Serenity Spring Senior Living at Scandia Village

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure physician recommendations were followed for 1 resident (R) (R5) of 1 sampled resident from a total sample of 5 residents. R5 did not receive physician recommended shoes to aid in wound healing. In addition, staff did not monitor R5 for factitious disorder/picking behaviors to prevent further foot trauma.

Inspectors wroteBased on observation, staff, resident, represenatative interview, and record review, the facility did not ensure the resident enviornment was as free of accident hazards as possible for 2 residents (R) (R10 and R15) of 3 sampled residents. In addition, the facility did not ensure 2 residents (R6 and R18) of 2 sampled residents had behavioral interventions and were adequately supervised. R10 had a fall with injury on 4/24/26. The facility did not update R10's care plan post-fall. R15 had a fall with injury on 6/2/26. The facility did not complete post-fall assessments, provide prompt or appropriate medical care, implement falls interventions, or notify the required parties. R6 and R18 were known to wander into other residents' rooms uninvited. R6 and R18's care plans did not contain interventions to address wandering or appropriate levels of supervision.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R7 and R23) of 3 sampled residents were offered the opportunity to create or obtain Power of Attorney for Healthcare (POAHC) paperwork. R7 was admitted to the facility on [DATE]. The facility did not obtain R7's POAHC document or offer R7 the chance to fill out a new document prior to 6/1/26. R23 was admitted to the facility on [DATE]. The facility did not obtain R23's POAHC document or offer R23 the chance to fill out a new document prior to 6/1/26.

Inspectors wroteBased on staff and resident interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when they did not ensure an allegation of misappropriation was reported to the State Agency (SA) or local police for 1 resident (R) (R14) of 1 sampled resident. R14's wallet went missing after 4/15/26. The facility did not report the allegation of misappropriation to the SA or local police.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure an allegation of misappropriation was thoroughly investigated for 1 resident (R) (R14) of 1 sampled resident. R14's wallet went missing after 4/15/26. The facility did not thoroughly investigate the allegation of misappropriation or report the findings to the State Agency (SA).

Inspectors wroteBased on staff interview and record review, the facility did not ensure proper discharge procedures and/or a written transfer or bed hold notice was provided to 3 residents (R) (R43, R8, and R41) of 3 sampled residents. R43 discharged from the facility on 4/10/25. R43's medical record did not contain a recapitulation of stay, confirmation of discharge against medical advice (AMA), indicate discharge orders were received from R43's primary care physician, or indicate education and further services were offered prior to discharge. R8 was transferred to the hospital on 2/23/26 and 4/29/26. R8's medical record did not contain written transfer or bed hold notices. R41 was transferred to the hospital on 4/5/26. R41's medical record did not contain a written transfer or bed hold notice.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a comprehensive care plan was developed and implemented for 1 resident (R) (R7) of 14 sampled residents. R7 had orders for oxygen use and Hospice care. R7's care plan did not contain goals or interventions to address R7's dependence on oxygen and potential for airway disturbance or need for Hospice care.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure physican orders were followed and appropriate wound care and treatment was provided for 1 resident (R) (R35) of 4 sampled residents. R35 was seen in the wound clinic on 5/8/26 for non-pressure right anterior and posterior leg wounds. New treatments were ordered. The facility did not update R35's orders until 5/14/26. R35 was seen in the wound clinic again on 5/22/26. The physician ordered a wound vac and transitioned R35 from non weight-bearing to weight-bearing status. The facility did not order the wound vac, update R35's weight-bearing status, or update R35's care plan and Kardex (an abbreviated care plan used by nursing staff).

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R23 and R3) of 4 sampled residents received the necessary care and services to promote healing and/or prevent pressure injuries from worsening. R23 was seen in the wound clinic on 5/28/26 for right dorsal foot, left fifth dorsal toe, and right hallux bunion wounds. New treatments were ordered. The facility was not aware of the updated orders which resulted in a missed dressing change for R23's right dorsal foot on 5/31/26. R3 had a stage 4 pressure injury on the left heel and an order for a dressing change every other day. R3's Treatment Administration Record (TAR) indicated the dressing change was not completed on 5/20/26.

