A list of the most recent deficiencies for Serenity Hill Nursing 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-09 | 2023-04-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-09 | 2023-04-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-09 | 2023-04-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-09 | 2023-04-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-09 | 2023-04-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-09 | 2023-04-21 | N |
| Report COVID19 data to residents and families. | Health | 2023-03-09 | 2023-04-21 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-03-09 | 2023-04-21 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-01-06 | 2020-02-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-06 | 2020-02-10 | 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 | 2020-01-06 | 2020-02-10 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-01-06 | 2020-02-10 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-01-06 | 2020-02-10 | 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 | 2020-01-06 | 2020-02-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-06 | 2020-02-10 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2020-01-06 | 2020-02-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-06 | 2020-02-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-10-22 | 2018-11-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-10-22 | 2018-11-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-22 | 2018-11-16 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2018-10-22 | 2018-11-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-22 | 2018-11-15 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2018-10-22 | 2018-11-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-22 | 2018-11-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-10-22 | 2018-11-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-22 | 2018-11-12 | N |
