Serenity Rehabilitation and Health Center LLC

Inspectors wroteBased on record review and staff interview, for one (1) of four (4) sampled residents, facility staff to ensure that one resident's Quarterly Minimum Data (MDS) assessment was accurately coded for a facility acquired pressure injury (deep tissue injury/DTI). Resident #1.

Inspectors wroteBased on observations, record review and staff interviews, for one (1) of four (4) sampled residents, facility staff failed to provide the necessary podiatry consult, treatment and foot care to Resident #2, who is a diabetic with increased risk to developing foot problems.

Inspectors wroteBased on observations and staff interviews for seven (7) of 56 sampled residents, facility staff failed to properly store medications in accordance with Standards of Practice as evidenced by: (1) Employee #29 failed to ensure Resident #12's individual compartment did not contain Resident #74's medication; (2) Employee #30 failed to ensure Resident #138's individual compartment did not contain Resident #32's medication and Resident #135's individual compartment did not contain Resident #59's medication; [...]

Inspectors wroteBased on observations and staff interviews, facility staff failed to: (1) distribute and serve foods under sanitary conditions, as evidenced by using wet dome covers on the tray line to help maintain food temperatures in serving plates; (2) follow infection control standards and practices to prevent the spread of infections and communicable diseases; and (3) ensure there were no breaks in infection control standards and practices to prevent the widespread of commnicable diseases. Resident #332.

Inspectors wroteBased on observations, staff and resident interviews, for one (1) of 56 sampled residents, facility staff failed to treat a resident with dignity and respect while also recognizing the residents individuality as evidenced by staff observed entering the resident's room without first knocking on the closed door or addressing the resident and informing the resident who they were and why they were there upon entering the room. Resident #93.

Inspectors wroteBased on record review, resident interview and staff interview for one (1) of 56 sampled residents, facility staff failed to provide a quarterly statement to a resident or resident's legal representative of the resident's personal funds account.

Inspectors wroteBased on observation, record review, family and staff interviews, for one (1) of 56 sampled residents, facility staff failed to exercise reasonable care for the protection of one resident's property from loss. Resident #142.

Inspectors wroteBased on record review and staff interviews, for one (1) of 56 sampled residents, facility staff failed to timely report Resident #176's injury of unknown injury to the Administrator and the State Agency.

Inspectors wroteBased on record review and staff interviews, for one (1) of 56 sampled residents, facility staff failed to conduct a thorough investigation of Resident #56's injury of unknown origin (fracture of right index finger).

Inspectors wroteBased on record review and staff interview for two (2) of 56 sampled residents, facility staff failed to provide written notification to the resident and/or the resident's representative of the facility policy for bed hold, remaining bed hold days and reserve bed payment for two (2) residents who were transferred from the facility to the hospital. Residents' #20 and #51.

Inspectors wrote2. Facility staff failed to accurately code Resident #11's Quarterly Minimum Data Set (MDS) assessment to reflect that she was receiving opioid medications. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses that included: Pain, Type 2 Diabetes Mellitus (DM), Bipolar Disorder, and Edema. Review of the resident's medical record revealed the following: A care plan focus area last reviewed on 11/20/24: [Resident #11] is on pain medication therapy Oxycodone (type of narcotic pain reliever) r/t (related to) osteoarthritis and polyneuropathy. A physician's order dated 01/12/25 that directed, Oxycodone HCl (Hydrochloride)Tablet 5 MG (milligrams), give 1 tablet by mouth two times a day for severe pain (#7-10). [...]

Inspectors wroteBased on record review and staff interview for one (1) of 56 sampled residents, facility staff failed to refer a resident to the appropriate state-designated authority, known as PASRR Level II, for evaluation and determination to ensure a resident received specialized services to meet the resident's needs. Resident #34.

Inspectors wroteBased on observations, record reviews, staff and resident interviews, for one (1) of 56 sampled residents, facility staff failed to implement Resident #5's care plan intervention to have the resident have access to functioning hearing aids.

