Inspection visit
Fire Safety inspection
Citations
20 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.
- 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.
- 0712GeneralS&S Fpotential for harm
Have simulated fire drills held at unexpected times.
- 0914GeneralS&S Dpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 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 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 20 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SERENITY HILL NURSING CENTER on May 14, 2024?
Yes, 20 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and maintain an Emergency Preparedness Program (EP)."
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.