Inspectors wroteBased on staff interview and record review, the facility did not maintain acceptable parameters of nutritional status, including usual body weight range for 1 resident (R) (R39) of 1 sampled resident. R39 experienced a weight gain of greater than 5 pounds (lbs) in one week. The facility did not update the dietitian or R39's physician as ordered.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the provision of pharmacy services to meet the needs of 1 resident (R) (R6) of 5 sampled residents. A urinalysis and culture was ordered for R6 for a possible urinary tract infection. The facility did not promptly follow-up on the results or an antibiotic order which caused a delay in R6's treatment.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 2 residents (R) (R21 and R15) of 7 sampled residents. R21 was on contact precautions which required staff to don a gown and gloves prior to room entry. Registered Nurse (RN)-L did not don a gown and gloves prior to entering R21's room to provide medication. RN-L did not complete hand hygiene in accordance with the facility's policy during wound care for R15.

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccines were offered for 2 residents (R) (R2 and R7) of 5 sampled residents. R2 was not offered the influenza vaccine in accordance with the facility's policy. R7 was not offered the PCV20 vaccine in accordance with the facility's policy.

Inspectors wroteBased on staff and resident interview and record review, the facility did not have a process to ensure mail was delivered on Saturdays. This practice had the potential to affect all 37 residents (R) residing in the facility. The facility did not have a process to deliver mail on weekends. Mail delivered to the facility on Saturdays was not provided to residents until the following Monday.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R12) of 4 sampled residents received the necessary pressure injury care and treatment to promote healing and prevent pressure injuries from worsening. R12 had a stage 2 sacral pressure upon admission that measured 6.2 centimeters (cm) (length) x 4.1 cm (width) x 0.2 (depth) cm. A wound clinic note included in R12's admission paperwork stated offloading was of the utmost importance and R12 should be repositioned side-to-side every two hours. If the sacral wound progressed, R12 should be started on an alternating air mattress as soon as possible. R12's sacral wound was documented as worsening on 1/21/26 and 1/28/26 and measured 9.1 cm x 7.9 cm x 0.1 cm with a reddened peri-wound and pain. As of 2/10/26, R12 did not have an alternating air mattress. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure residents with orders for a consistent carbohydrate (CCHO) diet received their prescribed diet. This practice had the potential to affect 12 residents (R) (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14) of 12 sampled residents. R1's hospital discharge orders indicated R1 should have a low carb diet (60 grams of carbohydrates per meal). The order in R1's medical record indicated R1 should have 90 grams of carbohydrates per meal. R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14 had orders for a CCHO diet and did not receive what was on the CCHO diet lunch menu on 2/10/26.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not notify a physician when blood sugars were outside the ordered parameters for 3 residents (R) (R4, R3, and R1) of 3 sampled residents. R4 had an order to notify the physician of blood sugars above 450 milligrams/deciliter (mg/dL). The physician was not notified when R4's blood sugars exceeded 450 mg/dL on 1/3/26, 1/11/26, 1/15/26, 1/16/26, 1/19/26, 1/20/26, and 1/31/26. R3 had an order to notify the physician of blood sugars above 350 mg/dL. The physician was not notified when R3's blood sugars exceeded 350 mg/dL on 1/5/26 and 2/6/26. R1 had an order to notify the physician of blood sugars above 400 mg/dL. The physician was not notified when R1's blood sugar exceeded 400 mg/dL on 1/31/26.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 40 residents residing in the facility. The deep fryer was stored uncovered and had food debris along the sides and in the oil. In addition, there was no cleaning schedule for the deep fryer. Butter was observed in an uncovered container in the prep area. Equipment in the kitchen was not in clean condition. The hood vent above the deep fryer and oven contained a greasy black substance. The stove top had dried food debris. The microwave in the kitchen contained dried food on the inside. Fifteen boxes were observed on the floor in the freezer.

