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Deficiency Records for Serenity Estates at Morris
A list of the most recent deficiencies for Serenity Estates at Morris. 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 Estates at Morris. 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? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-05-02 | 2025-05-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-01-17 | 2025-01-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-10-11 | 2024-11-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-10-26 | 2024-11-12 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-10-16 | 2024-10-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-10-16 | 2024-10-31 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-10-16 | 2024-10-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-10-16 | 2024-10-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-10-16 | 2024-10-25 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-10-11 | 2024-10-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-10-11 | 2024-10-23 | 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 | 2024-10-11 | 2024-10-23 | 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 | 2024-10-11 | 2024-10-23 | 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 | 2024-10-11 | 2024-10-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-10-11 | 2024-10-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-10-11 | 2024-10-21 | 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 | 2024-10-11 | 2024-10-21 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-10-11 | 2024-10-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-10-11 | 2024-10-21 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-10-11 | 2024-10-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-10-11 | 2024-10-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-10-11 | 2024-10-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-10-16 | 2024-10-18 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-10-16 | 2024-10-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-16 | 2024-10-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-10-16 | 2024-10-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-10-16 | 2024-10-17 | 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 | 2024-10-16 | 2024-10-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-28 | 2024-01-08 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-28 | 2023-10-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-28 | 2023-10-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-28 | 2023-10-12 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-09-28 | 2023-10-12 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-09-28 | 2023-10-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-28 | 2023-10-10 | N |
| Keep all essential equipment working safely. | Health | 2023-09-28 | 2023-10-09 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-09-28 | 2023-10-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-28 | 2023-10-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-28 | 2023-10-09 | 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 | 2023-09-28 | 2023-10-09 | 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 | 2023-09-28 | 2023-10-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-28 | 2023-10-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-28 | 2023-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-28 | 2023-10-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-28 | 2023-10-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-28 | 2023-10-03 | 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 | 2023-09-28 | 2023-10-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-28 | 2023-09-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-09-28 | 2023-09-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-24 | 2023-08-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-05 | 2023-08-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-05 | 2023-08-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-24 | 2023-08-11 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-04-15 | 2023-04-20 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-21 | 2022-08-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-21 | 2022-08-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-21 | 2022-08-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-07-21 | 2022-08-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-21 | 2022-08-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-21 | 2022-07-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-07-21 | 2022-07-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-08 | 2022-07-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-21 | 2022-07-21 | 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 | 2022-07-08 | 2022-07-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-08 | 2022-07-21 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-08 | 2022-07-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-08 | 2022-07-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-08 | 2022-07-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-08 | 2022-07-08 | N |
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