Inspectors wroteBased on observations, record review, and staff interviews, for one (1) of 56 sampled residents, the facility staff failed to revise interventions on a resident's comprehensive care plan to address the resident's behavior of wearing gloves and two masks throughout the facility. Resident #332.

Inspectors wroteBased on observations, record reviews, staff and resident interviews, for one (1) of 56 sampled residents, facility staff failed to provide Resident #5 with the necessary care and service to ensure that their ability to perform activities of daily living do not diminish as evidenced by the facility staff failing to ensure the residents malfunctioning hearing aides were replaced.

Inspectors wroteBased on record review and staff interviews, for one (1) of 56 sampled residents, facility staff failed to ensure that Resident #67, who had limited range of motion, received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

Inspectors wroteBased on record review and staff interviews for one of fifty-six (56) sampled residents, the facility staff failed to monitor and supervise a resident with a history of elopement and failed to ensure that all doors were secure in the facility after a fire drill. Subsequently, on 08/14/24, the Resident eloped. Resident #59.

Inspectors wroteBased on observation, record review and staff interview, for one (1) of 56 sampled residents, facility staff failed to ensure that Resident #142, who has an indwelling Foley Catheter, received the appropriate care to prevent urinary tract infections.

Inspectors wroteBased on observations, record review and staff interviews, for one (1) of 56 sampled residents, facility staff failed to demonstrate the competencies and skills to provide appropriate nursing services to ensure resident safety and well-being. Resident #89.

Inspectors wroteBased on record reviews and staff interviews for two (2) of 56 sampled residents, facility staff failed to show documented evidence in the resident's medical records that the pharmacist's monthly medication regimen reviews and recommendations were reviewed and acted upon by the physician. Resident's #40 and #30.

Inspectors wroteBased on observations, record review and staff interviews, for one (1) of 56 sampled residents, facility staff failed to administer medications or biologicals in accordance with the physician's order and the manufacturer's specifications. Resident #89.

Inspectors wroteBased on observations, record reviews, staff and resident interviews for one (1) of 56 sampled residents, facility staff failed to provide Resident #77 with a diet that met the residents' daily nutritional and special dietary needs while taking into consideration the residents' preferences for fresh fruits and vegetables.

Inspectors wroteBased on observations and staff interview, facility staff failed to distribute and serve foods under sanitary conditions as evidenced by one (1) of one (1) ice machine that was soiled on the inside, eight (8) of eight (8) four-inch pans and ten (10) of ten (10) six-inch pans that were stacked wet, torn air curtains in one (1) of one (1) walk-in freezer, one (1) of one (1) flour bin and one (1) of one (1) sugar bin without scoops, and one (1) of one (1) milk box that lacked a thermometer.

Inspectors wroteBased on observations, record reviews, and staff interviews, for eight (8) of 57 sampled residents, facility staff failed to report allegations abuse to the State Agency immediately (within 2 hours of the incident); and failed to send the results/follow-up of all investigations to the State Survey Agency within five (5) working days of the incident. Residents' #103, #46, #366, #91, #54, #99, #22 and #63.

Inspectors wroteBased on record reviews and staff interviews, for four (4) out of 57 sampled residents, facility staff failed to have documented evidence that they conducted thorough investigations of allegations of abuse by failing to have interviews or statements of all staff represent at the time of the alleged incidents. Residents' #103, #46, #366, and #91.

Inspectors wroteBased on observation, record reviews, resident and staff interviews, for one (1) of 57 sampled residents, the facility staff failed to treat Resident #102 with respect and dignity and care for the resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, as evidenced by staff not closing the privacy curtain before opening the resident's door that opens to a public hallway. Resident #102.

Inspectors wroteBased on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, comfortable environment as evidenced by a window blind in one (1) of 34 resident's rooms with a broken chain.

