Serenity Spring Senior Living at Northwood

In the surveyor’s words

From the most serious findings on record at Serenity Spring Senior Living at Northwood, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 9, 2023

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 2 of 2 residents reviewed for accidents. Care plan interventions were not followed or updated after falls, and one random observation of a treatment cart containing prescription medication was observed left unlocked and unattended. This deficient practice resulted in Resident 44 having 9 falls in 11 months resulting in three fractures. (Resident 44, Resident 28, Treatment Cart) Findings include: 1. During an interview on 2/1/23 at 9:21 A.M., CNA (Certified Nurse Aide) 73 indicated Resident 44 falls a lot. […]

• Actual harm, isolatedF689Jan 21, 2022

  Based on observation, interview, and record review, the facility failed to ensure 2 staff members were present during the transfer of a dependent resident with a mechanical lift, resulting in a fall with multiple fractures of bilateral feet, for 1 of 4 residents reviewed for falls. (Resident B) Findings include: On 1/20/22 at 9:50 A.M., RN 1 indicated Resident B had recently fallen. On 1/20/22 at 9:55 A.M., Resident B was observed lying in bed. Staff were providing care. The resident was non-verbal. On 1/20/22 at 12:00 P.M., the clinical record of Resident B was reviewed. […]

• No harm, potential for more than minimal, patternF921Apr 7, 2026

  Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 3 of 6 unit halls and common resident spaces. The 100 unit hall temperature was 70 degrees Fahrenheit (F), the Garden Ridge unit hall was 64 degrees F, and the Cedar point unit hall was 69 degrees F. (100 unit, Garden Ridge unit, Cedar Pointe unit, Resident B, Resident D). Finding includes:During a record review on 4/6/26 at 11:30 A.M., minutes from a Resident Council meeting on 2/17/26 mentioned facility temperature levels as a topic of concern. During an interview on 4/6/26 at 2:50 P.M., Resident B indicted the Garden Ridge unit temperature was cool.During an observation on 4/6/26 at 3:00 P.M., the Garden Ridge unit hallway thermostat read 65 degrees F. […]

• No harm, potential for more than minimal, patternF553Jun 13, 2025

  Based on observation, interview, and record review, the facility failed to ensure care plan conferences were held for 4 of 5 residents reviewed for unnecessary medications. (Resident 6, Resident 7, Resident 11, Resident 44) Findings include: 1. On 6/11/25 at 8:20 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to anxiety, osteoporosis, depression, and early-onset cerebellar ataxia (a neurological disorder that primarily affects the cerebellum, a part of the brain responsible for coordinating movement and balance). The most recent quarterly Minimum Data Set (MDS) assessment, dated 5/20/25, indicated Resident 6 was cognitively intact. […]

• No harm, potential for more than minimal, patternF580Jun 13, 2025

  Based on interview and record review, the facility failed to ensure notification to family/resident representative with a change in resident condition for 4 of 5 residents reviewed for falls. Family/resident representatives were not notified following falls. (Resident 39, Resident 43, Resident 52, Resident 56) Findings include: 1. On 6/11/25 at 2:33 P.M., Resident 39's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease, dementia, anxiety, and depression. […]