Deficiencies (last 3 years)
Deficiencies (over 3 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Enforcement
Census: 63
Deficiencies: 3
Date: Jan 18, 2024
Visit Reason
The inspection was conducted following findings of staffing shortages and an elopement incident resulting in significant harm to a resident. The report documents disciplinary actions and enforcement measures against Serene Manor Medical Center.
Findings
The facility failed to maintain sufficient staffing levels, resulting in an elopement with significant harm to a resident. The facility also failed to follow proper procedures during the incident and subsequent investigation, including failure to preserve security video and documentation.
Deficiencies (3)
The facility failed to maintain sufficient staffing levels, with only one nurse and three or fewer CNAs on night shifts for all three floors housing up to 70 residents. This staffing shortage contributed to an elopement incident causing significant harm to a resident.
Staff failed to follow proper procedures during the elopement incident, including marking the resident as 'in bed' despite being outside and failing to preserve security video footage for surveyors.
Facility staff failed to make electronic copies of investigation reports, and physical documentation was missing when requested by surveyors, with no excuse provided.
Report Facts
Civil Monetary Penalties: 1500
Civil Monetary Penalties: 25000
Resident count: 63
Resident count: 70
Probation period: 6
Discharge period: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Bowman | CEO | Authorized representative who signed the Consent Order. |
| Vishan J. Ramcharan | Associate General Counsel | Signed the Consent Order on behalf of the Health Facilities Commission. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 23, 2022
Visit Reason
The visit was a follow-up survey conducted to determine if previously cited deficient practices detrimental to resident health, safety, or welfare had been corrected following an earlier annual and complaint survey.
Findings
The follow-up survey found that the deficient practices had been corrected and the facility returned to substantial compliance for state licensing purposes. Consequently, the suspension of admissions was lifted.
Report Facts
Survey dates: Initial survey from May 16 to May 24, 2022; follow-up survey August 22 to August 23, 2022
Suspension effective date: Suspension of admissions effective June 10, 2022
Inspection Report
Enforcement
Deficiencies: 1
Date: May 24, 2022
Visit Reason
The inspection was conducted as an annual survey combined with a complaint survey to assess compliance with regulatory standards at Serene Manor Medical Center.
Findings
The survey identified deficient practices and conditions detrimental to resident health, safety, or welfare, specifically in Administration, Basic Services [Performance Improvement], and Basic Services [Nursing Services]. As a result, a Suspension of Admissions was imposed along with five Type A Civil Monetary Penalties totaling $25,000.
Deficiencies (1)
Violations were found in Administration, Basic Services [Performance Improvement], and Basic Services [Nursing Services] that were detrimental to resident health, safety, or welfare.
Report Facts
Civil Monetary Penalties: 5
Penalty amount: 25000
Special monitor hours: 20
Inspection Report
Enforcement
Deficiencies: 0
Date: May 20, 2021
Visit Reason
The Department of Health conducted a complaint survey at Serene Manor Medical Center to investigate alleged violations of licensure statutes and regulations impacting patient care.
Complaint Details
The visit was complaint-related, and the investigation was completed on December 3, 2021. Specific substantiation status is not stated.
Findings
The survey revealed violations of licensure statutes and regulations that directly impact patient care in the nursing home, resulting in the imposition of Type B Civil Monetary Penalties.
Report Facts
Civil Monetary Penalties: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Piercey | Commissioner | Signed the order assessing civil penalty. |
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