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Deficiency Records for Serenethos Care Center, LLC
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.
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? |
|---|---|---|---|---|
| Address subsistence needs for staff and patients. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-15 | 2024-07-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-10 | 2024-06-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-10 | 2024-06-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-10 | 2024-06-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-05-10 | 2024-06-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-10 | 2024-06-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-10 | 2024-06-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-05-10 | 2024-06-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-10 | 2024-06-06 | N |
| Keep all essential equipment working safely. | Health | 2024-05-10 | 2024-06-06 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-05-10 | 2024-06-06 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-05-10 | 2024-06-06 | N |
| 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 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-22 | 2022-12-09 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-22 | 2022-12-09 | Y |
| 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 |
| 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 |
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