A list of the most recent deficiencies for Serene Manor Medical Ctr.. 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 or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-06-05 | 2023-06-23 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-03 | 2023-05-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-23 | 2023-05-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-24 | 2022-07-05 | 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 | 2022-05-24 | 2022-07-05 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-05-24 | 2022-06-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-24 | 2022-06-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-24 | 2022-06-29 | 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 | 2022-05-24 | 2022-06-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-24 | 2022-06-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-24 | 2022-06-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-05-24 | 2022-06-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-24 | 2022-06-29 | Y |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-05-16 | 2022-06-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-16 | 2022-05-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-06 | 2021-11-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-10 | 2021-08-02 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-10 | 2021-08-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-10 | 2021-08-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-10 | 2021-08-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-10 | 2021-08-02 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-06-10 | 2021-08-02 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-06-10 | 2021-08-02 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-06-10 | 2021-08-02 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-06-10 | 2021-08-02 | Y |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2021-06-10 | 2021-08-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-10 | 2021-08-02 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-06-10 | 2021-08-02 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-06-10 | 2021-08-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-08-27 | 2019-10-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-27 | 2019-10-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-27 | 2019-10-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-27 | 2019-10-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-08-25 | 2019-10-11 | 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 | 2019-08-25 | 2019-10-11 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-08-25 | 2019-10-11 | 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 | 2019-08-25 | 2019-10-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-25 | 2019-10-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-25 | 2019-10-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-25 | 2019-10-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-08-25 | 2019-10-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-08-13 | 2018-09-29 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-08-13 | 2018-09-29 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-08-15 | 2018-09-06 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-08-15 | 2018-09-06 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-08-15 | 2018-09-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-15 | 2018-09-06 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-08-13 | 2018-09-06 | 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 | 2018-08-13 | 2018-09-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-13 | 2018-09-06 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2018-08-13 | 2018-08-13 | N |