Inspectors wroteBased on record review and staff interview for one (1) of 57 sampled residents, facility staff failed to accurately code the residents Quarterly Minimum Data Set (MDS) assessment to accurately reflect the resident's fall that occurred on 08/17/23. Resident #415.

Inspectors wroteBased on observation, record review, and staff interview for (3) of 57 sampled residents, facility staff failed to do the following: follow an intervention included in a residents fall care plan, perform a weekly skin assessment as ordered by the physician for Resident #418, and use a 2 person physical assist when transferring Resident #102 from a wheelchair to the bed using a Hoyer lift. Resident #57, #418, and #102.

Inspectors wroteBased on record review, resident interview and staff interviews for one of (1) of 57 sampled residents, facility staff failed to assist a resident in gaining access to vision services by failing to ensure that the resident was able to have an appointment with an ophthalmologist for evaluation for cataract surgery as recommended by the physician on 07/24/2023. Resident #145.

Inspectors wroteBased on an observation, record review, staff interview and resident interview, for two (2) of 57 sampled residents, the facility's nursing staff failed to ensure a Customer Service Representative did not administer Vitamin C (supplement) to one resident; and failed to demonstrate competent nursing skills as evidenced by failing to ensure that one resident's medication orders were clarified to indicate specific administration times. Residents' #18 and #159.

Inspectors wroteBased on record reviews and staff interviews, for two (2) of 57 sampled residents, facility staff failed to maintain accurate and complete medical records. Residents' #23 and 418.

Inspectors wroteBased on record review and staff interviews, for one (1) out of 57 sampled residents, facility staff failed to have evidence in Resident #132's medical record of an established communication process between the hospice provider and the nursing home; and failed to have in writing, a designated member of the nursing home's interdisciplinary team who is responsible for working with hospice to coordinate care for its residents.

Inspectors wroteBased on an observation, record review and staff interview, the facility's staff failed to maintain Infection Control and Prevention Practices during wound care for one (1) of 57 sampled residents. (Resident #5).

Inspectors wroteBased on record review and staff interview, the facility's staff failed to ensure two (2) of seven (7) residents in the sample with allegations of abuse, were free from alleged/witnessed non-consensual sexual contact by Resident #126. (Residents #108 and #145). This failure resulted in actual harm to Residents #108 and #145.

Inspectors wroteBased on record review and staff interviews, for seven (7) of 67 sampled residents, facility staff failed to implement: their Prohibition of Abuse policy by not reporting allegations of sexual abuse to the State Survey Agency within two (2) hours for Residents #108 and #145; and their Investigation Process policy by not interviewing or obtaining statements from all potential witnesses with knowledge of an incident for Residents' #108, #145, #86, #112, #121, #303 and #304.

Inspectors wroteBased on record reviews and staff interviews, for nine (9) of 67 sampled residents, facility staff failed to: report allegations of resident-to-resident alleged/witness sexual abuse (inappropriate non-consensual sexual touch /willful non-consensual sexual contact) to the State Survey Agency immediately or no later than two hours of the allegation for Residents #108 and #145; report the results of investigations to the State Survey Agency, within 5 working days of the incident for Residents' #8, #84, #86, #108, #145, #112, #303 and #304; and report a resident-to-resident incident involving Resident #121. Residents' #108, #145, #8, #84, #86, #112, #303, #304 and #121.

Inspectors wroteBased on record review and staff interviews, for seven (7) of 67 sampled residents, facility staff failed to: conduct thorough investigations evidenced by failure to interview and/or obtain statements from potential witnesses for: Resident #108's allegation of resident-to-resident inappropriate non-consensual sexual touch [sexual abuse]; Resident #86's allegation of a resident-to-resident altercation; Resident #8's allegation of staff-to-resident physical abuse; Resident #112's allegation of sexual abuse; Resident #303's allegation of staff-to-resident physical abuse; Resident #304's allegation of staff neglect; and conduct an investigation of Resident #121's resident-to-resident incident. Residents' #108, #86, #8, #112, #303, #304, #121.