Inspectors wroteBased staff interview and record review, the facility did not ensure their abuse policy was implemented for 5 (Certified Nursing Assistant (CNA)-F, CNA-H, Dietary Aide (DA)-J, CNA-G, and Registered Nurse (RN)-I) of 8 employees reviewed for background checks. CNA-F was hired and started work on 2/24/25. CNA-F's Background Information Disclosure (BID) form was completed on 3/1/25 and Department of Justice (DOJ) report was run on 3/28/25. CNA-F did not have an Integrated Background Information System (IBIS) report. CNA-H and DA-J's background checks did not contain IBIS reports. CNA-G did not have a background check completed within the last 4 years. RN-I's DOJ and IBIS reports were completed before RN-I signed a BID form.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 residents (R) (R25, R7, and R22) of 5 sampled residents or their legal representatives were thoroughly informed in advance of the risks and benefits of prescribed psychotropic medication. R25 was prescribed lorazepam (an anti-anxiety medication), duloxetine (an antidepressant medication), trazodone (an antidepressant medication), and quetiapine (an antipsychotic medication). The facility did not ensure written consents were thoroughly reviewed and completed with R25's Power of Attorney for Healthcare (POAHC). R7 was prescribed venlafaxine (an antidepressant medication) and bupropion (an antidepressant medication). The facility did not ensure written consents were thoroughly reviewed and completed with R7's POAHC. R22 was prescribed citalopram (an antidepressant medication). [...]

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure grievances were thoroughly investigated and resolved for 1 resident (R) (R28) of 13 sampled residents. The facility did not document, investigate, and follow-up with R28 after R28 reported seven missing articles of clothing.

Inspectors wroteBased on staff interview and record review, the facility did not monitor the effectiveness of psychotropic medication for 1 resident (R) (R25) of 5 sampled residents. R25 had an order for lorazepam (an anti-anxiety medication) 0.5 milligrams (mg) as needed (PRN) every 6 hours for anxiety disorder/irritability and anger with a start date of 2/25/25. The medication was not discontinued or reviewed after 14 days.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R11) of 1 resident reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and name and address (mailing and email) with telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the facility did not ensure R11 received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R11 was transferred to the Emergency Department (ED) on 5/1/25. R11 was not provided with a written transfer or bed hold notice.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Pre-admission Screening and Resident Review (PASRR) Level I Screen was updated to initiate a PASRR Level II Screen when a newly evident mental disorder and/or change in medication was identified for 1 resident (R) (R22) of 5 sampled residents. R22 received new diagnoses and orders for psychotropic medication, including an antipsychotic medication. The facility did not update R22's PASRR Level I Screen and submit for PASRR Level II reevaluation.

Inspectors wroteBased on staff interview and record review, the facility did not revise a care plan in accordance with current care needs for 1 resident (R) (R34) of 4 sampled residents. R34 fell on 3/20/25 and fractured R34's left wrist. R34's care plan was not updated after the fall and did not include interventions to prevent future falls.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R18) of 4 sampled residents received care and treatment based on the resident's needs and hospital discharge instructions. R18 had a fall with a head laceration on 1/5/25. R18 was transferred to the emergency room (ER) and received staples to repair the laceration. R18's hospital discharge instructions stated to apply Neosporin or bacitracin ointment to the wound. The order was not implemented until two days after R18 returned to the facility.

Inspectors wrote2. From 5/5/25 to 5/7/25, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure, renal insufficiency, diabetes, and malnutrition. R33's most recent MDS assessment, dated 2/10/25, had a BIMS score of 13 out of 15 which indicated R33 had intact cognition. On 5/6/25 at 9:17 AM, Surveyor observed medication administration for R33 with LPN-O. While in R33's room, Surveyor observed a bottle of lubricating eye drops on R33's bedside table. Surveyor noted the eye drops were not labeled or dated. LPN-O removed the eye drops from R33's room. On 5/6/25 at 9:22 AM, Surveyor interviewed LPN-O who indicated LPN-O was not sure where the eye drops came from and was not sure if R33 had a self-administration of medication assessment. On 5/6/25 at 2:24 PM, Surveyor interviewed DON-B regarding the eye drops at R33's bedside. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure monthly medication reviews were completed for 2 residents (R) (R7 and R25) of 5 sampled residents. R7 did not have a monthly medication review (MMR) documented for November 2024, January 2025, or March 2025. R25 did not have a monthly medication review (MMR) documented for April 2025.

