Inspection visit
Inspection
Citations
15 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.
F909 - Conduct Regular inspection of all bed frames, mattresses, and bed
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.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0885GeneralS&S Fpotential for harm
Report COVID19 data to residents and families.
- 0161GeneralS&S Fpotential for harm
Use approved construction type or materials.
- 0211GeneralS&S Cno actual harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0232GeneralS&S Cno actual harm
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
- 0241GeneralS&S Fpotential for harm
Have correct number of accessible exits for each story.
- 0311GeneralS&S Fpotential for harm
Have an enclosure around a vertical opening shaft.
- 0521GeneralS&S Cno actual harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0541GeneralS&S Fpotential for harm
Install properly constructed and protected linen or trash chutes.
FAQ · About this visit
Common questions about this visit
What happened during the March 9, 2023 survey of SERENITY HILL NURSING CENTER?
This was a inspection survey of SERENITY HILL NURSING CENTER on March 9, 2023. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SERENITY HILL NURSING CENTER on March 9, 2023?
Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must a..."
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.