29 | 2019-09-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-29 | 2019-09-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-29 | 2019-09-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-29 | 2019-09-22 | N |