Inspectors wroteBased on staff interview and record review, the facility did not ensure allegations of potential neglect were thoroughly investigated for 2 residents (R) (R2 and R1) of 3 sampled residents. R2 passed away on [DATE] following a fall on [DATE]. The facility did not thoroughly investigate the incident of potential neglect. R1 fell on [DATE]. R1 went to the hospital on [DATE] due to increased pain and a change in condition and was diagnosed with a clavicle fracture. The facility did not thoroughly investigate the fall or the potential for abuse or neglect.

Inspectors wroteBased on staff interview and record review, the facility did not ensure thorough neurological checks were completed per the facility's policy for 2 residents (R) (R2 and R1) of 3 sampled residents. Staff did not consistently complete vital signs during neuro checks following R2's fall on 8/24/24. Staff did not complete neuro checks per the facility's policy after R1 fell and hit R1's head on 8/17/24.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure adequate assistive devices and interventions were in place to prevent falls for 1 resident (R) (R1) of 3 sampled residents. R1's care plan contained an intervention for a tab alarm. The intervention was not consistently implemented.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 27 of 27 residents residing in the facility. Staff did not ensure time/temperature control foods were labeled with open or use-by dates. Staff did not wear hair or beard restraints consistently throughout the kitchen. Kitchen equipment and food services areas were not in a clean and sanitary condition.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain infection control and water management programs designed to help prevent the development and transmission of disease and infection. In addition, the facility did not ensure enhanced barrier precautions were implemented for 4 residents (R) (R2, R18, R4, and R79) of 4 residents to reduce the transmission of multidrug-resistant organisms (MDROs) and did not ensure staff performed appropriate hand hygiene for 5 (R1, R9, R16, R129 and R19) of 5 residents observed during medication administration. These practices had the potential to affect all 27 residents residing in the facility. The facility did not maintain surveillance logs to assist with the recognition of trends and patterns of infection to help prevent the spread of communicable disease. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure the designated Infection Preventionist (IP) completed infection prevention and control training and was employed at least part-time in the facility. This practice had the potential to affect all 27 residents residing in the facility. The facility's designated IP worked remotely and did not work in the facility at least part-time. In addition, the IP's certificate of completion for infection prevention and control training was not provided to Surveyor.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the comprehensive plan of care was reviewed and revised in a timely manner for 6 residents (R) (R2, R16, R18, R20, R21, and R22) of 13 sampled residents. R2, R16, R18, R20, R21 and R22's care plans were not reviewed prior to or on the due dates listed on the care plans.

Inspectors wroteBased on observation, staff interview, record review, the facility did not ensure weights were obtained per physician orders for 4 residents (R) (R13, R20, R16 and R128) of 4 sampled residents. Staff did not obtain and document weekly weights for R13, R20, and R16 per physician orders. R128 was admitted to the facility on [DATE]. R128's medical record did not contain weight information.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a resident or their representative was informed and consented to the risks and benefits of care and the treatment for 2 residents (R) (R16 and R20) of 5 sampled residents. R16 was prescribed Seroquel (an antipsychotic medication), Lexapro (an antidepressant medication), Depakote (an anticonvulsant/mood stabilizing medication), Paxil (an antidepressant medication), Buspar (an anti-anxiety medication), and Namenda (a cognition-enhancing medication). R16's medical record did not contain current consents for the medications. R20 was prescribed Seroquel, Depakote, Paxil, Namenda, and Exelon (a cognition-enhancing medication). R20's medical record did not contain current consents for the medications.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R12 and R22) of 2 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. In addition, the facility did not notify the Ombudsman of the transfers. R12 was transferred to the hospital on 6/3/23. R12 was not provided with a written transfer notice and the Ombudsman was not notified of the transfer. R22 was transferred to the hospital on [DATE]. R22 was not provided with a written transfer notice and the Ombudsman was not notified of the transfer.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R12 and R22) of 2 residents reviewed for hospitalization received written information of the duration of the facility's bed-hold policy, the reserve bed payment policy, and the right to return to the facility. R12 was transferred to the hospital on 6/3/23 and was not provided a copy of the facility's bed-hold policy. R22 was transferred to the hospital on [DATE] and was not provided a copy of the facility's bed-hold policy.

