Public Record
Serenity Spring Senior Living at Scandia Village
From CMS
Facility profile
- CMS overall rating
- 2 / 5
- Certified beds
- 50
- Avg. residents per day
- 46.1
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 63
- Inspections on file
- 10
- Last inspection
- 2026-02-10
*CMS
*CMS
*CMS
Citations
63 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.
- 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.
- 0803Generalpotential for harm
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0644Generalpotential for harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0628Generalpotential for harm
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- 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.
- 0925Generalpotential for harm
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0521Generalpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0161Generalpotential for harm
Use approved construction type or materials.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0552Generalpotential for harm
Ensure that residents are fully informed and understand their health status, care and treatments.
- 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.
- 0605Generalpotential for harm
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0552Generalpotential for harm
Ensure that residents are fully informed and understand their health status, care and treatments.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0625Generalpotential for harm
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0645Generalpotential for harm
PASARR screening for Mental disorders or Intellectual Disabilities
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 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.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0868Generalno actual harm
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0882Generalpotential for harm
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
- 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.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0522Generalpotential for harm
Have an externally vented heating system.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0753Generalpotential for harm
Have restrictions on the use of highly flammable decorations.
- 0919Generalpotential for harm
Meet requirements for the use of electrical equipment.
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 0004Generalpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0039Generalpotential for harm
Conduct testing and exercise requirements.
- 0293Generalpotential for harm
Have properly located and lighted "Exit" signs.
- 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.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0293Generalpotential for harm
Have properly located and lighted "Exit" signs.
- 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.
- 0625Generalpotential for harm
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
FAQ
Questions and answers
- What is Serenity Spring Senior Living at Scandia Village?
- Serenity Spring Senior Living at Scandia Village is a Medicare- and Medicaid-certified nursing home in Sister Bay, WI, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 525494.
- What is the CMS rating for Serenity Spring Senior Living at Scandia Village?
- Serenity Spring Senior Living at Scandia Village has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Serenity Spring Senior Living at Scandia Village have?
- Serenity Spring Senior Living at Scandia Village is certified for 50 beds. It serves an average of 46.1 residents per day.
- How many citations does Serenity Spring Senior Living at Scandia Village have?
- Serenity Spring Senior Living at Scandia Village has 63 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Serenity Spring Senior Living at Scandia Village last inspected?
- Serenity Spring Senior Living at Scandia Village was last inspected on February 10, 2026. 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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