A list of the most recent deficiencies for Serenethos Care 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? |
|---|---|---|---|---|
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-03-09 | 2023-03-27 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-09 | 2023-03-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-09 | 2023-03-27 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-16 | 2023-02-10 | N |
| Dispose of garbage and refuse properly. | Health | 2022-12-16 | 2023-02-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-16 | 2023-02-09 | 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 | 2022-12-16 | 2023-02-09 | 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 | 2022-12-16 | 2023-02-09 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-12-16 | 2023-02-09 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-12-16 | 2023-02-09 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-12-16 | 2023-02-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-16 | 2023-02-09 | N |
| Keep all essential equipment working safely. | Health | 2022-12-16 | 2023-02-09 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-12-16 | 2023-02-09 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-04 | 2023-01-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-01-04 | 2023-01-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-01-04 | 2023-01-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-01-04 | 2023-01-20 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-01-04 | 2023-01-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-04 | 2023-01-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-01-04 | 2023-01-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-04 | 2023-01-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-04 | 2023-01-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-04 | 2023-01-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-04 | 2023-01-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-04 | 2023-01-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-04 | 2023-01-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-08 | 2022-05-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-23 | 2021-05-04 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-07-24 | 2019-08-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-24 | 2019-08-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-24 | 2019-08-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-24 | 2019-08-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-24 | 2019-08-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-24 | 2019-08-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-23 | 2019-06-11 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-05-23 | 2019-06-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-23 | 2019-06-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-05-23 | 2019-06-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-23 | 2019-06-11 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-05-23 | 2019-06-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-23 | 2019-06-11 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-05-23 | 2019-06-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-06-11 | 2018-06-29 | 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 | 2018-06-11 | 2018-06-29 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-06-11 | 2018-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-11 | 2018-06-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-06-11 | 2018-06-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-06-11 | 2018-06-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-06-11 | 2018-06-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-06-11 | 2018-06-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-06-11 | 2018-06-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-06-11 | 2018-06-29 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-06-11 | 2018-06-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-04-13 | 2018-05-03 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-04-13 | 2018-05-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-13 | 2018-05-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-13 | 2018-05-03 | 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 | 2018-04-13 | 2018-05-03 | 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 | 2018-04-13 | 2018-05-03 | 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 | 2018-04-13 | 2018-05-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-13 | 2018-05-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-13 | 2018-05-03 | N |
