Serenity Estates of Lincolnshire

Inspectors wroteBased on interview and record review the facility failed to have sufficient staff on a nursing unit to provide care for residents on 7/12/26. This applies to 14 of 17 residents (R1, R4-R16) reviewed for staffing in the sample of 17. The finding including:On 7/17/26 R1 stated, On that day (7/12/26) I was laying here and there was no one around. I was trying to call the front desk, and no one was answering the phone. So, I called the police, 911. The police came to my room. I always give them my name and my room number so they can find me. He came in and said, How can I help you? I told him I want to get up but I can't get out of my bed by myself. I think he then went out the door, and I am not sure who showed up after that. (Surveyor explained that the police report states 2 staff came to assist her) R1 stated, That is very unusual because it is hard enough to get one. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure timely administration of medications prescribed to control symptoms related to Parkinson's disease, and failed to ensure a resident's medication for restless leg syndrome was administered as ordered for 2 of 3 residents (R2 and R3) reviewed for care and services in the sample of 17.

Inspectors wroteBased on interview and record review the facility failed to ensure daily weight was performed as ordered for a resident with congestive heart failure (CHF). This failure resulted in R1's worsening heart failure condition causing fluid retention and shortness of breath requiring hospitalization for 1 of 3 residents (R1) reviewed for care and services in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from significant medication errors for 1 of 4 residents (R1) reviewed for medications in the sample of 7. This failure resulted in R2 receiving a double dose of an antipsychotic medication for 33 days.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's family of a room change for 1 of 4 residents (R1) reviewed for notification in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to thoroughly investigate an allegation of abuse for 1 of 7 residents (R3) reviewed for abuse in the sample of 7.

Inspectors wroteBased on interview and record review the facility failed to conduct a post fall analysis to ensure fall interventions were appropriate for a resident's self-reported fall for 1 of 3 residents (R1) reviewed for safety in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to be administered in a manner to ensure supplies were available for dependent residents for 1 of 3 residents (R2) reviewed for administration in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a cognitively impaired resident with a known history of elopement while at home did not elope from the facility for 1 of 3 residents (R1). This failure resulted in R1 exiting a secured unit and the facility unsupervised, walking approximately 1,000 feet and crossing a four-lane road in the dark until found by staff approximately 45 minutes later. The Immediate Jeopardy began on 4/19/26 at approximately 3:30 AM, when R1 exited from a secured unit, walked to a different unattended unit and past a nurse's station, down a hallway, and exited the facility unsupervised through a fire exit door. [...]

Inspectors wroteBased on interview and record review the facility failed to adequately schedule staff to ensure all units were attended during the overnight shift. This has the potential to effect all 128 residents residing in the facility during the overnight shift.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff reported an allegation of verbal abuse to the abuse coordinator for 1 of 3 residents (R1) reviewed for abuse in the sample of 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to suspend a staff member accused of abuse when an allegation was reported for 2 of 3 residents (R1, R2) reviewed for abuse in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident with cognitive impairment did not elope the facility and failed to ensure all residents were accounted for one of three residents (R1) reviewed for safety/supervision in the sample of seven. The Immediate Jeopardy began on February 4, 2026, at 5:43 AM when R1 was found sitting outside in the cold in her wheelchair by herself, a block away from the facility and was transferred to the local hospital for cold exposure. V1 Administrator was notified of the Immediate Jeopardy on February 9, 2026, at 3:45 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on February 10, 2026, at 10:34 AM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.

Inspectors wroteBased on interview and record review the facility failed to administer medications as order for 3 of 5 residents (R1, R4 and R5) reviewed for pharmacy services in the sample of 12.

Inspectors wroteBased on interview and record review the facility failed to ensure significant medications were administered as ordered for 2 of 5 residents (R4 and R5) reviewed for medication administration in the sample of 12.

Inspectors wroteBased on interview and record review the facility failed to ensure a respiratory viral panel was performed as ordered for 1 of 5 residents (R4) reviewed for laboratory services in the sample of 12.

