Serenity Estates of Lena: CNA Abuse on First Solo Day - IL
The incident happened on November 8, 2025, at Serenity Estates of Lena, a nursing facility in this small town in the far northwestern corner of Illinois. The resident, identified in inspection records only as R1, had been admitted to the facility with diagnoses including dementia, psychosis, and pain. During a quarterly assessment completed in September, he had been rated as having moderate cognitive impairment. He moans during personal care. Staff knew this. It was, according to the CNA supervisor, common knowledge among the employees.
The nursing assistant who grabbed him, identified as V5, was on her first day working without a trainer.
The witness, a CNA identified as V4, described what she saw to federal inspectors on November 18. She said there was no doubt in her mind about what V5 was doing when she grabbed R1's nose. V4 said V5 was trying to get him to be quiet by twisting and pulling it. When V5 did that, R1 squealed. V4 said she separated R1 from V5 after the incident, reported what she had seen, and then V5 was escorted from the building.
V5 told inspectors a different story. She said R1 had cursed her out. She said she was used to racial slurs and that they did not affect her ability to provide care. She denied the incident entirely and said the facility was lying.
The administrator, V1, told inspectors he believed V4. He said V4 was a trusted and valued staff member, and he substantiated the abuse finding. The Director of Nursing called V4 "one of our best."
The CNA supervisor, V10, had her own history with V5 that painted a fuller picture of who had been working in that room. V10 told inspectors that V5 had poor customer service. She said V5's demeanor and speech came off as lacking compassion, and that V5 would talk to residents like children. V10 said she had personally heard V5 tell a resident they should not be using their call light constantly because she had things to do. V10 pulled her aside and told her that residents need to be encouraged to use their call lights for safety and that she could not say that to them.
It did not stop there. V5 had apparently told V10 something remarkable during their conversation: that at her previous facility, she and other CNAs would turn off the call light system when residents kept using it.
V10 also told inspectors that V5 had mentioned feeling like she was going to get fired, and that she had in fact been fired from her previous job. V5 had volunteered this information herself.
None of it had stopped V5 from being placed on the floor. November 8 was her first day off training.
The registered nurse who escorted V5 out of the building, V11, told inspectors she had not worked with V5 directly. She described V4 as "a sweet girl" who does her job. V11 said she assessed R1 after the incident and found him aggravated. She noted that R1 moans and groans during care because of discomfort from a catheter, and that he was receiving an ointment for that discomfort. She said she observed no facial trauma.
R1's son, V7, visited on Monday, November 10, two days after the incident. He told inspectors his father reported there had been "a ruckus" but could not provide any further details. V7 said he saw no injuries to his father's face. He said R1 would have shrugged off something like this if he were cognitively intact, but noted that his father had started to experience a recent decline in both his health and his cognition.
R1's daughter, V6, who holds power of attorney, did not see her father until the following Wednesday. She said her brother had been at the facility shortly after the incident on Saturday and that R1 had told him about the ruckus. She also saw no injuries to R1's face. She told inspectors that if her father had been cognitively intact, an incident like this would have upset him, but there would not have been any lasting consequences to his behavior or mood. She, too, noted his recent decline.
By the time supper was over on the evening of November 8, V10 said, R1 was back to his baseline.
The inspection was a complaint investigation, triggered before federal inspectors arrived on November 18. The deficiency was cited under F0600, the federal tag covering abuse, neglect, and exploitation. CMS rated the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected.
What the record shows is a man with dementia who moaned during care, a nursing assistant who had already demonstrated she found residents' needs an inconvenience, a supervisor who knew it, and a facility that put her on the floor alone anyway. When R1 made noise, V5 grabbed his nose and twisted it until he squealed. She was walked out of the building. He was upset through supper, and then he was fine, or at least back to whatever fine looks like when you have dementia and a catheter and someone has just hurt you and you can't quite explain to your son what happened, only that there was a ruckus.
He knew something had happened to him. He just couldn't say what.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Serenity Estates of Lena from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
Serenity Estates of Lena in LENA, IL was cited for abuse-related violations during a health inspection on November 18, 2025.
The incident happened on November 8, 2025, at Serenity Estates of Lena, a nursing facility in this small town in the far northwestern corner of Illinois.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.