Serenity Estates of Lena

In the surveyor’s words

From the most serious findings on record at Serenity Estates of Lena, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 9, 2021

  Based on interview and record review the facility failed to follow their policies and procedures related to routine bed checks and provision of necessary care. Staff failed to confirm R1's well-being and provide necessary care for a period of approximately 10 hours. It was determined by the coroner that R1 had been deceased approximately 8- 12 hours prior to being found by facility staff. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 10:30PM when R1 was last assisted by staff. The Immediate Jeopardy was identified on [DATE]. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 10:30 AM. The surveyor confirmed by interview and record review that the immediacy was removed on [DATE] at 10:00 AM. […]

• Immediate jeopardy, isolatedF684Jun 9, 2021

  Facility failures resulted in two deficient practice statements. I. Based on observation, interview, and record review the facility failed to provide necessary care and services by not repositioning, toileting, or providing incontinence care for a resident dependent upon staff for all activities of daily living and who was severely cognitively impaired. This failure resulted in R1 receiving no personal care or well-being check for a period of approximately ,d+[DATE] hours prior to R1 being found deceased . The facility failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 10:30PM when R1 was last assisted by staff. The Immediate Jeopardy was identified on [DATE]. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 10:30 AM. […]

• Actual harm, isolatedF689Aug 1, 2024

  Based on interview and record review, the facility failed to perform safe bed mobility for 1 resident (R1) reviewed for safety and supervision. This failure resulted in R1 sustaining a nasal bone fracture, a femoral neck fracture, and a 4x4cm (centimeter) laceration to her forehead that was repaired with 9 sutures. This applies to 1 of 3 residents reviewed for safety and supervision in the sample of 3. The findings include: R1's electronic face sheet printed on 8/1/24 showed R1 has diagnoses including but not limited to intracapsular fracture of right femur, localization-related idiopathic epilepsy and epileptic syndrome with seizures, laceration of head, dementia with agitation, and osteoporosis. […]

• Actual harm, isolatedF689May 25, 2023

  Based on observation, interview, and record review the facility failed to provide supervision to a resident with repeated falls (R55). This resulted in R55 having an two unwitnessed falls, the first fall resulted in a left femur fracture requiring surgical intervention and the second fall resulting in a right humerus fracture. The facility failed to ensure a resident at risk for falls was supervised (R59). This resulted in R59 experiencing an unwitnessed fall and fracturing her lumbar one, spinal vertebrae (lower back fracture). The facility failed to implement their fall protocol and assess a resident for falls (R40), resulting in an unwitnessed fall in R40's room. […]

• Actual harm, isolatedF692May 4, 2022

  Based on observation, interview, and record review the facility failed to ensure a residents nutritional caloric needs were met and failed to notify the physician for a continued weight loss for a resident with enteral feeding who had a significant weight loss this applies to 1 of 3 (R50) reviewed for weight loss in the sample of 20. This failure resulted in R50 losing 14.8 pounds in 3 months. The findings include: On 5/2/22 at 11:50 AM, R50 was lying in his bed. He appeared thin and frail his sternum bones were protruding from under his skin. The tube feeding was in his room was not connected. V10 (Certified Nursing Assistant) fed R50 his noon meal. R50 took one bite of the puree meal and said, that's enough. R50's diet card showed he was on a puree meal with pleasure feeding. […]