Serenity Bay Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Serenity Bay Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 10, 2023

  Based on observation, record reviews and interviews, the facility failed to prevent the neglect of one (Resident #1) out of four residents sampled during the time of this survey. The facility's staff failed to supervise and implement adequate measures to prevent the elopement of Resident #1 who was coded as an elopement risk. The facility neglected to adequately monitor and address Resident #1's displayed exit seeking behaviors and intent of elopement. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate alert monitoring system was in place allowed the resident to elope undetected by staff on [DATE] at 10:32 AM. […]

• Immediate jeopardy, isolatedF607May 10, 2023

  Based on record reviews and interviews, the facility failed to implement their abuse and neglect policy as evidenced by staff failure to provide care and services including adequate supervision for one (Resident #1) out of four residents sampled during the time of this survey. This deficient practice has the potential to affect all 107 residents residing in the facility. This enabled resident #1 to elope from the facility undetected on [DATE] at 10:32 AM. The resident was not located until 6:10 PM on [DATE] wandering in a neighborhood 17.1 miles from the facility by law enforcement who reported Resident #1's location to the resident's son. […]

• Immediate jeopardy, isolatedF689May 10, 2023

  Based on observation, interviews and record review, the facility failed to provide adequate supervision and a secured environment for one (Resident #1) out of four sampled residents with exit seeking behaviors. This deficient practice enabled Resident #1 to exit the facility at 10:32 AM on [DATE], undetected. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate and effective alert monitoring system was in place allowed the resident to elope undetected by staff on [DATE] at 10:32 AM. The resident was not located until 6:10 PM on [DATE] wandering in a neighborhood 17.1 miles from the facility by law enforcement who reported Resident #1's location to the resident's son. […]

• Immediate jeopardy, isolatedF835May 10, 2023

  Based on observations, record reviews and interviews, the facility's administration failed to implement, provide and ensure an effective and efficient preventative measures were in place to prevent the neglect and elopement of one resident (Resident #1) out of four sampled residents who displayed exit seeking behaviors. As evidenced by inadequate safety measures that included failure to ensure exit door alarm was audible in all areas of the facility in the event of an emergency and failure by staff to implement assigned level of supervision for resident #1 who was a high risk for elopement. These deficient practices enabled resident #1 to exit the facility undetected at 10:32 AM through an emergency exit door on [DATE] placing the resident at risk for harm and/or injury. […]

• No harm, potential for more than minimal, widespreadF812Dec 4, 2025

  Based on observations, interviews and record reviews facility failed to store and prepare food in a sanitary manner in the kitchen as evidenced by milk box temperature measured at 50 degrees Fahrenheit, a refrigerated serving of nectar thick milk temperature measured at 51 degrees Fahrenheit, a personal item on top of dishwasher, and a kitchen staff member with a beard not wearing a beard covering. These deficient practices had the potential to result in food borne illness for all residents who consume food prepared in the facility's kitchen. There were 129 residents residing in the facility at the time of survey. […]