Inspection Results » Serenity Rehabilitation and Health Center LLC

Health Inspection on July 20, 2018 ^[1]

1. Isolated: Actual harm that is not immediate jeopardy

   • Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. (Corrected 2018-10-10)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-10-10)

2. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. (Corrected 2018-10-10)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-10-10)
   • Provide and implement an infection prevention and control program. (Corrected 2018-10-10)

3. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Assist a resident in gaining access to vision and hearing services. (Corrected 2018-10-10)
   • Keep all essential equipment working safely. (Corrected 2018-10-10)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-10-10)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-10-10)
   • Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (Corrected 2018-10-10)

4. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-10-10)
   • Reasonably accommodate the needs and preferences of each resident. (Corrected 2018-10-10)
   • Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. (Corrected 2018-10-10)
   • Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. (Corrected 2018-10-10)
   • Have a plan that describes the process for conducting QAPI and QAA activities. (Corrected 2018-10-10)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-10-10)
   • Plan the resident's discharge to meet the resident's goals and needs. (Corrected 2018-10-10)
   • 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 ne (Corrected 2018-10-10)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-10-10)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-10-10)
   • Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. (Corrected 2018-10-10)
   • Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (Corrected 2018-10-10)
   • Make sure that a working call system is available in each resident's bathroom and bathing area. (Corrected 2018-10-10)
   • Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. (Corrected 2018-10-10)
   • Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. (Corrected 2018-10-10)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-10-10)