Serenity Transitional Care

In the surveyor’s words

From the most serious findings on record at Serenity Transitional Care, in the surveyor’s own words.

• Actual harm, isolatedF689May 1, 2025

  Based on record review, Hoyer lift manual review, interview, and review of the facility's investigation report, it was determined the facility failed to ensure resident safety during Hoyer lift transfers. This was true for 1 of 8 residents (Resident #174) whose record was reviewed for falls. This resulted in harm to Resident #174 when a proper Hoyer lift transfer was not provided. Findings include: Joerns Hoyer User Instruction Manual undated, documented under Warnings, always plan your lifting operations before commencing. […]

• No harm, potential for more than minimal, widespreadF812May 1, 2025

  Based on review of the FDA Food Code, observation, and interview, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include: The FDA Food Code revised 2022, documents Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . […]

• No harm, potential for more than minimal, patternF550Jun 26, 2026

  Based on observations, resident and staff interviews, and document review, it was determined that the facility failed to treat each resident with respect and dignity. This was true for 3 of 3 residents (#73, #77, and #79) observed for dignity. This deficient practice had the potential for residents to experience embarrassment and low feelings of self-worth. Findings include: The facility's Nursing Facility Services and admission Agreement dated 5/14/24, documented on page 24, to protect your right to be treated with dignity and respect include, it is our policy to provide the kind of care to our residents that will maintain and enhance their dignity, individuality, and quality of life. […]

• No harm, potential for more than minimal, patternF684Jun 26, 2026

  Based on record review and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 4 of 4 residents (#4, #10, #19, and #44) reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when their medications were not administered according to the physician's order. Findings include:a) Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including post-laminectomy syndrome (PLS) (a condition where a patient experiences persistent, new, or recurring back and/or leg pain following spinal surgery) and diabetes.On 6/22/26 at 11:52 AM, Resident #4's medical record documented the following related to bowel care within the last 45 days.- No documented BM… […]

• No harm, potential for more than minimal, patternF880Jun 26, 2026

  Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not offer or encourage residents hand hygiene prior to meals and follow proper cleaning of medical equipment and handling of linens. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The facility's Hand Hygiene policy dated 12/11/25, documented wash hands with soap and water whenever they are visible dirty, before eating, and after using the restroom. […]