Federal Nursing-Home Survey Record
SERENITY HILL NURSING CENTER
Does SERENITY HILL NURSING CENTER have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), SERENITY HILL NURSING CENTER (CCN 225752), in WRENTHAM, MA, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 17 deficiencies; the most serious carries scope/severity F on CMS's A–L scale — CMS's "potential for harm" tier, below actual harm. The most recent federal survey on file is dated 2025-04-29. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
The most recent federal inspection on file records no actual-harm or immediate-jeopardy citations for this facility.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 1 · CMS state average: 3.1
Deficiency timeline — full federal history
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Provide and implement an infection prevention and control program.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide care or services that was trauma informed and/or culturally competent.
Honor the resident's right to organize and participate in resident/family groups in the facility.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Implement a program that monitors antibiotic use.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
18 citations from earlier inspection cycles — historical, not current (expand)
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide and implement an infection prevention and control program.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Give the resident's representative the ability to exercise the resident's rights.
Report COVID19 data to residents and families.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide and implement an infection prevention and control program.
Ensure services provided by the nursing facility meet professional standards of quality.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Document what happened
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