Federal Nursing-Home Survey Record
Serenity Spring Senior Living at Scandia Village
Does Serenity Spring Senior Living at Scandia Village have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), Serenity Spring Senior Living at Scandia Village (CCN 525494), in Sister Bay, WI, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 14 deficiencies; the most serious carries scope/severity G on CMS's A–L scale, a level CMS classifies as actual harm. The most recent federal survey on file is dated 2025-05-07. 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
At its most recent federal inspection, CMS cited this facility for 1 actual-harm deficiency.
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: 2 · CMS state average: 3.0
Deficiency timeline — full federal history
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure that residents are fully informed and understand their health status, care and treatments.
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.
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
24 citations from earlier inspection cycles — historical, not current (expand)
Respond appropriately to all alleged violations.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide enough food/fluids to maintain a resident's health.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
PASARR screening for Mental disorders or Intellectual Disabilities
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure each resident receives an accurate assessment.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Ensure that residents are fully informed and understand their health status, care and treatments.
Provide care and assistance to perform activities of daily living for any resident who is unable.
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.
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
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.
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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.
Document what happened
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