Inspection visit
Inspection
Citations
30 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.
F551 - In the case of a resident who has not been adjudged incompetent by the state
Give the resident's representative the ability to exercise the resident's rights.
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.
F727 - Except when waived under paragraph (f) or (g) of this section, the
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.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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.
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.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0004GeneralS&S Dpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0023GeneralS&S Dpotential for harm
Establish policies and procedures for medical documentation.
- 0024GeneralS&S Dpotential for harm
Establish policies and procedures for volunteers.
- 0030GeneralS&S Dpotential for harm
List the names and contact information of those in the facility.
- 0031GeneralS&S Dpotential for harm
Provide emergency officials' contact information.
- 0032GeneralS&S Dpotential for harm
Provide primary/alternate means for communication.
- 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.
- 0291GeneralS&S Dpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0311GeneralS&S Fpotential for harm
Have an enclosure around a vertical opening shaft.
- 0321GeneralS&S Dpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0511GeneralS&S Dpotential for harm
Have properly installed electrical wiring and gas equipment.
- 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.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F918 - Bathroom Facilities
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 May 14, 2024 survey of SERENITY HILL NURSING CENTER?
This was a inspection survey of SERENITY HILL NURSING CENTER on May 14, 2024. The surveyor cited 30 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SERENITY HILL NURSING CENTER on May 14, 2024?
Yes, 30 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Give the resident's representative the ability to exercise the resident's rights."
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.