Cycle 1
Health 2025-04-29 · Fire 2025-04-29
17 health deficiencies
Top issue: Infection Control (4 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Wrentham, MA
Serenity Hill Nursing Center
1-star overall rating with 1-star inspections with 17 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
655 Dedham St, Wrentham, MA
(508) 384-3400
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
44
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing
LPN hours / resident day
0.99
Licensed practical nurse staffing
Aide hours / resident day
2.67
Nurse aide staffing
Weekend hours
3.54
Weekend nurse staffing
RN turnover
40%
Annual RN turnover
Total nurse turnover
58%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.9
0.9 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
92.2%
2 pts better
|
93.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
94.8%
2.6 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.5%
3.5 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
12.0%
10.1 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.0% |
5.2%
1.8 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6% |
19.2%
0.6 pts better
|
19.6%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 36.3% |
22.5%
13.8 pts worse
|
16.7%
19.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.8% |
17.7%
7.1 pts worse
|
16.3%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.1% |
17.6%
6.5 pts worse
|
14.9%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.3% |
1.0%
4.3 pts worse
|
1.0%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
2.0%
0.5 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.8% |
21.7%
8.9 pts better
|
19.8%
7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.6%
1.3 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 35.1% |
77.1%
42 pts worse
|
81.7%
46.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-14 · Fire 2024-05-14
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
20 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Cycle 3
Health 2023-03-09 · Fire 2023-03-09
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-29
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-04-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-04-29
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-04-29
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-04-29
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-04-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-18
F · Potential for more than minimal harm
2025-04-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-18
F · Potential for more than minimal harm
2025-04-29
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-04-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-18
F · Potential for more than minimal harm
2025-04-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-04-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-08
F · Potential for more than minimal harm
2024-05-14
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-05-14
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-05-14
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-05-14
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-05-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-17
E · Potential for more than minimal harm
2024-05-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-14
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-14
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-14
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-14
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-14
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-14
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-06-10
C · Minimal harm
2024-05-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-09
C · Minimal harm
2024-05-14
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-07-09
C · Minimal harm
2024-05-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-09
F · Potential for more than minimal harm
2023-03-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-09
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-09
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-09
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-04-07
C · Minimal harm
2023-03-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-07
C · Minimal harm
2023-03-09
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-04-07
C · Minimal harm
2023-03-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-07
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-29
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-04-29
F909 · Environmental Deficiencies
Health
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.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-29
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-05-31
E · Potential for more than minimal harm
2025-04-29
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-31
E · Potential for more than minimal harm
2025-04-29
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-05-31
E · Potential for more than minimal harm
2025-04-29
F742 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-05-31
E · Potential for more than minimal harm
2025-04-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-29
F887 · Infection Control Deficiencies
Health
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.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-04-29
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-29
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-29
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-03
F · Potential for more than minimal harm
2024-05-14
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-14
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-14
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-14
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-05-31
F · Potential for more than minimal harm
2023-03-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-04-21
F · Potential for more than minimal harm
2023-03-09
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-03-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F909 · Environmental Deficiencies
Health
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.
Corrected 2023-04-21
Penalties and ownership
What sits behind the stars
Ownership
Woods, Thomas
5% Or Greater Direct Ownership Interest · Individual
Woods, Charles
5% Or Greater Direct Ownership Interest · Individual
Harrington, John
5% Or Greater Direct Ownership Interest · Individual
Sweeney, Matthew
5% Or Greater Direct Ownership Interest · Individual
Harrington, John
Corporate Officer · Individual
Harrington, John
W-2 Managing Employee · Individual
Sweeney, Matthew
Corporate Officer · Individual
Sweeney, Matthew
W-2 Managing Employee · Individual
Woods, Thomas
Corporate Officer · Individual
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#2
Cedarwood Gardens
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3-star overall rating with 2-star inspections with $7,596 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Foremost At Sharon LLC
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2-star overall rating with 2-star inspections with $25,773 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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