Serenity Hospice Homes LLC
A hospice in Brooklyn Park, Minnesota 55443
8948 Stratford Court, Brooklyn Park, Minnesota 55443. (612) 398-6993.
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The short answer
Record last released by CMS on Oct 23, 2026. We couldn’t read Centers for Medicare & Medicaid Services’ list since Oct 27, 2026: qcor.cms.gov now refuses our reader. This record is as of then.
- 11 deficiencies cited in the last three years
- Not rated family caregiver rating
- Not available CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
11 deficiencies cited in the last three years
The middle of the 26 hospices serving ZIP code 55443 had 3.
The last inspection on record was on Dec 28, 2023: an initial inspection by the Accreditation Commission for Health Care.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
11 deficiencies in 1 month of the last 36. Last cited Dec 2023. Most serious: Standard-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Dec 28, 2023: initial inspection by the Accreditation Commission for Health Care11 deficiencies
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Timeframe for completion of assessment (42 CFR 418.54(b))
“Upon patient record review 2 of 6 (Patient #1,#2) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient#1: The patient was admitted on 11/14/23. The record indicated that the spiritual assessment was completed on 11/21/23. Patient#2: The patient was admitted on 11/14/23. The record indicated that the spiritual assessment was completed on 11/24/23.”
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Content of comprehensive assessment (42 CFR 418.54(c)(6))
The inspectors’ words, 126 words
“Upon patient record review, 2 of 6 (Patient #1,#3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient#1: The medication profile indicated Polyethylene Glycol 17 Gm daily PO daily without evidence of a diluent. Corrected on site. Patient#3: The medication profile indicated Acetaminophen 500mg PO 3 tablets daily for pain. Acetaminophen 650mg rectal suppository every 4 hours PRN pain/fever. There was no parameters for fever or maximum daily dose listed. Corrected onsite.”
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Content of plan of care (42 CFR 418.56(c)(4))
The inspectors’ words, 91 words
“Upon patient record review, 2 of 6 (Patient #1,#3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient#1: The record indicated Polyethylene Glycol 17 Gm daily PO daily without evidence of a diluent. Corrected on site. Patient#3: The record indicated Acetaminophen 500mg PO 3 tablets daily for pain. Acetaminophen 650mg rectal suppository every 4 hours PRN pain/fever. There was no parameters for fever or maximum daily dose listed. Corrected onsite.”
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Counseling services (42 CFR 418.64(d)(1))
The inspectors’ words, 147 words
“Upon patient record review, 1 of 6 (Patient #6) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient#6: There was no evidence of a bereavement risk assessment or bereavement plan of care. Patient died 12/5/23, Chaplain made a bereavement visit on 12/6/23. There was no evidence of a follow-up bereavement care plan (re: frequency of calls, sending cards and letters, etc).”
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Hospice aide assignments and duties (42 CFR 418.76(g)(2))
The inspectors’ words, 115 words
“Upon patient record review 1 of 6 (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient#3: The aide plan of care indicated for nail care to be done at each visit. The record indicated that the task was not performed on 11/07/23, 11/20/23, 12/08/23, and 12/11/23. Also, the aide plan of care indicated for mouthcare to be done at each visit. The record indicated that the task was not performed on 12/15/23.”
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Discharge or transfer of care (42 CFR 418.104(e)(3))
“Upon client record review, 1 of 6 (Patient #4) did not have evidence that the discharge summary includes all required information. Patient#4: The initial discharge summary that was sent to the hospice agency receiving patient did not contain: The transfer order, the patient’s current plan of care, patient’s latest physician orders, and documentation of wound care provided by the customer that would assist in post-discharge continuity of care.”
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Personnel qualification (42 CFR 418.114(a))
“Upon personnel record review, 3 of 13 (Personnel #10,#11,#12) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements.”
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Personnel qualification (42 CFR 418.114(b)(4))
“Upon personnel record review, 1 of 13 (Personnel #12) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state’s Speech-Language Pathology Practice Act and the hospice’s policies and procedures and/or job descriptions.”
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Personnel qualification (42 CFR 418.114(b)(5))
“Upon personnel record review, 1 of 13 (Personnel #11) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state’s Occupational Therapy Practice Act and the hospice’s policies and procedures and/or job descriptions.”
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Personnel qualification (42 CFR 418.114(b)(7))
“Upon personnel record review, 1 of 13 (Personnel #10 ) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state’s Physical Therapy Practice Act and the hospice’s policies and procedures and/or job descriptions.”
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Criminal background checks (42 CFR 418.114(d)(1))
“Upon personnel record review, 3 of 13 (Personnel #10,#11,#12) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Dec 28, 2023 | Initial inspection by the Accreditation Commission for Health Care | 11 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Jan 19, 2024.
- CMS doesn’t list its type of ownership.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency or CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3. on record in the last three years.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- CMS hasn’t published nursing time from Medicare claims for this hospice.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 6% at home, 94% in assisted living.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
Who owns it?
- 5 owners or officers are people: Carolyne Ellis (owns 5% or more directly, 100%); Carolyne Ellis (corporate director, 50%); Carolyne Ellis (managing employee (on the payroll), 50%); Wendi Tvedt (corporate director, 50%); Wendi Tvedt (managing employee (on the payroll), 50%).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
What do families say?
- CMS gives no family caregiver survey rating: “The number of cases is too small to report Star Ratings.”
- CMS gives no Hospice Care Index for this hospice.
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
How does it compare nearby?
- Of the 26 hospices CMS’s data show serving patients in ZIP code 55443, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 3; this one had 11.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| Mary T Hospice | 5 |
| Serenity Hospice Homes LLC This hospice | 11 |
| North Memorial Home Hlth Hospc | 4 |
| Park Nicollet Methodist Hospital | 5 |
| Allina Health Hospice & Palliative Care | 13 |
| Accentcare Fairview Hospice - West, LLC | 0 |
| Healthpartners Hospice and Palliatice Care | 0 |
| Horizon Public Health | 0 |
| Ecumen Hospice | 2 |
| Ridgeview Hospice | Not given |
| Our Lady of Peace Hospice | 0 |
| Triniti Hospice | 0 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.