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Inspection visit

Inspection

SERENITY ESTATES AT MORRISCMS #14607725 citations on this visit
25 citations recorded

Citations

25 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0689GeneralS&S Epotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0677GeneralS&S Dpotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0211GeneralS&S Epotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0311GeneralS&S Epotential for harm

    Have an enclosure around a vertical opening shaft.

  • 0321GeneralS&S Epotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0324GeneralS&S Epotential for harm

    Provide properly protected cooking facilities.

  • 0345GeneralS&S Fpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0351GeneralS&S Dpotential for harm

    Install an approved automatic sprinkler system.

  • 0353GeneralS&S Fpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0374GeneralS&S Epotential for harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

  • 0511GeneralS&S Fpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0911GeneralS&S Epotential for harm

    F911 - Accommodate no more than four residents

    Meet requirements for the installation and maintenance of electrical systems.

  • 0918GeneralS&S Fpotential for harm

    F918 - Bathroom Facilities

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0578GeneralS&S Dpotential for harm

    F578 - The right to request, refuse, and/or discontinue treatment, to participate in or

    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.

  • 0688GeneralS&S Dpotential for harm

    F688 - Mobility

    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.

  • 0690GeneralS&S Dpotential for harm

    F690 - Incontinence

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  • 0694GeneralS&S Dpotential for harm

    F694 - Parenteral Fluids

    Provide for the safe, appropriate administration of IV fluids for a resident when needed.

  • 0758GeneralS&S Dpotential for harm

    F758 - Medication Errors

    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.

  • 0761GeneralS&S Epotential for harm

    F761 - Labeling of Drugs and Biologicals

    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.

  • 0802GeneralS&S Fpotential for harm

    F802 - Staffing

    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

  • 0803GeneralS&S Fpotential for harm

    F803 - Menus and nutritional adequacy

    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.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0867GeneralS&S Cno actual harm

    F867 - Program feedback, data systems and monitoring

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  • 0868GeneralS&S Cno actual harm

    F868 - Quality assessment and assurance

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

  • 0880GeneralS&S Epotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the October 11, 2024 survey of SERENITY ESTATES AT MORRIS?

This was a inspection survey of SERENITY ESTATES AT MORRIS on October 11, 2024. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SERENITY ESTATES AT MORRIS on October 11, 2024?

Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.