Inspectors wroteBased on staff interview and record review, the facility did not accurately code Minimum Data Set (MDS) 3.0 assessments for 2 residents (R) (R4 and R21) of 13 sampled residents. R4's MDS assessment, dated 2/21/24, did not contain a Brief Interview for Mental Status (BIMS) score or indicate R4's cognition was assessed. R21's MDS assessment, dated 3/28/24, did not contain a BIMS score or indicate R21's cognition was assessed.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Level I Pre-admission Screening and Resident Review (PASRR) Screen was completed prior to admission for 1 resident (R) (R22) of 5 residents. The facility did not ensure R22's Level I PASRR Screen was completed prior to admission.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a baseline care plan was developed or provided within 48 hours of admission for 1 resident (R) (R178) of 13 sampled residents. A baseline care plan was not completed or provided to R178 within 48 hours of admission.

Inspectors wroteBased on staff interview and record review, the facility did not develop or implement an individualized comprehensive care plan for 1 resident (R) (R21) of 13 sampled residents. R21 required assistance with activities of daily living (ADL). The facility did not develop a comprehensive care plan that included ADL interventions related to toileting and incontinence care.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide assistance with activities of daily living (ADLs) for 1 resident (R) (R21) of 13 sampled residents. R21 required assistance with toileting and incontinence care which was not consistently provided.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the provision of care and treatment in accordance with professional standards of practice for 1 resident (R) (R13) of 1 sampled resident with edema. R13 had a diagnosis of edema. R13's plan of care did not contain interventions to treat, monitor, or provide edema relief. In addition, the facility did not update R13's physician on the effectiveness of a short-term medication order for edema.

Inspectors wrote2. On 4/23/24, Surveyor reviewed R16's medical record. R16 had an activated Power of Attorney for Healthcare (POAHC) and diagnoses including dementia with delusional disorder, cognitive communication disorder, dysthymic disorder, acquired absence of other specified parts of digestive system, and anxiety. R16's MDS assessment, dated 3/6/24, contained a BIMS score of 0 out of 15 which indicated R16 had severely impaired cognition. A progress note, dated 4/22/24, indicated: Certified Nursing Assistant (CNA) indicated R16 lost footing when walking and fell to buttocks on the floor. Bruising noted to R16's right mid back and right hip. R16 transferred with assist and reported no pain. The progress note indicated R16 did not have footwear on during the fall. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring of a high-risk medication was provided for 1 resident (R) (R22) of 5 residents reviewed for unnecessary medications. The facility did not monitor R22 for potential side effects or adverse reactions of anticoagulant (blood thinner) medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring for adverse effects of psychotropic medication was provided for 3 residents (R) (R16, R128, and R178) of 5 residents reviewed for unnecessary medications. R16 was prescribed antipsychotic, antidepressant, and anti-anxiety medication. R16's medical record did not indicate a gradual dose reduction was attempted within the last year or that a GDR was contraindicated. R128 was prescribed antipsychotic, antidepressant, and anti-anxiety medication. R128's plan of care did not contain monitoring for signs and symptoms of adverse effects or the effectiveness of the medication. In addition, R128's medical record did not contain an Abnormal Involuntary Movement Scale (AIMS) assessment. R178 was prescribed antipsychotic and anti-anxiety medication. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure the minimum required members of the Quality Assurance Performance Improvement (QAPI) committee met at least quarterly which had the potential to impact all 27 residents residing in the facility. Three of four required quarterly QAPI meetings held over the past year did not have the Medical Director (MD), Nursing Home Administrator (NHA), Director of Nursing (DON) and/or Infection Preventionist (IP) in attendance as required.