Serenity Hill Nursing Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF908Mar 3, 2026

  Based on observation, interview and document review, the facility failed to maintain kitchen equipment in safe operating condition. Specifically, the facility failed to promptly repair or replace a broken dish machine.Findings include:Review of the facility's policy titled Maintaining Food Service Equipment, last reviewed 1/1/25, indicated but was not limited to:-The facility shall maintain all food preparation, storage, and service equipment in good repair and condition to prevent foodborne illness, ensure resident safety, and comply with federal and state regulatory requirements.-Equipment shall be: -Cleaned and sanitized per manufacturer guidelines -Inspected regularly -Preventatively maintained -Removed from service if unsafePreventative Maintenance-Documentation includes:… […]

• No harm, potential for more than minimal, widespreadF761Apr 29, 2025

  3. On 4/25/25 at 8:49 A.M., the surveyor entered the open door of the clean utility room in the nursing unit hallway. Inside the room were two unlocked cabinets with several items noted inside including: -11 bottles of Antifungal powder with Miconazole Nitrate 2% -28 tubes of moisture barrier antifungal cream mupirocin ointment 2% -9 bottles of DermaCream During an interview on 4/29/25 at 1:29 P.M., the Director of Nursing said the clean utility room has a keypad lock on it and the door should be closed and locked at all times to prevent residents from accessing the hazardous items inside. 4. […]

• No harm, potential for more than minimal, widespreadF909Apr 29, 2025

  Based on observation, record review, and interview, the facility failed to complete a new assessment of the bed, side rails and mattresses in active use for potential entrapment when the bed mattress was changed from the previously assessed mattress, placing two Residents (#22 and #34), out of a sample of 12 residents, who had limited mobility and utilized bilateral side rails, at risk for possible entrapment. Following an interview with the facility's Maintenance Director, it was determined that 38 of 38 beds in use in the facility were affected. Findings include: Review of the facility's policy titled Proper Use of Siderails, revised 2/1/2018, indicated but was not limited to the following: - Manufacturer instructions for the operation of side rails will be adhered to. […]

• No harm, potential for more than minimal, widespreadF727May 14, 2024

  Based on review of the facility's licensed nurse staff schedules, employee punch cards, and interviews, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Specifically, the facility failed to provide at least eight consecutive hours of RN services in the facility over a 24-hour period for 13 days between 3/30/24 and 5/12/24, when no nurse staffing waivers were in place. Findings include: During an interview on 5/8/24 at 8:54 A.M., the Administrator said the facility had no Nurse staffing waivers. […]

• No harm, potential for more than minimal, widespreadF867Mar 9, 2023

  Based on staff interview and review of the facility policy, the facility failed to track and analyze data, including the progress and outcome of projects identified in the facility's Quality Assurance Performance Improvement (QAPI) program. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI), revised 1/1/2021, indicated the following: - The Design and Scope: A QAPI program will address clinical care, quality of life, resident choice, and care transitions, utilizing the best available evidence to define and measure goals. […]