Inspectors wroteBased on record reviews and interviews, for six (6) of 67 sampled residents, facility staff failed to provide written notice of the facility's bed-hold policy to residents or their representative(s). Residents' #35, #54, #93, #97, #110 and #84.

Inspectors wrote12. Facility staff failed to administer Resident #54 supplemental oxygen as ordered. Resident #54 was re-admitted to the facility on [DATE] with diagnoses including, Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), and Dependence on Supplemental Oxygen. During an observation on 06/23/22 at 12:12 PM, Resident #54 was awake, resting comfortably, with non-labored breathing. The resident was receiving supplemental humidified oxygen via nasal cannula at a rate of 5 liters per minute. A Quarterly Minimum Data Set (MDS) dated [DATE] showed in Section C (Cognitive Patterns) that facility staff documented the resident as having a Brief Interview for Mental Status summary score (BIMS) of 00, indicating that the resident had severely impaired cognition. [...]

Inspectors wroteBased on observation, record review and staff interviews, for five (5) of 67 sampled residents, facility staff failed to ensure that residents received care consistent with professional standards of practice for pressure ulcers as evidenced by failing to: perform weekly skin assessments for four (4) residents and first observing facility acquired pressure ulcers for two (2) residents at an advanced stage. (Residents' #4, #56, #84, #138, and #257)

Inspectors wroteBased on record review and interview, the facility staff failed to provide dignity for a resident as evidenced by not providing incontinent care in a timely manner for one (1) of 67 sampled residents (Resident #256).

Inspectors wroteBased on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by soiled bathroom vents in two (2) of 34 resident's rooms, soiled privacy curtains in four (4) of 34 resident's rooms, a worn out, dirty floor in one (1) of 34 resident's bathroom, and one (1) of one (1) dusty oxygen concentrator in one (1) of 34 resident's rooms.

Inspectors wroteBased on record review and staff interviews, for two (2) of 67 sampled residents, facility staff failed to: (1) develop a comprehensive care plan to address Resident #150's use of Plavix (anticoagulant) and (2) implement the care plan intervention for changing Resident #354's central line dressing.

Inspectors wroteBased on record review and staff interview, for one (1) out of 67 sampled residents, facility staff failed to revise Resident #124's comprehensive care plan reflect the resident's preference to not be discharged .

Inspectors wroteBased on observation, record review, staff and resident interview for two (2) of 67 sampled residents, facility staff failed to ensure that residents are given the appropriate treatment and services to maintain or improve their ability to carry out activities of daily living by not providing documented evidence that residents were provided with ADL(activities of daily living) care such as personal hygiene care on multiple days. (Residents' #84 and #4).

Inspectors wroteBased on record reviews and interviews, for three (4) of 67 sampled residents, facility staff failed to ensure that residents who were unable to independently carry out activities of daily living (ADLs) were provided services necessary to maintain personal hygiene. Residents' #4, #19, #84 and #93.

Inspectors wroteBased on observation, record review and staff interview for three (3) out of 67 sampled residents, facility staff failed to ensure residents with limited range of motion received the appropriate services to maintain or improve range of motion. Facility staff failed to show evidence that restorative nursing services were provided and failed to ensure that a resident received prescribed orthotics and multi-podus boots as ordered by the physician to prevent worsening contracture. (Residents' #32, #95, and #102)

Inspectors wroteBased on record review and staff interviews, facility staff failed to ensure that three (3) of 67 sampled residents received adequate monitoring and supervision to prevent avoidable accidents as evidenced by the following occurrences: one resident that left the facility without staff knowledge; one resident who fell out of her wheelchair while being escorted back into the facility; and one resident who fell after receiving assistance from one staff person during a transfer. (Residents' #124, #135, #35).

Inspectors wroteBased on observation, record review and staff interview, for two (2) of 67 sampled residents, facility staff failed to provide pain management in accordance with the physician's order. Residents' #104 and #133.