Inspectors wroteBased on interview and record review the facility failed to obtain a STAT (immediate) chest x-ray as ordered for 1 of 5 residents (R4) reviewed for radiology services in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary care, services, and translation services after a resident experienced a fall and subsequent hip and arm fractures. This failure resulted in R1 experiencing pain and a delay in treatment. This applies to 1 of 3 residents (R1) reviewed for nursing care in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify a resident's family and nurse practitioner after the resident fell. This applies to 1 of 3 residents (R1) reviewed for nursing care in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to identify and assess a resident with a change of condition and requiring medical intervention. This applies to 1 of 3 residents (R1) reviewed for change of condition in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) assistance for residents that require staff assistance for incontinence care and/or toileting for 2 of 5 residents (R2, R5) reviewed for ADLs in the sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R1) reviewed for transfers in the sample of 7.

Inspectors wroteBased on observation, interview and record review the facility failed to provide sufficient nursing staff to meet the needs of the residents for 3 of 6 residents (R2, R3, R5) reviewed for sufficient staffing in the sample of 7.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately administer medications to meet the needs of the residents for 3 of 4 residents (R2, R3, R4) reviewed for medication administration in the sample of 7.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications as ordered (at ordered times). There were 30 opportunities with 6 errors resulting in a 20% error rate. This applies to 2 of 3 residents (R2, R3) observed in the medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dressing changes and/or intravenous (IV) tubing changes were completed to decrease the potential for infection for 2 of 2 residents (R1 and R2) in the sample of 2 with central lines.

Inspectors wroteBased on interview and record review, the facility failed to administer intravenous (IV) antibiotics as ordered by the physician for 2 of 2 residents reviewed for intravenous therapy in the sample of 2.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a written grievance and follow their policy for 1 of 3 residents (R2) reviewed for grievances in the sample of 9.

Inspectors wroteBased on observation, interview, and record review the facility failed to safely position a dependent resident in a manner to prevent minor injury for 1 of 3 residents (R2) reviewed for safety in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately store food items by not properly labeling and/or dating items. This failure has the potential to affect all 102 residents who currently reside in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for 2 of 5 residents (R58, R47) reviewed for pressure ulcers in the sample of 62.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safety of a resident while smoking for 1 of 2 residents (R33) reviewed for smoking in the sample of 62.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a system in place to ensure all residents received their meal for 1 of 5 residents reviewed for nutrition and dining in the sample of 62.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician prescribed medications were administered as ordered for 3 of 3 residents (R29, R204, R199) reviewed for medication administration in the sample of 62.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore personal protective equipment when providing care for residents on enhance barrier precautions (EBP) and carrying soiled linen from a room for 3 of 3 residents (R47, R23, & R203) on transmission based precautions in the sample of 62.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who is a high risk for falls was supervised and failed to ensure fall interventions were individualized for a resident with poor safety awareness and cognitive deficits and failed to ensure bed rails were installed in manner to prevent entrapment. This failure resulted in R1 being found in her room kneeling on the floor with her right arm trapped between the side rail and the mattress sustaining a right comminuted humerus fracture. This applies to 1 of 3 resident (R1) reviewed for safety in the sample of 9.

Inspectors wroteBased on observation, interview, and record review the facility failed to consistently implement treatments and assessments for R3's Left Ventricular Assistive Device (LVAD) for 1 of 2 residents (R3) reviewed for quality of care in the sample of nine.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to adequately assess and monitor a resident for skin integrity issues and failed to obtain a physician's order for wound care for 1 of 4 residents (R4) reviewed for quality of care in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to include a resident in her care plan meetings for 1 of 4 residents (R7) reviewed for resident rights/right to participate in their plan of care in the sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were implemented to prevent/heal pressure ulcers for 2 of 3 residents (R1 and R11) reviewed for wounds in the sample of 12.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was supervised while ambulating which contributed to the resident sustaining a fall for 1 of 3 residents (R8) reviewed for supervision/falls in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a residents pain was managed for 1 of 4 residents (R1) reviewed for pain in the sample of 4. This failure resulted in R1 experiencing severe pain.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a residents nasal spray was obtained from pharmacy and administered for 1 of 3 residents (R2) reviewed for pharmacy services in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to obtain physician orders upon admission. This applies to 1 of 1 residents (R1) reviewed for admission orders in the sample of 7 .

