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Public Record

Serenity Hill Nursing Center

Nursing HomeWrentham, MACMS 225752
73 citations on record

From CMS

Facility profile

CMS overall rating
1 / 5

*CMS Five-Star

Certified beds
44

*CMS

Avg. residents per day
33.8

*CMS

Inspection record

On record from CMS

Citations on record
73

*CMS

Inspections on file
6

*CMS

Last inspection
2025-04-29

*CMS

Citations

73 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

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.

  • 0550Generalpotential for harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0565Generalpotential for harm

    Honor the resident's right to organize and participate in resident/family groups in the facility.

  • 0585Generalpotential for harm

    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.

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0657Generalpotential for harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0658Generalpotential for harm

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0699Generalpotential for harm

    Provide care or services that was trauma informed and/or culturally competent.

  • 0742Generalpotential for harm

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

  • 0756Generalpotential for harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0758Generalpotential for harm

    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.

  • 0761Generalpotential for harm

    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.

  • 0812Generalpotential for harm

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

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0881Generalpotential for harm

    Implement a program that monitors antibiotic use.

  • 0883Generalpotential for harm

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0887Generalpotential for harm

    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

  • 0909Generalpotential for harm

    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

  • 0161Generalpotential for harm

    Use approved construction type or materials.

  • 0211Generalpotential for harm

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

  • 0232Generalpotential for harm

    Have corridors or aisles that are unobstructed and are at least 8 feet in width.

  • 0241Generalpotential for harm

    Have correct number of accessible exits for each story.

  • 0311Generalpotential for harm

    Have an enclosure around a vertical opening shaft.

  • 0321Generalpotential for harm

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

  • 0324Generalpotential for harm

    Provide properly protected cooking facilities.

  • 0521Generalpotential for harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  • 0541Generalpotential for harm

    Install properly constructed and protected linen or trash chutes.

  • 0918Generalpotential for harm

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

  • 0920Generalpotential for harm

    Ensure proper usage of power strips and extension cords.

  • 0551Generalpotential for harm

    Give the resident's representative the ability to exercise the resident's rights.

  • 0291Generalpotential for harm

    Install emergency lighting that can last at least 1 1/2 hours.

  • 0311Generalpotential for harm

    Have an enclosure around a vertical opening shaft.

  • 0321Generalpotential for harm

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

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0511Generalpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0521Generalno actual harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0658Generalpotential for harm

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0727Generalpotential for harm

    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.

  • 0757Generalpotential for harm

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • 0758Generalpotential for harm

    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.

  • 0761Generalpotential for harm

    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.

  • 0842Generalpotential for harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0883Generalpotential for harm

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0541Generalpotential for harm

    Install properly constructed and protected linen or trash chutes.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0914Generalpotential for harm

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  • 0918Generalpotential for harm

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

  • 0004Generalpotential for harm

    Develop and maintain an Emergency Preparedness Program (EP).

  • 0023Generalpotential for harm

    Establish policies and procedures for medical documentation.

  • 0024Generalpotential for harm

    Establish policies and procedures for volunteers.

  • 0030Generalpotential for harm

    List the names and contact information of those in the facility.

  • 0031Generalpotential for harm

    Provide emergency officials' contact information.

  • 0032Generalpotential for harm

    Provide primary/alternate means for communication.

  • 0161Generalpotential for harm

    Use approved construction type or materials.

  • 0211Generalno actual harm

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

  • 0232Generalno actual harm

    Have corridors or aisles that are unobstructed and are at least 8 feet in width.

  • 0241Generalpotential for harm

    Have correct number of accessible exits for each story.

  • 0658Generalpotential for harm

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0842Generalpotential for harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0867Generalpotential for harm

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

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0885Generalpotential for harm

    Report COVID19 data to residents and families.

  • 0909Generalpotential for harm

    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

  • 0521Generalno actual harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  • 0541Generalpotential for harm

    Install properly constructed and protected linen or trash chutes.

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0580Generalpotential for harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0161Generalpotential for harm

    Use approved construction type or materials.

  • 0211Generalno actual harm

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

  • 0232Generalno actual harm

    Have corridors or aisles that are unobstructed and are at least 8 feet in width.

  • 0241Generalpotential for harm

    Have correct number of accessible exits for each story.

  • 0311Generalpotential for harm

    Have an enclosure around a vertical opening shaft.

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

FAQ

Questions and answers

What is Serenity Hill Nursing Center?
Serenity Hill Nursing Center is a Medicare- and Medicaid-certified nursing home in Wrentham, MA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 225752.
What is the CMS rating for Serenity Hill Nursing Center?
Serenity Hill Nursing Center has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Serenity Hill Nursing Center have?
Serenity Hill Nursing Center is certified for 44 beds. It serves an average of 33.8 residents per day.
How many citations does Serenity Hill Nursing Center have?
Serenity Hill Nursing Center has 73 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Serenity Hill Nursing Center last inspected?
Serenity Hill Nursing Center was last inspected on April 29, 2025. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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