Inspectors wroteBased on record review, resident and staff interview, for one (1) of 67 sampled residents, facility staff failed to remove the pressure dressing from Resident #21's arteriovenous (AV) Fistula site in accordance with the physician's order.

Inspectors wroteBased on observation, record review and staff interview, for two (2) of 67 sampled residents, facility staff failed to provide nursing and related services to assure resident safety as evidenced by failure to: (1) provide Resident #133 pain management that met professional standards of practice and (2) ensure Resident #257 received care consistent with professional standards of practice to prevent the development of a pressure ulcer (Stage 3).

Inspectors wroteBased on record review and staff interviews, facility staff failed to ensure that the controlled medications were accurately recorded as given and accurately recorded wasted in the designated location; and accurately reconcile controlled medications for one (1) of three (3) sampled resident controlled drug records reviewed. Residents #256.

Inspectors wroteBased on observation, record review, staff and resident interview for two (2) of 67 sampled residents, facility staff failed to provide menus to all the facilities residents so that they could make food choices and the facility's staff failed to update menus periodically and have them reviewed by the facilities dietician. (Residents' #102, and #82)

Inspectors wroteBased on observations and staff interview, facility staff failed to prepare and serve foods under sanitary conditions as evidenced by food temperatures that tested under 135 degrees fahrenheit (F) during a test tray assessment, a cracked and loose ceiling light in the main kitchen, a damaged wall behind the grease fryer, and staff failure to follow food quality standards of practice.

Inspectors wrote3) Facility staff failed to properly minimize or prevent the potential spread of infection by not thoroughly cleaning Resident #406's room prior to their admission. Resident #406 was admitted to the facility on [DATE] with diagnoses including Cervical Stenosis of the Spinal Canal, Fracture of the Left Femur, Cervicalgia (neck pain), Lumbago (low back pain)[https://icd.codes/icd10cm/M542], and S/P (status post) accidental fall. Review of Resident #406's medical record revealed: 06/10/22 at 8:02 PM [Nurses admission Note] documented, .admitted from [Local Hospital] . Resident is alert/oriented x 3, cooperative, able to make needs know(n) .[Name of Physician] made aware of resident admission to the facility . During an observation and interview on 06/16/22 at approximately 9:20 AM, Resident #406 was resting in her bed. [...]

Inspectors wroteBased on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by one (1) of one (1) conveyor dishwasher that failed to automatically move peg racks filled with cups, dishes, silverware and/or food trays through the machine.

Inspectors wroteBased on observations and interview, it was determined that facility staff failed to prepare and serve foods under sanitary conditions as evidenced by 12 of 12 baffles from the kitchen hood system that were soiled with grease deposits and hot foods that tested at less than 135 degrees Fahrenheit (F) during a test tray assessment.

Inspectors wroteBased on record review and staff interview the facility failed to develop a system of surveillance to identify infections or communicable diseases; and staff failed to maintain a safe, sanitary environment as evidenced by a soiled ice machine on one (1) of three (3) resident care units. The census on the first day of survey was 175.

Inspectors wroteBased on record review and staff interview, the facility's staff failed to ensure annual in-services sheets failed to record the mandatory 12 hours of training, the subject, the date, the time/duration, the purpose, and/or who conducted the training in four (4) of four (4) in-service(s) reviewed.

Inspectors wroteBased on review of the facility's trial balance and staff interview, for 12 of 138 sampled residents with personal fund accounts, facility staff failed to ensure that residents who chose to deposit personal funds with the facility, completed a written authorization form giving the facility permission to act as a fiduciary of the residents' funds.