Inspectors wroteBased on interview and record review the facility failed to assess or provide wound care to a resident admitted with wounds. This applies to 1 of 3 residents (R1) reviewed for wounds in the sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident was assisted and supervised while ambulating to her room for 1 of 3 residents (R3) reviewed for safety and supervision in the sample of 6 residents. This failure resulted in R3 falling and sustaining subarachnoid and subdural hemorrhages.

Inspectors wroteBased on interview and record review the facility failed to have quarterly care plan conferences. This applies to 3 of 5 residents (R1, R2, R4) reviewed for care plan conferences in the sample of 5.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their contact isolation policy by failing to implement contact isolation precautions for a resident (R3) with a suspected contagious skin rash. The facility failed to ensure a resident (R3) diagnosed with scabies remained isolated from other residents. The facility failed to disinfect and sanitize a communal shower room after a resident (R3) diagnosed with scabies was showered in the room, failed to handle the personal belongings of a resident (R3) diagnosed with scabies, in a manner to prevent cross contamination to others (R7) and failed to ensure housekeeping staff wore the required personal protective equipment (PPE) when cleaning the room of a resident (R6) on contact isolation for a rash. These failures have the potential to affect all 95 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to identify and assess a resident experiencing a change in condition. This failure resulted in a delay in treatment for R1, and R1 experiencing pain due to fractured hip for 1 of 3 residents (R1) reviewed for falls in the sample of 9.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from physical abuse. This failure resulted in R1 being struck in the face by R2. R1 was sent to the local hospital and sustained a closed fracture of the left zygomatic arch (cheek bone). This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3.

Inspectors wroteBased on interview and record review the facility staff failed to immediately report an allegation of sexual abuse to the abuse coordinator for 1 of 3 residents (R1) reviewed for abuse in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to ensure the safety of a resident when facility staff failed to recognize that a resident (R1), did not return to the facility after being out of the facility on a community/day pass. This failure applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered according to professional standards for 2 of 3 residents (R1, R8) reviewed for medications in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to supervise a cognitively impaired resident (R65), with a history of falls, in a dining room of the facility. This failure resulted in R65 sustaining an unwitnessed fall requiring R65 to be emergently transported to a local hospital where she was diagnosed with two brain bleeds as result of the fall. This failure applies to 1 of 17 residents (R65) reviewed for safety and supervision in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was at a safe temperature before serving meals by not checking the temperatures of food before serving from the steam table and by not checking the temperature of reheated food. This applies to all 67 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to change gloves and wash hands to prevent the spread of infection for one resident (R62). The facility also failed to place three residents (R122, R45, R35) on enhanced barrier precautions. These failures affect 4 of 17 residents (R62, R122, R45, R35) reviewed for infection control in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to provide ongoing, direct monitoring of the resident's condition during the use of a physical restraint. The facility failed to implement interventions to attempt to reduce the use of a physical restraint. These failures apply to 1 of 1 resident (R5) reviewed for physical restraints in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to provide ADL (activity of daily living) assistance for residents that require staff assistance for toileting/incontinence care for 2 of 17 residents (R13, R26) reviewed for ADL's in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the necessary care and services to a resident when a new, non-pressure wound was identified for 1 of 17 residents (R19) reviewed for necessary care and services in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide interventions to reduce the risk of pressure ulcer development for 1 of 5 residents (R56) reviewed for pressure ulcers in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a physician ordered palm protector for 1 of 5 residents (R3) reviewed for range of motion in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to provide dietary supplements for residents with significant weight loss for 2 of 7 residents (R31, R5) reviewed for weight loss in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications according to standard of practice to 1 of 17 residents (R57) reviewed for medications in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure gloves were changed to prevent cross contamination when providing ileostomy care for 1 of 24 residents (R40) reviewed for infection control in the sample of 24.