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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? |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 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 |
| 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 |
| Keep all essential equipment working safely. | Health | 2023-09-28 | 2023-10-09 | 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 |
| 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 |
| 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 | 2023-08-05 | 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 | 2023-07-24 | 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 care and assistance to perform activities of daily living for any resident who is unable. | 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 safe, appropriate pain management for a resident who requires such services. | 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 |
| 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 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 |
| 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 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-01 | 2021-12-02 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-25 | 2021-04-01 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-02-25 | 2021-03-16 | 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 | 2021-02-25 | 2021-03-16 | 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 | 2021-02-25 | 2021-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-25 | 2021-03-15 | 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 | 2021-02-25 | 2021-03-10 | 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 | 2021-02-25 | 2021-03-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-25 | 2021-03-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-02-25 | 2021-03-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-02-25 | 2021-03-02 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-02-25 | 2021-03-01 | N |
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