Inspectors wroteBased on record review and staff interview for one (1) of 70 sampled residents, the physician failed to ensure that one (1) resident's order for Humalog Insulin was written correctly. The dosage was written incorrectly x 4 months. Resident #66. Findings Include . Resident #66 was admitted to the facility on [DATE], with diagnoses which included Anemia, Diabetes and End Stage Renal Disease. According to Section I (Diagnoses) of the annual Minimum Data Set (MDS) dated [DATE] and a quarterly MDS dated [DATE] the resident was documented to have a history of diabetes. Review of the physician's order for Humalog Insulin show that for the months of May 2019, June 2019, July 2019 and August 2019 the order was written as: Humalog 100 Unit/ML (3ML vial) Inject 3 ml subcutaneously three times a day for DM (Diabetes Mellitus) . dated 05/07/19. [...]

Inspectors wroteBased on observation, record review and staff interview for one (1) of 70 sampled residents, the consultant pharmacist failed to identify and make recommendations to correct the Insulin dosage for Resident #66.

Inspectors wroteBased on observation of medications stored and staff interview for one (1) of three (3) medication carts on [DATE], at approximately 12:30 PM the facility staff on the first floor failed to date the labels of seven (7) of 12 multi-dose vials/medication containers when they were first accessed; and to remove an expired medication for one (1) resident from a medication cart on the second floor.

Inspectors wroteBased on observation, record review and staff interview for four (4) of 70 sampled residents, facility staff failed to accurately carry over Insulin orders for one (1) resident from one month to another, to complete the dialysis communication form for two (2) dialysis residents, and failed to ensure that recorded weights for one (1) resident were correctly documented in the resident's clinical records. Residents' #8, #66, #71 and #108.

Inspectors wroteBased on resident and staff interview and record review for one (1) of 70 sampled residents, facility staff failed to ensure that Resident #112 was free from staff verbal abuse.

Inspectors wroteBased on record review and staff interview for two (2) of 70 sampled residents, facility staff failed to develop comprehensive, person centered care plans for use of an antidepressant for one (1) resident, to address dental care t and the use of anticoagulant for one (1) resident. Residents' #54 and #95.

Inspectors wroteBased on medical record review and staff interview for one (1) of 70 sampled residents, facility staff failed to update care plan with goals and approaches for resident-centered care for one (1) resident's gastrostomy tube (GT). Resident #53.

Inspectors wroteBased on Medpass observation and staff interview for two (2) of four (4) sampled residents observed during medication administration, the facility staff failed to provide care in accordance with professional nursing standards as evidenced by the staff was observed to incorrectly used the blood pressure cuff to measure one (1) resident's blood pressure and administer one (1) resident eye drops. Residents' #88 and #126.

Inspectors wroteBased on record review and staff interview, the facility staff failed to provide evidence of monitoring or modifying interventions consistent with resident needs and goals to maintain acceptable parameters of nutritional status for one (1) of 70 sampled residents (Resident #132).

Inspectors wroteBased on observation, record review and staff interview for two (2) of 70 sampled residents, facility staff failed to ensure the dialysis communication form used to reflect ongoing collaboration between the facility and dialysis staff was included in the medical record for Residents' #8 and #71

Inspectors wroteBased on observation, record review and staff interview, the facility staff failed to: (I) adequately assess a wound per professional standards of practice for one (1) of 70 sampled residents (Resident #34); and (II) correctly transcribe an insulin order for one (1) of 70 sampled residents (Resident #66).

Inspectors wroteBased on medical record review and staff interview for one (1) of 70 sampled residents, the facility staff failed to develop a care plan with individualized, person-centered approaches to address Resident #120 with a diagnosis of Dementia.

Inspectors wroteBased on observation, record review and staff interview for one the facility's staff failed to assist one (1) of 70 sampled resident in obtaining dental care (Resident #95).

Inspectors wroteBased on observation and staff interview facility staff for one (1) of 70 sampled residents facility staff failed to provide Resident #65 with a wheelchair with operable parts (leg rest).

Inspectors wroteBased on observations and staff interview, facility staff failed to maintain the call bell system in good working condition as evidenced by a call bell in three (3) of 38 resident's rooms that did not emit an audio or visual alarm when tested.