Serenity Spring Senior Living at Scandia Village

In the surveyor’s words

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

• Immediate jeopardy, patternF689Nov 2, 2022

  Based on observation, record review and staff interview, the facility failed to ensure that three residents (R) (R13, R11 and R23), received the necessary services to prevent wandering and ensure personal safety. The facility implemented a resident elopement warning system (Wanderguard - a sensor, attached to the resident's body via a band, designed to alarm when the resident exits through the door,) device on R13's body to prevent elopement from the facility. On 8/6/22, a staff member saw R13 outside through the window. Staff working at that time indicated the Wanderguard system was not alarming as intended when a resident wearing the Wanderguard device exited the door. The facility implemented a Wanderguard device on R11's body to prevent elopement from the facility. […]

• Actual harm, isolatedF686Feb 10, 2026

  Based 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. […]

• Actual harm, isolatedF689Apr 27, 2023

  Based on staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R1) of 3 sampled residents reviewed for falls had adequate assistive devices and interventions in place to prevent future falls. R1 was at risk for falls and fell out of bed on 3/21/23 while having a bad dream. The facility did not implement additional interventions to prevent R1 from falling out of bed again while having a bad dream. On 4/7/23, R1 fell out of bed and fractured R1's right upper arm. […]

• Actual harm, isolatedF686Nov 2, 2022

  Based on observation, record review, and staff interview, the facility did not ensure each resident received necessary treatment to prevent pressure injuries from developing for 1 Resident (R) (R9) of 5 sampled residents reviewed for pressure injuries. R9 developed an unstageable pressure injury to the right ankle on 8/1/22. When R9 developed a scab to the pressure injury, facility staff did not properly assess R9's pressure injury until 10/18/22 after the pressure injury developed a scab and after A & D ointment was placed on the wound to soften the scab. The wound developed to a stage 3 pressure injury. R9's plan of care was not updated to include R9's unstageable pressure injury and R9 did not have a treatment plan in place. […]

• No harm, potential for more than minimal, widespreadF812May 7, 2025

  Based 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. […]