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Deficiency Records for Serenity Spring Senior Living at Scandia Village
A list of the most recent deficiencies for Serenity Spring Senior Living at Scandia Village. 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 Spring Senior Living at Scandia Village. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-23 | 2024-08-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-23 | 2024-08-15 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-04-24 | 2024-05-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-04-24 | 2024-05-24 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-04-24 | 2024-05-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-04-24 | 2024-05-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-04-24 | 2024-05-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-04-24 | 2024-05-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-24 | 2024-05-24 | 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 | 2024-04-24 | 2024-05-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-24 | 2024-05-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-24 | 2024-05-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-24 | 2024-05-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-04-24 | 2024-05-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-04-24 | 2024-05-24 | 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 | 2024-04-24 | 2024-05-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-24 | 2024-05-24 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-04-24 | 2024-05-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-24 | 2024-05-24 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-04-24 | 2024-05-24 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-04-23 | 2024-05-24 | 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 | 2024-04-23 | 2024-05-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| Have an externally vented heating system. | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| 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 | 2023-05-30 | 2023-06-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-27 | 2023-05-26 | Y |
| 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 | 2023-04-27 | 2023-05-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-27 | 2023-05-26 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-02-01 | 2023-03-01 | 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 | 2023-02-01 | 2023-03-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-01-31 | 2023-03-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-31 | 2023-03-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-13 | 2023-01-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-13 | 2023-01-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-13 | 2023-01-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-13 | 2023-01-13 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-23 | 2023-01-04 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-11-23 | 2023-01-04 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-11-23 | 2023-01-04 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-11-13 | 2022-12-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-13 | 2022-12-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-13 | 2022-12-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-02 | 2022-12-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-02 | 2022-12-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-02 | 2022-12-12 | 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 | 2022-11-02 | 2022-12-12 | Y |
| Post nurse staffing information every day. | Health | 2022-11-02 | 2022-12-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-02 | 2022-12-12 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-11-02 | 2022-12-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-02 | 2022-12-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-02 | 2022-12-12 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-11-02 | 2022-12-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-06 | 2022-02-05 | 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 | 2022-01-06 | 2022-02-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-06 | 2022-02-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-07 | 2022-02-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-01-07 | 2022-02-05 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-01-07 | 2022-02-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-07 | 2022-02-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-01-07 | 2022-01-21 | N |
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