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Deficiency Records for Serenity Estates of Lincolnshire
A list of the most recent deficiencies for Serenity Estates of Lincolnshire. 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 of Lincolnshire. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-13 | 2024-11-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-13 | 2024-08-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-10 | 2024-07-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-05 | 2024-06-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-06 | 2024-05-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-30 | 2024-05-06 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-02-13 | 2024-05-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-13 | 2024-05-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-02-13 | 2024-05-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-13 | 2024-05-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-13 | 2024-05-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-13 | 2024-04-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-13 | 2024-03-28 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-01-31 | 2024-02-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-31 | 2024-02-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-31 | 2024-02-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-31 | 2024-02-23 | 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 | 2024-01-31 | 2024-02-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-31 | 2024-02-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-31 | 2024-02-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-31 | 2024-02-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-31 | 2024-02-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-31 | 2024-02-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-13 | 2024-02-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-13 | 2024-02-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-13 | 2024-02-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-13 | 2024-02-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-31 | 2023-11-09 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-10-31 | 2023-11-09 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-10-31 | 2023-11-09 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-31 | 2023-11-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-15 | 2023-07-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-15 | 2023-07-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-15 | 2023-06-09 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-05-15 | 2023-06-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-15 | 2023-06-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-15 | 2023-06-09 | 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 | 2023-05-15 | 2023-06-09 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-05-15 | 2023-06-09 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-15 | 2023-06-09 | 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 | 2023-05-15 | 2023-06-09 | Y |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-03-23 | 2023-04-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-23 | 2023-03-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-22 | 2023-03-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-23 | 2023-03-23 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-03-23 | 2023-03-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-19 | 2023-01-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-25 | 2022-09-01 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-08 | 2022-02-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-08 | 2022-02-11 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-02-08 | 2022-02-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-08 | 2022-02-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-08 | 2022-02-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-08 | 2022-02-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-26 | 2022-02-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-26 | 2022-02-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-26 | 2022-02-02 | 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 | 2022-01-26 | 2022-02-02 | 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 | 2022-01-26 | 2022-02-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-26 | 2022-02-02 | N |
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