Serenity Estates of Lincolnshire: Staffing Failures Overnight - IL
The facility's own internal assessment said that number should never exceed 30.
Inspectors reviewed nursing schedules dating back to late February and found the pattern was not a one-night gap or a staffing emergency. It was the routine. Three nurses covered seven units and 128 residents every overnight shift, with each nurse responsible for somewhere between 41 and 44 residents depending on the night.
On April 18, the schedule showed a licensed practical nurse identified in inspection records as V3 was assigned to the 700 unit, the 100 unit, and half of the 200 unit. That came to 42 residents. A registered nurse identified as V10 covered the 300 unit, the 400 unit, and the other half of the 200 unit, 41 residents total. A third RN, V11, handled the 500 and 600 units, 44 residents.
The facility's own Facility Assessment, updated April 1, 2026, stated directly that licensed staff ratios on the overnight shift should not exceed one to 30. Every nurse working overnight was assigned a load at least 37 percent above that ceiling. V11's assignment exceeded it by nearly 47 percent.
The certified nursing assistant coverage told a similar story. Three CNAs were split across four units on the lower floors, each responsible for roughly 20 residents, while the facility's own assessment set the overnight CNA limit at one to 18. The upper units, 500, 600, and 700, each had their own dedicated CNA. The lower floors did not.
A CNA identified as V13 told inspectors on April 27 that this arrangement was standard. "It is normal to split the four units with only three CNAs," V13 said, adding that staff try to divide the load so each CNA has about 20 residents. V13 acknowledged the geography made it harder than the numbers suggested. "When you are on one unit, you can't see what's going on with the other unit," V13 said. "There is a lot of distance between some of the units."
That distance matters at 2 a.m. in a 128-bed facility. A resident who falls, a resident in respiratory distress, a resident who has wandered into the wrong room — none of those situations wait for a nurse to finish her rounds on a unit two hallways away.
The facility's Human Resources Director, identified as V15, confirmed on April 28 that the staffing pattern had been in place for some time. V15 also acknowledged that the 400 unit, one of the four units sharing three CNAs at night, needed more coverage. "The 400 unit could use a full time nurse on all shifts, seven days a week," V15 said. Then V15 added that it was not V15's decision to make.
The Facility Assessment the administration had signed off on just four weeks before inspectors arrived described its own purpose in precise terms: evaluate the resident population, determine what resources are necessary to care for residents competently during nights and weekends, and use that assessment to make decisions about direct care staff needs. The document set specific overnight ratios. The schedule the facility was actually running violated both of them.
Inspectors classified the violation as having the potential for actual harm, affecting all 128 residents present during overnight shifts. The complaint investigation covered a two-month window, February 27 through April 27, during which the understaffing was documented as continuous.
The Human Resources Director knew the 400 unit needed more help. The Facility Assessment had already calculated the minimum safe ratios. The schedule ignored both.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Serenity Estates of Lincolnshire from 2026-04-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
SERENITY ESTATES OF LINCOLNSHIRE in LINCOLNSHIRE, IL was cited for violations during a health inspection on April 29, 2026.
The facility's own internal assessment said that number should never exceed 30.
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.