Inspection visit
Fire Safety inspection
Citations
21 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
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.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0022GeneralS&S Fpotential for harm
Establish policies and procedures for sheltering.
- 0041GeneralS&S Fpotential for harm
Implement emergency and standby power systems.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0281GeneralS&S Fpotential for harm
Install proper backup exit lighting.
- 0001GeneralS&S Fpotential for harm
Establish an Emergency Preparedness Program (EP).
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
- 0711GeneralS&S Fpotential for harm
Provide a written emergency evacuation plan.
- 0712GeneralS&S Cno actual harm
Have simulated fire drills held at unexpected times.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0023GeneralS&S Fpotential for harm
Establish policies and procedures for medical documentation.
- 0024GeneralS&S Fpotential for harm
Establish policies and procedures for volunteers.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0032GeneralS&S Fpotential for harm
Provide primary/alternate means for communication.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 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.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the March 27, 2025 survey of Serenity Estates of Lena?
This was a inspection survey of Serenity Estates of Lena on March 27, 2025. The surveyor cited 21 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Serenity Estates of Lena on March 27, 2025?
Yes, 21 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Address subsistence needs for staff and patients."
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.
SourceView on CMS Care Compare
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.